Infertility Q and A

Hello again. Here is the latest entry.

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


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


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


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


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



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


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


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


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


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

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


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


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


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


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


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


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


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

Frequent Fertility Questions

Hello to all,
Here is your latest entry.

What if I have had miscarriages but my HSG and clotting tests are normal? Make sure you get the karyotype test, the blood test to check your chromosomes.

What if your partner recently had a vasectomy reversal and the motility is only 20% with poor morphology. Will these numbers improve with time? Hard to say. If there is not much improvement in 6 months, there will probably not be much change after that.

Are there any tests to explain poor embryo quality? At this time there are none. We don’t know why within a batch of embryos, some look good and others do not. We don’t know why some women make nicer embryos than other women.

What about shared risk IVF programs? They have their pluses and minuses. The name is deceiving. It sounds like your doctor is somehow contributing to and sharing your financial burden, but this is not the case. Shared risk means the other patients in the program are all sharing the risk. The price of shared risk in many cases does not include all of your costs. It’s all figured out mathematically. Some patients will end up pay less, some pay more, but what the average a person pays in most shared risk programs is the same the average person would pay without the program.

Are there options other than IVF ICSI with 6% motility? Realistically; no. Miracles can happen. We don’t know why but to get pregnant on your own, your need millions of moving sperm. Even IVF without icsi requires millions, although not as many as you need for a natural pregnancy.

What if you are young and have had 4 unexplained miscarriages and your workup is normal? Facing another pregnancy and miscarriage sounds impossible to you, and your doctor says there are no other tests? The unemotional cold hard fact is that trying again is the only real option and the odds are that the next pregnancy will be successful. Your miscarriage risk is higher than others without your history. I’m not saying trying again is the best thing for you, I understand why you may not want to.

Mini IVF. It has its place. Things to watch out for are any hidden costs, which could be high. There is a higher chance that there will be no egg retrieved. You really need to know what the deliver rate is for people your age. The “pregnancy rate” is not the delivery rate. There are different versions of mini IVF. Most involve clomid, but sometimes low doses of injections are added. Also be careful about the freezing option. Many times the doctor will say the lining is not right and he wants to freeze the embryos, so they can be transferred when the lining is more favorable. This gets a mini Arghh. Mini IVF has a lower pregnancy rate and freezing embryos probably makes the rates lower still. Plus if the goal of mini IVF is to save money, it seems that the costs will add up between the cycle, the freeze and the frozen transfer.

What if you have been offered frozen donor eggs (not embryos). This could be a good option. Ask for details (not an estimate) about success at your clinic. If they do not have good results from at least 10-15 thaws, you may want to reconsider. People in the field feel all of donor egg will be using frozen eggs in the near future, although today the science is still new.

Should you consider a surrogate if you have had 2 failed fresh DE cycles, one with a proven donor? If you have no uterine issues i.e. a nice lining and no scaring/previous surgery, the added benefit from a carrier will be minimal. However, if you have access to a good carrier and are open to the idea it is not unreasonable to at least explore the option.

What if you only have access to insemination M-F? Not great. Most of the time there is room for getting inseminated a little early or late, but having weekend services available to you is much better.

Does natural cycle insemination increase your odds of twins? No. Twins come from 2 or more eggs and in the natural cycle, usually only one is produced.

What if you have pain and your doctor is not listening? Maybe your doctor does not feel that you have a pelvic problem that requires further evaluation because your exam and ultrasound are normal, and she does not feel a laparoscopy is right for you. If that’s the case your doctor needs to at least give you another complete exam and a repeat the ultrasound, and then needs to discuss your options. She needs to let you know what she is thinking and visa versa. If you can’t get this with her, try someone else.

What if you are 41, and have gotten pregnant easily twice. Is there an advantage to going to IVF? Theoretically yes because if you have more than one embryo to transfer you will increase your odds of success. The dilemma is that you are getting pregnant on your own easily, which does not necessarily mean you will get pregnant easily with IVF. If you decide to try on your own again, get help quickly if you don’t get pregnant soon.

What if you have stage 3 endometriosis and have not become pregnant with a few iuis? You should consider moving to IVF sooner than average. Pregnancy even without drugs is certainly possible, but the odds are lower because of potential tubal issues related to the endometriosis.

What about stress management programs to increase the odds of conception? I think these programs are extremely helpful. I started the NYU Fertility Center Wellness Program, which incorporates acupuncture, mind-body and yoga into our practice. I don’t like selling these things as ways to get you pregnant, because more research needs to be done. But they are very beneficial for stress management and treatment tolerance.

What’s better for low sperm counts, IVF/ICSI or donor sperm? Donor sperm is a lot easier and cheaper and may lead to a quicker pregnancy. That being said, most people prefer partner’s sperm, IVF and ICSI.

Could a hydrosalpinx prevent pregnancy? The answer is yes. A publication of the American Society of Reproductive Medicine states that a hydrosalpinx can lower pregnancy rates by as much as 50%. I think it’s closer to 30%. Many years ago I would remove a hydrosalpinx in any woman wishing to attempt IVF. More recently I let people know that a hydro will lower the odds in some women but not all, and with the hydro the odds are still good. So I let them decide if they want the surgery prior to IVF. Having a hydro will increase the chances of an ectopic pregnancy with IVF. Hydros can be a problem even if you are not yet a candidate for IVF. In other words if one tube is normal and the other a hydro, removing the hydro may help you get pregnant on your own.

What if you are 44 and were told the chances of IVF are 5%, but you make 14 eggs and have nice embryos? Are your odds higher? Yes they are. Most, but not all, women who get pregnant in their mid 40’s are lucky enough to make a high egg number. The more the better.

What if you were just diagnosed with terrible endometriosis and are offered Lupron? There are no good studies showing Lupron will take away any of the endometriosis or improve scarring. The story is different for pain; Lupron can help tremendously with that.

How to find the best IVF clinic? Start with SART.org and look up the pregnancy rates for your age group. The tables are a little hard to read, go to the line that says live births per retrieval. After that it’s about chatting it up in person and on line.

What if you are obese and the doctor is worried about doing IVF in the office safely? Different doctors will have different thresholds for maximum weight. Some are more relaxed when dealing with very obese patients. So get more opinions. Some IVF centers do their retrievals in the hospital, and they may be more eager to treat you. At 26 you do have time to lose weight before you start, which would be better for the baby. There is new data every day on the detrimental effects of obesity on the fetus. The old saying"you are what you eat" has been replaced by "you are what your mom eats."

What if you have a 2 cm endometrioma on your ovary? As long as they are sure that’s what it is, and it’s not another type of tumor, a 2 cm endometrioma will not hurt your chances of conceiving with IVF.

What next? You are young and have had a baby then 3 miscarriages, the workup doesn’t show much. Too many women have been hit with similar issues. It’s all about the tough decision to continue. If you get pregnant again, odds are that you will have the baby. However the thought of facing another loss sometimes overwhelms us. I try to encourage more attempts, but it’s your decision in the end.

Thanks for reading and read the disclaimer 5.17.06.

Dr. Licciardi

Please Vote for the InfertilityBlog

Dear All,

Congratulations to all of you who read this blog, it has been nominated for the People's HealthBlogger Award. See the yellow blue and orange box to the right? Clicking it would be a great help. Winning would be very helpful because the blog would get more publicity, which will bring us more readers. This in turn could help us get the blog to even more health-related web sites. The voting ends December 15Th.

Thanks for everything through the years.

Dr. Licciardi
PS The company encourages you to ask your contacts to vote too. I guess they want some publicity too, which is fine with me.

Question and Answer Time

Hello Again. I will spend the next few blogs catching up on questions. It’s been a while and I see that many were time sensitive, so I am sorry if missed your immediate problem. I’ll try to keep more up to date. One problem is that not all readers like the questions, but I like doing them, and if I make the answers relevant to a group of people, I think they work for a larger group of people. I got caught up in a bunch of topics that I wanted to cover, but for now, back to the questions.

What if you are young, make many eggs and embryos, have very nice quality, a normal uterus and are not getting pregnant? Could it be an implantation issue related to the uterus? Chances are this is not the case. Your doctor may be right, it could be bad luck. It could also be that you need to try another IVF clinic. It could also be there is some unknown genetic problem with your eggs or sperm, but the answer here is years away. Some would consider PGD in this case, but it is questionable if it would help.

If you do clomid, do you need to wait 2 weeks and provera to start? No. Your doctor wants 2 things. He wants you to bleed before the clomid, and he wants you not to be pregnant when you take the povera or clomid. There are ways around this. If you have not bled in many many months, it’s not a bad idea to get a period to start, so provera is not a bad idea. If you have had a period in the past few months, provera is probably not necessary. To be sure you are not pregnant; you can just do a progesterone blood test. You can’t be pregnant if you never ovulated, so if your progesterone is very low, it’s ok to start the clomid (if your doctor says it’s ok). If it’s high, you did ovulate, and you will need to wait less than 2 weeks for your period. If your period does not come, do a pregnancy test.

What if you were diagnosed with stage one enodmetriosis and were told to take Lupron for 3 months. Here is today’s ARGHHHHHHHHHH!!!!!
No one has ever shown that being on Lupron after surgery does anything to reduce endometriosis or improve pregnancy rates. It works like this. Endometriosis grows from estrogen; when Lupron takes away the estrogen the endometriosis stops growing. But Lupron does not kill the endo, it just suppresses it. So once the lupron is stopped, the endometriosis goes right back to where it was. Yes staying on the lupron will take away pain, but once the lupron is stopped, the pain comes right back. So the 3-6 moths of lupron will not help you become pregnant, it just makes you older and more frustrated. A new endometrioma should not appear on Lupron. If the cyst was not well removed at surgery, it can reappear, even if on lupron.

Is a large clot during the period a problem? Probably not. A very large clot is probably not coming from the uterus. It’s from fresh blood that flows from the uterus into the vagina, then sits there and clots. If you think overall the amount you are bleeding is excessive, there could be issues related to fibroids, polyps, etc.

Do we know more about Unexplained Infertility? The problem with writing about unexplained infertility (UI) is that patients are put in the category of UI only after the things we know about have been excluded. It is true that in the past many years, no new meaningful tests have been developed to get people out of the UI group and into one of the groups that are explained.


What if you have severe endometriosis and are not getting pregnant with IVF. Women with endometriosis do make few eggs than average, but 16 is plenty. Should you go to another IVF center? Look up their stats at SART.org. If the numbers look good, stay, if not, get another opinion. Genetic testing is always an option. With a mostly normal family history, the odds of a chromosomal problem are 1-3%.

What if you are 37-38 and your FSH is very normal buy you only make 4 eggs? Well FSH is not the whole story. It’s a good guide but if your number is low, it doesn’t mean you will definitely make many eggs. If you are starting on 2 Follistim and one Menopur, there is definitely room to increase your dose, which could make a difference.

What about a poor responder with normal FSH levels and antral follicle counts? Our pre cycle predictions don’t always match what we get during the cycle. Estrogen prime is probably as good as day 2 start. But if you have tried one, it makes sense to try the other next time.

What if you spot for 51 days straight? You need a pregnancy test and an ultrasound. Things may be just fine but there could be problems with ovulation (or non-ovulation) or uterine issues.


Are frozen embryos any worse because of ICSI? If they were frozen on day 3, is it ok to they and transfer day 5? Yes it is. ICSI will not negatively affect the embryo’s ability to grow from day 3 to day 5 after the thaw, depending on the labs experience with day 5 culture.

If you have regular cycles can you have mild PCO? No, because by definition, PCO women have irregular or lengthy cycles. Now this does not mean you can’t have ovaries that have a high number of eggs and follicles. So your ovaries can look like they are pco, but you don’t have a disease or syndrome. It also means that clomid could still be indicated, even if you do not have PCO.

Someone actually had a conversation with her doctor and he paid attention, and now she is pregnant. One of the most important things I learned in medical school was, “If all else fails, listen to the patient”. “When all else fails examine the patient” is another good one.

Should you have the laparoscopy or do the IVF? It would be easy to answer of either could get you pregnant right away. With a family history of endometriosis and severe cramps, and infertility, a laparoscopy is very reasonable. On the other hand, if you are a good candidate for IVF, the pregnancy will do a good job in suppressing your endometriosis, and some women have a permanent reduction in endometriosis pain after a pregnancy. If your tubes are open on HSG, and there are no endometromas of your ovary (ultrasound visible cysts of endometriosis), the odds of meaningful endometriosis (endometriosis severe enough to be preventing pregnancy) are low.

What about the third biochemical pregnancy in a row? The testing is normal so far. Here are just a couple of suggestions. If you and your husband did not have the blood karyotype test, that should be done. Even though you had a laparoscopy, consider a hysterogram.

After testicular surgery, will a sperm count of 18 million and 20% motility improve with time? It could go either way. At 31 you have few more months to see. Getting pregnant on your own with these numbers is not unheard of, but it may take longer.

I think I should have more frozen embryos. It is very disappointing to have 17 eggs, 12 embryos , 2 for transfer and none to freeze. There could be a few reasons related to the lab for this. If they transfer on day 3 and wait till day 5 or 6 to freeze, they may not have enough experience going to day 5, if they did they would do more fresh transfers on day 5. It’s also possible that the embryos look fair on day 5 and they just do not want to freeze them. There are 2 elements to this. One is a cycle using frozen embryos has a lower pregnancy rate than a cycle using fresh embryos, and that’s when using embryos that look very nice when they are frozen. So if you freeze embryos that are marginal looking, the pregnancy rates will be even lower, and many times not worth the freeze. The other element is that some programs are too restrictive on the quality of the embryos they freeze. I other words, they want their frozen rates to be high. One easy way to do this is to just freeze the really nice embryos and not the ones that look ok or worse. Lastly, it is possible you have some average or good embryos to transfer and all of the others are not really that nice. It may have nothing to do with the lab. Modifying your protocol may possible improve the quality of the lot.

We do not recommend amnio based on just ICSI. However, every case is different. For some, amnio may be indicated.

We have never dealt with a day 7 embryo.

Progesterone orally or vaginally? For IVF we use IM because we had some bad experiences with vaginal. However that was years ago, and maybe the preparations are better now (that’s what’s claimed). The oral is too unreliable to be used alone. If we use oral, it’s in combination with vaginal. Oral progesterone may make you very tired or dizzy.

What if you ovulate every month and on clomid, nothing, no ovulation? Yes indeed, this can happen. Why, we do not know, but it is pretty rare. If you are taking estrogen with the clomid, the estrogen may stop your cycle (like the birth control pill ) . But otherwise, we really don’t know why. If you take clomid another month, odds are you will ovulate. These types of problems usually do not recur.


Is it bad to switch doctors because the first doctor has your history? No not at all. We can all tell exactly what’s going on with you by listening to you in person and studying the paper work. IVF is about the stimulation and embryos, both of which should be clear in the documents.

It seems that there are doctors who tell patients that IVF is the way to go because in their case FSH iui is too risky. It is a little risky but it can be handled correctly. Start on a low dose, get monitored and stop the cycle you are on track to make too many eggs. If a low dose causes a big response, use even less drug next time. Yes, it’s easier to do IVF but if you chose to do FSH iui, talk to your doctor about trying.

If you hyperstimulated during an IVF cycle, and have frozens, generally it does not make sense to do another fresh. The point about saving young embryos for later is valid, although I do not push for that much. Saying you can get kids from a frozen cycle is not appropriate. You really don’t know if you will get pregnant from any embryos, fresh or frozen. If your plan is to have 3-4 kids, doing another fresh and saving the frozen is reasonable. Clearly you need a much lower dose of drug for the next fresh cycle.

OK that’s it for now, more to come.
Thanks and see disclaimer 5/17/06.
Dr. Licciardi

Dr. Licciardi on TV

I was invited to the MSNBC show "Dr. Nancy". Here's what I had to say.

http://www.msnbc.msn.com/id/31388323/#33006217

When is the Right Time for hCG?

The time between the hCG and retrieval
For an FSH injection cycle leading to insemination, it’s ok if the ovulation naturally occurs a little early (via a premature LH surge) because we can just do the insemination early. Rarely it’s too early, before the follicle is big enough, and we cancel the cycle. However, for an IVF cycle we have to cancel the cycle if there is an early natural LH surge, even if it’s only a little early, because the timing of the retrieval is very dependent on when the surge starts. The retrieval needs to be about 34-36 hours past the start of the surge (which would also be the time if the hCG shot).

Because we are not taking blood every hour, if the blood test shows a rise in the LH level, we don’t really know when the rise started so we don’t know the right time for retrieval. Lupron, Antagon and Cetrotide prevent the natural rise of the LH, so the premature surge usually cannot occur. However, these drugs do not interfere with the effects of an hCG injection. So there is no natural surge, but there is an artificial surge which starts the moment the hCG goes in.

Final Maturation
There is a second very important job of the LH Surge/hCG injection:
it causes the egg to mature. As the days of stimulation progress the eggs are slowly maturing, but more is needed for the final maturation. Necessary last minute changes occur inside the egg from the LH/ hCG.

Why is this important? An immature egg will not fertilize. If the retrieval is before about 33 hours after the hCG, the result will be immature eggs. Sometimes they are all immature, or just some.

If the retrieval is 38-39 hours after the hCG, the eggs will be mature but they will already have ovulated. We would retrieve none; they would be floating in the pelvis around the ovaries waiting to get picked up by the tubes. So we need to grab the eggs just after they mature but just before they ovulate, which is at about 34-37 hours after the hCG injection.

What day should you get your hCG?
hCG can only mature eggs that have been growing for enough time for the follicle to become large. The sizes of all of the follicles need to be taken into consideration before giving hCG in IVF cycle.

Not all of the follicles grow at the same rate. For example, if there are 10 follicles, and the biggest is 18mm, they will not all be 18 mm. Some will be mid-sized and some will be much smaller. Each follicle does not need to be 18 mm to produce an egg that is mature. As long as the biggest (the lead follicle) is 17-18mm, the mid-sized (13-16) should also have mature eggs. The small follicles (10-12) may or not be mature. But if the lead follicle is 14 mm, none of the eggs have yet reached maturity. Giving hCG would not be enough to achieve maturity.

How Important are Estrogen Levels?
Not very. When you are monitored for your IVF cycle, the follicle size is much more important that the estrogen (estradiol) levels. We need the estrogen to rise, but if midway through your cycle we see 10 follicles, with the biggest being 13 mm, we don’t really care if the estrogen level is 500 or 900. Estrogen is more important when we are monitoring someone who may be on track for hyperstimulation.

Therefore, we use mostly the size of the follicles, with not much emphasis on the estradiol levels, to determine when to give the hCG. At NYU we feel the best time to get the hCG is when the lead follicle reaches 18 mm. Now because there are many variations from cycle to cycle and from patient to patient, it’s not easy to say that 18 mm is the rule.

For example, let’s say there is one follicle 18 mm, three that are 15 mm and others that are smaller. Here we may worry that some of the small ones may be too immature, so we may wait another day before giving the hCG. Let’s say there are 20 follicles, with the biggest 17mm and an estrogen level of 2900. Here we are aware that the smaller follicles may be immature, but we also are concerned about the estradiol getting much higher because the woman would be increasing her risk of hyperstimulation. So we give the hCG at 17 mm, which may yield some immature eggs, but should give us enough mature eggs to work with.

And there are many more variations. Some women have gotten their hCG a little on the early side and have all mature eggs. Some women in their first cycle get the hCG at 18 mm with lots of good size follicles, and have ½ their eggs be immature. So next cycle we wait till the follicles are 20-22 mm before giving hCG. This sometimes gets more mature eggs but sometimes no matter what we do, that woman’s ovaries make more immature eggs than expected.

So why not wait and give hCG later? Because eggs can get over-mature. This over-maturity can lead to lower embryo quality and lower pregnancy rates.

When we see the records of women who have failed IVF elsewhere, many times we see that he hCG was given with large sized follicles. The first and easiest “fix” we can do is to give the hCG earlier in her next cycle, more inline with our standard procedures.

Why do some doctors wait longer to give the hCG?
Some may feel that the higher the estradiol level the better, so by waiting estrogen levels will go up. This is probably not important. Others may feel that it is necessary to wait so there will be no immature eggs. Well this sounds good, but it may not be worth sacrificing the quality of the eggs form larger follicles, which are probably the best eggs anyway.

And back to the original question.
What if instead of the average 11-12 days it takes to grow the follicles, they are of the right size after only 6 days or 8 days?
If the size is good, but it seems early, we usually go at least one more day that we normally would, maybe 2. If it’s day 9 and the follicles are 19-20 mm, it really sounds ok to give hCG. If it’s day 7 (so 5-6 days of FSH injections), and the follicles are 17-18 mm, more time would probably be a good idea.

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

Dr. Licciardi

The Natural LH Surge vs. the HCG Injection

We are still working towards the timing of the hCG shot, but we first need a little more background. We need to go over difference between the natural LH surge and the hCG injection.

After LH leaves the pituitary during the surge, it causes the ovulation by landing on specialized spots on the ovarian cells, the LH receptors. All hormones act by landing on (binding to) their specific receptor, and usually one hormone does nothing if it lands on the receptor of a different hormone. There has to be a match.

This is usually dictated by shape. It’s like a lock that recognizes the shape of the key. FSH and LH are similar hormones, but their shapes are a little different. So if LH comes across a FSH receptor, it would not bind.

There is a notable exception. Because hCG and LH are chemically very similar, with very similar shapes, hCG can bind to the LH receptor, and can do it well. Since hCG can land on the LH receptor, hCG can do the same job as LH.

This is actually very important to pregnancy. Pregnancy needs progesterone, which comes from ovarian cells with LH receptors. So LH causes the ovary to make progesterone after ovulation. Good: the progesterone allows the embryo to implant. Then the embryo makes hCG. Better: this causes the ovary to make even more and more progesterone which keeps the implantation going strong. Both occur via the LH receptor.

That hCG can behave like LH is good for treating fertility patients because we can cause ovulation with an injection of hCG instead of an injection of LH. This is good because hCG is easier to get than LH.

So why not just give LH? Up until very recently, LH was not available. Years ago the only way to get FSH for our fertility drugs was to extract it from the urine of menopausal women.

(This is a whole story by itself. Initially, starting in the 1970’s, the urine was obtained from menopausal Italian nuns who would leave jugs of pee for the drug company Serono to pick up in the mornings. Menopausal women have really high amounts of FSH in their blood, and most of it comes out in the urine. The pee would be taken to a factory with a swimming pool-sized pee vat, and they would somehow get the FSH from the pee. Serono went on to be the most profitable company in the world. The Catholic Church was rewarded for its cooperation. Even today, pee swimming pools exist for companies who make fertility drugs from urine.)


Because FSH and LH are similar molecules, the methods used to pull out the FSH grabbed LH too. Once we got the FSH/LH mix, we didn’t have the science to separate the two. So we could not get enough pure LH to cause ovulation. Today we can get pure LH made in a lab, but still in small amounts, not enough to get a good ovulation going.

How do we get the hCG? That is piece of cake, we get it from placentas. There are tons hCG in placentas and it’s easy to extract. Today hCG is also made in a lab, that’s the Ovidrel. It’s pure stuff, and that’s why it can be given in the skin. The placental hCG is given IM because it’s contaminated. hCG is also a protein, and the system for extracting the hCG protein from placentas is pretty crude, so tons of other placental proteins get caught in the net too. These extra proteins can cause a local allergic reaction when given in the skin, but not when given in the muscle.

When we used to get fertility drugs from urine, same thing, they had protein contaminants and needed to be given into the muscle. Recent exceptions are Menopur and Bravelle. These are from urine but using new systems that are better at cleaning out most of the unwanted contaminating proteins. Gonal-F and Follistim are both made in the lab and do not have the contaminants. They are given into the skin.

Today there are 2 products, placental hCG given in the muscle, and the lab-made hCG given in the skin. The placental is still cheaper and words great.

In a cycle stimulated with injected FSH (for IUI or IVF), most of the time the natural LH surge does not occur at all, so we need to give the hCG. In some cases the LH surge does occur, but it happens too soon, before the eggs are mature. This is probably due to the fact that estrogen levels are higher earlier in a medicated cycle, so the LH rises earlier. We don’t know why a premature LH surge only happens in about 20% of cases.

The bottom line is that we cannot count on the natural surge to occur at all, or at the right time, when we are using FSH injections. We need to use the hCG injection for proper timing of ovulation and proper timing of the egg retrieval.

That’s it for now. Next time we finish up by talking about the right time to give the hCG shot.

Thanks for reading,

Dr. Licciardi

A Little More About Normal Ovulation

Here is a question someone asked about the timing of hCG. It’s a good starting point for this blog.

“I am 40 and just had a failed first IVF cycle that resulted in all immature eggs (7 retrieved) after only 5 days of stims (follistim/menopur + ganirelix days 4 & 5) before the hCG shot.
The doctors were very surprised that by day 5 I had 7 follies 12 - 19 (more <10) and they said I had to trigger, my final E2 was only around 700. I had a good hCG level after the trigger.

I have never heard of anyone only stimming for 5 days. I am curious what your experience has been with people who are fast responders and what you recommend in terms of changing protocols? Do you believe that follicle size alone determines egg maturity or can a short follicular phase be a problem even with larger follicles?”

Figuring out the right time is not that difficult, but there are a few important factors that must be taken into consideration. We need to first start with a brief review of what happens in the natural menstrual cycle, then it will be easier to understand how the IVF cycle works. There are 3 important elements: the growing follicle’s schedule, estrogen levels, and the size of the follicle at ovulation.

Just a reminder: the follicle is the fluid-filled cyst that houses the egg. Each follicle has one egg. We can't see the egg on ultrasound because it's microscopic. But we can see the follicle.

The Growing Follicle’s Schedule: By the 2-3rd day of bleeding, the previous month’s follicle has disappeared and the new one, which has already been chosen, has not started to grow much. On ultrasound you may see it, but you may also see other small ones that look the same. It’s the FSH coming from the pituitary gland (the pituitary will be a blog to come) which causes the little follicle to start and continue to grow.

As the next week goes by, the chosen (or dominant) follicle gets bigger and bigger, until it ovulates somewhere usually between days 11 and 20, most often close to day 14. It’s pretty rare to ovulate before day 11, but not so rare to ovulate later. The day of ovulation is related when the follicle starts to grow, and the cycle length gives us a hint as to when this was. It takes about 2 weeks for the follicle to grow from tiny to big. That means for a 28 day cycle, the follicle grows till ovulation, usually day 14.

What if the cycles are, say, 35 days? Well it still takes the 2 weeks to grow, it just starts later. So for a 35 day cycle the early follicle sleeps for about a week, then wakes up and starts growing day 7 and ovulates day 21. We don’t know what causes these differences.

What if the cycle is 24 days? In this case the follicle probably takes less than 2 weeks to grow, so 2 weeks is not mandatory. Again, the reason for these differences are unknown.


Estrogen Levels: As the follicle grows, it makes more and more estrogen, so the blood levels of estrogen rise each day. The estrogen is not coming from the egg, it comes from the tons of little ovarian cells (the granulosa cells) that surround the egg. The estrogen is probably not important for the egg, but one of estrogen’s very important jobs is to thicken up the lining of the uterus.

Estrogen’s second job is to cause the ovulation. The pituitary gland is constantly monitoring the estrogen levels, and when they get high enough, the pituitary dumps out LH (this is what your home ovulation kit reads) and this is what causes the egg to pop out.

There is not an exact estrogen level that causes the ovulation. Most of the time it’s anywhere from 150 to 350. Why there is a difference we do not know, it may be that there are other unknown hormones that work with the estrogen to get the job done.

Follicle Size: The size of the follicle is important too. Most ovulations occur with a follicle that is 20-25 mm(about one inch), but 16 mm is close to the bare minimum and 30 mm is close to the top size.

Next time we will talk about the timing of ovulation in an IVF cycle.

Thanks for reading,

Dr. Licciardi

This Time Even I Got a Little Mad

It wasn’t supposed to end this way. We all knew going in that nothing was guarantied, but we felt good and optimistic about starting. Together, we believed that if we just obeyed the rules and had faith, that good things can happen to good people. We anticipated sacrificing time, emotion and money, for a process that was logically the most reliable way to go. We figured it was the best option, and we were “all in” to work towards success.

Shari was 41 when we first met and she was already at it for more than a year. She was very smart and informed. Shari understood the small details of each treatment, but didn’t dwell on the negativity. She was super practical. The plan, which she started at 39, was to start with iui, and move to IVF if nothing happened. She eagerly and compliantly stuck to the plan, and had 2 IVFs under her belt by the time she first saw me.

At our consultation I definitely saw hopeful signs from her previous cycles. She made 15 eggs the second time. Plus her embryo quality was very nice. I explained that 3 things really help when you are trying to get pregnant with IVF at 41; a high egg number, good looking embryos and chromosomally normal embryos. We knew off the bat that she at least had 2/3. More eggs means more selection. We all know that a large percentage of embryos have bad chromosomes, so if you have more embryos, you are increasing your odds of at least one of them being normal. And if they look nice, all the better.

Wow, she called to tell me she got pregnant on her own. Sweet. But there was no heartbeat at 7 weeks, and she needed a D and C. This caused her to pause, and logically concluded that maybe FSH iui could work. So she tried to no avail.

Doing more IVF cycles was not an easy decision. She had some infertility insurance coverage, but that was all gone, so she had to pay for anything else, including the medications. But she weighed the options and decided to proceed with more IVF based on her good response, recent pregnancy and advancing age.

So off she went into her 3rd and 4th IVF cycle with me. Each time producing eggs and very good embryos. We changed the protocol a bit, but in the end she had cycles that most other women could not achieve.

Except for the two negative pregnancy tests.

And that’s the end of the story.

When we last spoke she was again very practical. She just didn’t see the value in going into a 5th IVF cycle. She could not afford donor egg. She was very kind, expressing her gratitude for the treatment she received. But this was it; she was done. She had ended her quest for a baby. Stated differently, she was probably not going to have a baby.

So why am I bringing this story to you, as this is not the first tale of woe in the infertility world.

I think this one was tough for me because she had to stop, but I still had some hope in the chest. For many, stopping becomes the best option because multiple attempts have given me information saying that it really may not be worth continuing. Few eggs, very poor embryo quality, advanced age etc. When younger women have to throw it in, I can at least feel that with time their situation will change, and although it looks like the end now, they may get another shot later on. It’s also easier when the best option is donor egg, and donor egg is agreeable and affordable to the patient.

Now every doctor does get very disappointed every time a patient has a negative pregnancy test. But the story about Shari just left me hanging a little more than usual. Many eggs, nice embryos, and my sense that if she could just do more cycles her time would come. Maybe. The thing was, I couldn’t tell her it would happen, and that always makes it tough. And I couldn’t lay on the optimism thing, even though had some. After 4 cycles, the energy and drive to continue has to come from the patient.

But I will continue to have hope for her. Maybe she will fall into an insurance program that will get her at least one more cycle. She doesn’t have much time for that. May be her financial situation will change and she will get to donor egg. This she has a little time for. And maybe, she will get pregnant on her own, which is not out of the realm of possibilities.

Thanks for reading, and Shari is a substitute name.

Dr. Licciardi

More Answers to Great Infertility Questions

Here’s a little vignette first.

I have a patient who was told after a hysterogram (HSG) and laparoscopy that her tubes were blocked. So she did an IVF cycle, didn’t get pregnant and came to me.
She was not told what type of blockage. I asked for her op notes and saw that her problem was that her tubes looked normal, but were blocked near the uterus (proximal tubal occlusion).
I told her that there is a way, using another hysterogram, that the tubes could be potentially opened using a wire. She went for the test and one tube did not require fixing, it was open, and the other needed the wire and was successfully opened. So her first HSG was wrong, both tubes were not blocked, and her laparoscopy, the so called gold standard, was wrong. See blog from 10/05/06, Blocked Tubes: 2 Cases of Proximal Tubal Occlusion.
None of this is uncommon. When I have a patient with proximal occlusion I send them for the recanulization hsg (the wire), and in many cases the original blocked tubes were nothing more than spasm, and the next hsg is perfectly normal. Laparoscopy isn’t always good for showing if the tubes are open. Sometimes it’s just hard to get the dye to go out the tubes at laparoscopy. If I am convinced that there is blockage at laparoscopy, I can pass the wire at that time. If this woman had her tube properly opened at laparoscopy, she maybe could have avoided IVF and seeing me.

Are low grade, slow blastocysts chromosomally abnormal? There may be a slight difference; better looking blasts may have better chromosomes than a blast that does not look as good. If there is a difference, it’s too small to make a decision related to transfer. In other words, if you best embryo is a slow blast, you should not be afraid to take it. Odds are if it sticks, it will be normal.

I made 7 eggs, why did the clinic immediately exclude me from a day 5 blastocyst transfer? Every clinic has its own criteria. Yours sounds a little strict, but check their SART stats. If their rates are good take their advice and follow their plan.

What about getting your period early in an IVF cycle? Probably if you were pregnant your period would have not come, even though you got it early. If you are taking suppositories, I would ask your doctor about taking progesterone injections for the next cycle. Sometimes I add estrogen. In general estrogen is not necessary after transfer, but in cases of early bleeding it may help.

What if there is no ovulation with clomid? If you don’t respond to clomid, you can’t keep trying forever. The injections sound intimidating, but most people get it done. If you do injections, it is very important that your doctor start you on a low dose and monitor you carefully.

What if you were planning to go to IVF if this IUI didn't work, but you got pregnant and miscarried? Logic would say it makes sense to do 1 to 3 more IUIs, after all you proved the tubes work, fertilization can take place and implantation can happen. However, most people, but not all, stick to the original plan and go to IVF out of frustration. Plus, usually a miscarriage results in extra lost time, and this gets people to want to get to IVF.

If you are older (I’m 49, so most of you are young to me), do your eggs need ICSI? Is the shell of the egg harder and less penetrable? This is my ARGHHHHH of the day. Simply, the answer is no.

At a young age, can anorexia or exercise induced amenorrhea mess up your eggs later in life? It actually is a very interesting question; however I have not seen any studies supporting this. There is probably no effect.

Could a woman with unexplained infertility donate her eggs? This is a tough one but probably not. Only because the recipients are taking a big financial and emotional gamble on the quality of your eggs. If you have unexplained infertility then have a successful IVF and wanted to donate later, that would be great for a recipient.

What if you are young and all the tests are normal. Your day 3 FSH is normal but you estradiol on day 3 is 20. Low is usually ok. Repeat it if you want piece of mind.

Donor egg or donor sperm? If you are young and the sperm counts are very low, and the embryos don’t look good, of course it could be the eggs or sperm. It really could go either way. Which brings us to a common dilemma. Getting inseminated with donor sperm is quicker, easier and tremendously less expensive that donor egg. So for that reason, if it’s not perfectly clear where the problem lies, and you have accepted the idea of donor egg, it is reasonable to consider a few courses of donor sperm insemination. Couples do seem more reluctant to do the donor sperm than they are for donor egg.

Major League questions about blastocyst. Are cryo’d blasts as sturdy as day 3 embryos? The answer is yes. A day 5 3BB is better than a day 6 4AA, unless the day 64AA was a day 5 3BB or better. It the trick with frozens in the freeze or thaw? Most of the skill is in the freeze, not the thaw.

Sorry, I do not now how to get pregnancy rates from Canada.

Update on 0ne-embryo transfer? Yes, in the past 1-2 years, every clinic has performed more and more one embryo transfers. So ask about their latest stats. I strongly suspect that the pregnancy rates for one embryo are lower in a frozen cycle. One way to up your odds in a frozen cycle would be to thaw a few (if you have them) and transfer the best one.

What if the sperm count is 145 million, with 40% motility and 2% normal morphology? Most REs would tell you that’s normal, but you need to ask yours.

If money is not an issue and you are faced with the choice between iui and IVF, and you want to do IVF, IVF is your best option. The success rate with FSH iui when all the testing is normal depends on your age. At age 37 it’s about 15%. Could be as high as 20%. IVF will be about twice that.

Should you go to surrogate if you are 43, have failed 6 fresh and 2 frozens, your lining is 5-6 mm and have 4 frozen embryos remaining. It’s a lot to consider, but surrogacy is an option. I am sorry but I can’t make more of a recommendation without seeing everything.

Can Lupron’s effects linger after your stop taking it? Anything is possible. However I have not had a patient with that problem.

With fairly good sperm should you spend the money on 2 iui’s or save for IVF? IVF is more cost effective than FSH iui. FSH iui is cheaper but much less effective. IVF is usually 2-3 times more effective than iui. There was a recent study showing going to IVF gets a baby with less time and money compared to FSH iui and IVF later if necessary.

Post coital test? Very few RE’s do this test anymore. It is just not accurate. Even if the test is abnormal, iui bypasses the cervix so antibodies in the cervical mucus (if such a thing matters) do not come into play.

Is IVF the answer if there have been 3 miscarriages and sperm with DNA fragmentation? I can’t be too negative about DNA fragmentation because it’s a little early to really know. However there is no good evidence yet to show those test are predictive of infertility or miscarriage. If your doctor feels differently, ask him or her to show you the studies.

Can very poor sperm lead to biochemical pregnancies and miscarriage? Yes but it’s not common. We all know that ICSI is used for very low sperm counts, and leads to good embryos and excellent pregnancy rates. However occasionally we see very low sperm counts and very poor embryo quality. In these cases, some women want to repeat IVF and expose a few of their eggs to donor sperm to see if there will be an improvement in the embryo quality. In some cases the difference is dramatic, and some couples will change over to donor sperm. If you are getting pregnant on your own without IVF and are having biochemical pregnancies, I’m not so sure it’s the DNA fragmentation.

Is IVF a treatment for 3 miscarriages? There are studies showing IVF without PGD is not very helpful for the treatment of miscarriages. There are some limited studies showing PGD may reduce the odds of miscarriage, but the data is not overwhelming.


What if you have had 3 biochemical pregnancies in a row? It’s hard to put much faith in the platelets, antibody, and autoimmune issues. Early on there is no placenta to speak of. There are no significant blood vessels to clot off. I must be sensitive to those of you who have had early losses and biochemicals, and then normal pregnancies after treatment for autoimmune/clotting factors. Maybe these things helped, but it can be possible that after a number of early losses, it was time for normal pregnancy.

What if you are 36 with all tests normal and 4 months of trying with good timing? Your odds of getting pregnant on your own in the next 4 months are still very good. Clomid or FSH iui are options, but giving it at least a total of 6 months on your own is a good idea.

How’s it going with the Priming protocol? If seems to work as well as other protocols in producing eggs. However the pregnancy rates are a little lower, so far. This is explained by the fact that we save the priming protocol for the worst responders, many of who have been cancelled using other protocols. So even if it’s a good protocol, we may not be seeing it because we are giving it to the patients who have low rates to begin with. So my bottom line is it’s worth trying as alternative, but it’s not a magic potion.

I am sorry I am not aware of co-culture with green monkey cells. Such a process would not be allowed in the US.

Thanks for reading and don't forget to see the disclaimer 5/17/06

Dr. Licciardi

Dr. Licciardi’s “Infertility Blog” named as one of the top 50 Pregnancy Blogs

The list can be found at http://onlineultrasoundschool.com/2009/top-50-pregnancy-blogs-required-reading/.

Back to Frequently Asked Questions

Before getting to FAQ’s here is a little vignette.

Last week I saw a woman who has been trying for 3 years. 3 years ago she told her doctor she had an extremely heavy period, and during her other periods she was losing more blood than she did in the past. No ultrasound was performed. Well 3 years later another doctor got a scan right away and she was found to have a huge fibroid in the middle of the uterine cavity. There is no way she could have become pregnant in the past few years with this fibroid in place. She lost 3 years. Take home message: abnormal uterine bleeding requires an ultrasound. In fact all infertility patients need an ultrasound right off the bat.


Can you travel by plane after IUI and IVF? There is no evidence that plane travel hurts anything. However, you need to have a very flexible schedule. There are a few things that could force you to stay home after a cycle. One is hyperstimulation. The other is an abnormal pregnancy. If you’re pregnant, the worse time to plan travel is about 2 weeks after your transfer. This is a bad time because often enough we don’t the location of the pregnancy. So if the day 35 blood test does not show a doubling every other day, your doctor may order you to stay put. No one wants you to rupture a tubal pregnancy, especially on a plane. The condition and location of the pregnany will mostly be determined as the next 1-2 weeks progress, so after that travel becomes more of a possibility.


Prolactin: Will get its own blog

MTHFR: Methlyenetetrahydrofolate reductase (yes, I had to cut and paste): This is an enzyme (a protein that is involved in a chemical reaction in the body) that is involved with the metabolism of folic acid. Folic acid can’t be properly utilized if there are problems with this enzyme. We have 2 copies of the DNA for this enzyme. It’s more common to have on abnormal copy, but 2 abnormal copies are more rare. If there are one or 2 bad copies, the next step is to measure the homocystine level. If the homocystine is normal, this indicates that even of the copies are abnormal; folic acid is still doing its job. If the homocystine is high, there is an interference of folic acid’s function. In this case, treatment may be necessary, with folic acid and other vitamins. Some doctors will recommend Lovenox (a heparin blood thinner). Some doctors recommend these therapies when the homcystine level is normal, but this is very controversial.

Late Onset Congenital Hyperplasia(CAH). Testing is via hormone levels, however there is a DNA test. If you have CAH, you shuold have the DNA test and your partner needs to be tested too. Just like above, you have one copy. He may have one copy too. The bigger problem is that your offspring may inherit one from you and one from him, and have 2, which is a much more serious disease. As far as treatment and pregnancy attempts, if you have a mild form of CAH, DEX may be overkill. Ask your doctor about other options such as just going to clomid.

Is IVF the only option for 1% sperm morphology? No, you also have the option trying on your own or iui.

What if you did 3 FSH iui cycles and can’t afford IVF? Practicality will dictate your path. You can get pregnant with FSH iui in the 4th 5th or 6th try. The odds become lower in the later cycles, but it’s still better than on your own or with clomid.

A 29 year old who made 10 eggs and had 2 average quality embryos is being told she needs donor egg. ARRGHHHHHHHH!!!. Give me a break. Can I guarantee you will get pregnant with your own eggs? No. Keep at it. Keep tweaking it, and get to the best program you can.

One tube and Clomid. If you have one tube clomid can work, but it does help to have the follicle on the same side as the tube. You may not need IVF right away. Usually with FSH iui you can make eggs on both sides at the same time giving you a better chance each month.

What IVF protocol is best? No one knows. I prefer the day 2 start with pure FSH. Why? Because no one has ever shown that one protocol is better than another. This is especially true when comparing pure FSH with FSH combined with LH. So if they are the same, why not make it simple. With the day 2 start there are no pre-cycle medications, and with FSH only there is just one drug to worry about. If that does not work, I can use all of the other protocols out there. I do feel that day 21 lupron is not the best for women we expect to be low responders.

How long after having a baby should you try before seeing your RE? It depends on your fertility problem. Obviously there is no waiting for severe tubal or sperm issues. If ovulation was the problem, you can wait a little to see if your cycles straighten out, but if even early on you see that things are as they were, get back to the RE.

What about a short luteal phase when taking clomid or FSH? Studies have shown that the luteal phase in a clomid or FSH cycle is better than a luteal phase from a natural cycle, probably because the progesterone levels are higher. I routinely do not prescribe progesterone for clomid or FSH. However, occasionally a patient will let me know that the luteal phase after a drug cycle was unusually short, maybe 8-11 days. I don’t know why it happened but I agree it sounds too short. Now maybe it’s ok, and if there were a conception, early bleeding would not have happened, but here I make sure we give progesterone in any subsequent cycles.

What should my progesterone level be? It needs to be over 8. No one has shown that 11 is worse than 40. When using clomid we sometimes get levels to be sure ovulation took place, but I don’t worry about the level.

Female anti-sperm antibodies. I would definitely believe in them if there were quality papers showing they play a role in infertility.

What if you have a short cycle but home ovulation testing shows a color change late? Well either the kit is off or there is a short luteal phase. In this case, office monitoring is the way to go. There are a few people who do well growing the follicle, but it just sits there a few days before deciding to ovulate.

Should you take progesterone with normal levels and a normal luteal phase? Data does not support its use.

Is DE the only option if the FSH level is 16. You have to ask your doctor what the odds of having a baby are using your eggs with an FSH of 16. I am sure the odds are very very low. So you have to decide if the numbers make it worth it to you.

Should husbands with male factor get genetic testing? It depends on the counts. The lower the counts, the greater the chances of a genetic abnormality, although even in cases where the sperm counts are less than 2 million, the genetic testing usually comes back normal. So I suppose it’s up to you and the urologist. There’s always a small chance that the genetics will be abnormal.

What about clomid in the case of severe endmetriosis and and at least one blocked tube. You can try clomid, but with the enod and only 1 tube, your odds with clomid are low. Remember, for women with normal tubes and sperm and FSH levels, the odds with clomid are only 8%. So with a problem pelvis, the odds will only be lower.

What if you became pregnant naturally with a sperm count of 3.8 million, and you want to now try again? Yes miracles do happen, but not often enough. Start with repeating the semen analysis. Maybe the counts are higher now. It’s also possible that they are lower, so you should check. If they are still 3.8, you can try for a little while, but I would get help if you are not pregnant quickly.

This is for relatively young women who don’t make many eggs. Get off the lupron. Many times, but not every time, more eggs are produced without lupron. If the egg number remains the same, then you are stuck and you will have do decide if its worth going through with the retrieval.

How often do you need to monitor progesterone levels after IVF? Usually progesterone levels are very high the first week after retrieval, but after the ovaries decrease their progesterone production in the second week. If the levels are high enough 1 week after, they will probably be fine as the second week progresses. The hcg produced by the early pregnancy will increase the ovaries output of progesterone. The point is is that if the progesterone levels are low on the day of the pregnancy test, it’s probably because there is no pregnancy, not because there is not enough progesterone being given to the woman. If a person is getting more than the usual amount of progesterone(IM plus vaginal and or oral), measuring levels will be less helpful.

If you have a family history of miscarriage, genetic counseling is indicated.

That's it for now, thanks again. Please see disclaimer 5/17/06.

Dr. Licciardi

Spotting and other Variations in Bleeding

Spotting.

Really frustrating. Where does it come from? We first look for an anatomical reason (a problem due to some sort of growth that we can see usually with the ultrasound). The most common reason is that there is a polyp inside the uterus. A polyp is a benign growth inside the uterus, kind of like a skin tag on the inside. They are easily removed via hysteroscopy. If you have had polyps removed and still have spotting, you need to have a sono hysterogram to be sure that the polyps were completely removed. Or maybe they grew back. If the lining is pristine, you we have to look for other causes. Adenomyosis is another reason for spotting. Usually there is evidence of adenomyosis on ultrasound. If not, an MRI will make the diagnosis.

Women with endometriosis are more likely to have spotting, and this may be may be due to a few causes. With endometriosis, the glands of the uterus grow in areas they shouldn’t. The most common abnormal areas are around the ovary and tubes, but there can also be spots of endometriosis on the surface of the cervix. Because the glands don’t always behave as the normal endometrium, they can bleed anytime, causing spotting.

Another source of spotting in women with endometriosis is a hydrosalpinx. A hydroslapinx is a big scarred fallopian tube that is blocked on the part away from the uterus, near the ovary. If the hydro is caused by the chronic inflammation of endometriosis, blood can slowly built up inside the tube. This blood can sometimes back up from the tube into the uterus and then out the cervix, causing spotting. It’s usually not red, but more of a chocolate brown.

Occasionally no reason for the spotting is discovered. So we blame in on being “hormonal”, but we really don’t know what the specific hormonal abnormality is. Could spotting a few days before the period be due to a luteal phase defect and low progesterone levels? There may be one rare woman who has this issue, but for most women with pre-period spotting, their hormones are just fine. I have found that persistent spotting stops when moving to injectables, which do increase both of those hormones.

Post ovulation spotting can in many cases be controlled with progesterone and estradiol in the luteal phase. I remember one patient from years past who had the spotting mid cycle, had a negative hysteroscopy, and got pregnant on her own a few months later. So even though she had monthly spotting it had little effect on her ability to conceive. Maybe the spotting was normal for her and it stopped once she became pregnant.

If you are anovulatory due to PCO and you have frequent spotting, you may need to have a biopsy of the endometrium. PCO women who rarely get a period are at higher risk for endometrial hyperplasia or even cancer. This usually causes heavy irregular periods, but sometimes it’s just spotting. An office biopsy can usually make that diagnosis.

Other Variations in Bleeding

“I don’t bleed for a long as I used to”. I hear this a lot. Typically someone will say they used to bleed for 4-5 days and now they are finished after 3. There is no evidence that this means anything bad. Certainly after a delivery such changes are more common. But even without pregnancy, some women have changes that are hard to explain. I don’t think this means there is a change in fertility.

Heavier bleeding is more of a problem because it is more likely to signify a change that may be important. Remember that fibroid the doctor told you you had, but said it’s not a problem because it’s small? Unfortunately they can grow and become a problem with time. Increased estrogen levels associated with repeated drug cycles can accelerate their growth. Adenomyosis can also progress, leading to increased bleeding.

Consistent heavy bleeding in the setting of normal anatomy may require a consultation with a hematologist. Many of us are born with blood abnormalities that don’t’ allow for proper blood clotting. These issues are usually discovered in adolescence after the first periods are found to be abnormally heavy.

And of course, unexplained heavy bleeding may also require an office biopsy or hysteroscopy to rule out pre-cancerous or cancerous cells.

Thanks for reading and please see disclaimer 5/17/06.

Dr. Licciardi

Table of Contents

In February 2009, “The Infertility Blog” celebrated 3 years of production. I have been very pleased with the response. At least once per week someone tells me how valuable they find the information and how much they appreciate the effort.

Not only is it an effort to produce, I am finding it’s a lot of work for patients to read the 121 entries to date. Sometimes patients ask me to write on a certain topic, and I have to say, “I already did, go back and check.”

So to make it easier, here is the table of contents of Blogs so far. These are the “topic blogs”. They are not all of the blogs as there are many “Answers to Questions” sprinkled in between. Hopefully this will give you easier access to the information from earlier chapters. You can also print it to keep as a reference.

In addition, you can search the blog. In the upper left next to the orange e sign, is a box for you to type in your search words. If you type in a word such as FSH or SART, blogs containing those words will be listed.

Here you have it. Feel free to share it with others needing help.

2/05/06: A Woman Who Thought Her Hysterogram was normal. A classic story of a woman being surprised when I told her the radiologist read her hysterogram incorrectly.

2/07/06: From No Sperm, to a Few Sperm, to Twins. A classic story about a couple who was told by one doctor they had no sperm, but who saw another who said they had sperm.

2/15/06: No More Happy Birthdays. Birthdays and infertility can mix.

2/22/06: The Dreaded Biochemical Pregnancy. Explains the diagnosis and meaning of a biochemical pregnancy.

3/05/06: The First of a Few about FSH levels. Day 3 FSH levels explained.

3/09/06: FSH Levels: An Excuse to Send Patients Away. In some cases pregnancy is possible with elevated FSH levels.

3/12/06: FSH and Estradiol (Estrogen). Discusses day 2/3 estrogen levels and their relationship to FSH levels and pregnancy rates.

3/21/06: But Doc, What Went Wrong? Maybe Nothing. Your doctor can’t always explain why cycles are not successful.

3/27/06: Endometriosis: It’s Everywhere, but in Small Amounts. An introduction to endometriosis and its effect on fertility.

4/02/06: Endometriosis: What Are you Waiting For. Endometriosis is both over-diagnosed and under-diagnosed.

4/07/06: Why Do We Do IUI? Insemination can be more successful than intercourse.

4/12/06: Is There Enough Sperm for IUI? IUI can help with low, but not very low counts.

4/18/06: What are Your Odds? Don’t start treatments until you know your odds with each procedure.

4/22/06: This is Your Brain, This is Your Brain on Clomid. Clomid had some unique side effects.

4/27/06: The Clomid Death Sentence: Too many months on Clomid can kill your chances.

5/4/06: Sperm Morphology Mythology. Morphology may not be that important.

5/11/06: Abnormal Sperm Can Fertilize Eggs and Make Babies. More on morphology.

5/17/06The Disclaimer: Medical advice must come from your doctor.

5/19/06: Hysterograms: Let’s Not Forget the Uterus. Focusing on the tubes can miss important information about the uterus.

5/31/06: Who is Reading Your HSG? Reading the report without looking at the films doesn’t cut it.

6/04/06: Pregnancy Rates Matter. The pregnancy rates from each program are published by SART and the CDC. You should read the reports.

6/16/09: Your Doctor’s IVF Pregnancy Rates are Available to You. More of the same.

6/22/06: Ovarian Cysts Part One: Normal Ovulation. The term “Ovarian Cyst” can have many meanings.

7/01/06: The doctor said I can’t start because I have a cyst. What it means to have a cyst on day 2/3.

7/06/06: PCO: Pretty Cute Ovaries? What is PCO?

7/13/06: You Can't Have a Baby Unless you are Pregnant. The positive pregnancy test can be the start of a good thing.

7/20/06: How to subscribe to this blog. Get the blog sent to you.

7/21/06: Uterine Scar Tissue After a D&C. D &C, and the potential for scarring.

8/03/06: Abnormal Bleeding? Don’t have a D and C without a Hysteroscopy (and have an ultrasound first). “Blind” scraping doesn’t help much.

8/20/06: The Boxes of Pregnancy and Miscarriage. Especially when infertile, miscarriage really hits home.

8/28/06: Diagnostic Laparoscopy. Becoming a less-important infertility treatment.

9/11/06: Psychologists are Available: Consider Using Them. Why go it alone.

9/19/06: Hysteroscopy 101. An explanation of Hysteroscopy.

9/25/06: Is LH Important for IVF Success? There is little controversy; LH is not so magic.

10/05/06: Blocked Tubes: 2 Cases of Proximal Tubal Occlusion. Blocked tubes can mean different things.

10/17/06: I called and an embryo picked up the phone. Embryos do grow up.

10/27/06: What About Tubes that are Blocked at the Other End, Near the Ovary? More discussion about tubal blockage.

11/09/06: How Many Embryos are You Putting Back? Fewer is usually better.

11/20/06: How Can the Pregnancy be Bad But Still Growing? A few details about early pregnancy loss.

11/30/06 What’s a Hormone? Definition and examples of reproductive hormones.

12/09/06: What is Lupron and Why Are Only Some People Using It? Insight into different stimulation protocols.

12/12/06: More On Lupron and Why We Don’t use it as Much. More of the same.

1/08/07L Microdose or Microflare or Flare Lupron. More of the same.

1/20/07: Sperm Deficient Females Can Be Quite Fertile. Many donor sperm patients get pregnant quickly.

1/28/07: So Your Uterus is Bicornuate? Check Again, and Again. It may really be a septum, and it’s very important to know.

2/06/07: Bicornuate or Septate? What’s difference and why it matters.

2/26/07: Last One About Septums. How and why they are corrected.

3/10/07: When and How to time the IUI. Home and office monitoring.

3/16/07: A Little More about IUI. Inseminate one day or 2?

3/15/07: More on PCO. The basics workup, cysts and treatment.

4/02/07: Polycystic Ovaries and Insulin Resistance. What PCO can mean for your health.

4/04/07: Even More about Polycystic Ovaries. Is Metformin useful?

4/23/07: The Last Word on PCO, For Now. Modifying fertility the work-up for PCO patients.

5/06/07: The PGD Paradox: On paper, PGD for aneuploidy sounds great, but so far it has not lived up to expectations.

5/15/07: 3 Good Stories About 2 Opinions. Why wouldn’t you get a second opinion?

5/23/07: More About PGD. The pros and cons of PGD for aneupliody.

5/31/07: Ectopic Pregnancy. One woman’s story of a tubal pregnancy.

6/09/07: Ectopic Pregnancy FAQ’s. Some basics about ectopic pregnancies.

6/19/07: More questions About Ectopic Pregnancies. Treatment with Methotrexate.

6/29/07: Miscarriage and the Immune System (antibodies). Testing of the immune system.

7/12/07: Miscarriage, Infertility, Antibodies and the Immune System. More evidence would be helpful.

7/22/07: Meeting Your Doctor: What are You Thinking, What is the Doctor Thinking? Your doctor should make your first visit a positive experience.

7/30/07: A Bit More on Seeing Your New Doctor. Don’t let pre-conceived notions keep you from seeing a fertility doctor.

8/17/07: The Follicular Phase and the Luteal Phase. A basic understanding of the menstrual cycle.

8/25/07: Luteal Phase Defect. What are we looking for in the biopsy?

9/05/07: Luteal Phase Defect 3. More about how we make the diagnosis.

9/11/07: Four Simple Clicks Will Help You Have a Baby. You owe it to yourself to check the pregnancy rates of your clinic. It’s all at SART.org.

9/28/07: More About Pregnancy Rates: How to decipher the pregnancy statistics.

10/06/07: Why is Progesterone Used for IVF? The sources and actions of progesterone.

11/06/07: Are You Sure You Need Donor Eggs? Some women are pushed into Donor Egg.

11/19/07: What’s a Fibroid? What they are, how they start and the problems they cause.

12/01/07: Myomectomy. How it’s done.

12/06/07: Fertility and Diet. Mostly involves losing excess weight to improve ovulation.

12/17/07: Exercise. Please exercise.

1/03/08: Your Fibroid: Should it Stay or Should it Go? Which fibroids require removal.

1/12/08: More About Fibroid Surgery. Complications of the myomectomy procedure.

1/21/08: Minimal Stimulation. Less may not be more.

2/01/08: If You Live in the State of New York, the Government May Help Pay for Your IVF. It’s called the New York State Demonstration Project.

2/19/08: Fertility Questions: SCSA. Sperm DNA tests are unproven.

3/11/08: Fertility Preservation. Authoritative information about egg freezing.

4/13/08: Varicocele. A controversial operation.

6/10/08: The Endometrium. The essentials about the uterine lining.

6/22/08: The Endometrium Part II. The thin lining and scar tissue.

7/21/08: Improving Endometrial Thickness. Tricks of the trade to make the lining thicker; limited success.

8/02/08: The Endometrium Part III. Less conventional therapies.

9/01/08: Polyps. The significance of these benign growths inside the uterus.

11/26/08: Stories of Persistence. Women who succeeded by not listening to the doctor.

12/14/08: The Road to Blastocyst: Eggs and Embryos. Understanding the embryology part one.

1/12/09: More About Embryos. Developing embryos and embryo morphology.

1/27/09: Just Before Blastocyst: The Morlula. Day 4 embryos.

4/08/09: Meet the Blastocyst: Photos and descriptions of blastocysts.

4/27/09: What Can Blastocyst Do For You? A good blastocyst program can help you get pregnant with fewer embryos.

What Can Blastocyst Do For You?

The advantage of a day 5 blastocyst transfer has to do with selection. These days most reputable programs are putting 2 embryos back in youngish women (I know what you’re thinking, but we’ll skip the octo discussion). Anyway, let’s say you’re lucky and have 5 nice embryos on day 3. Even though some may look a litter nicer than others, we really may not be able to tell which embryos are the best ones. So, we can wait 2 more days. In that time, some embryos may not grow well, but probably those embryos would not have survived in the uterus anyway.

The advantage here is that the embryos that do survive are probably stronger, and these can give you a better chance of pregnancy. It’s like a stress test, those that pass are probably better. One of my partners puts it nicely: just because a horse is leading ½ way around the track doesn’t mean it’s going to win the race.

But not all programs use the day 5 transfers, and some do it selectively i.e. only in some patients. Why is that? Some of it has to do with initial experience. At NYU, our initial experience was excellent, in fact better than expected, so we felt very comfortable continuing with it and this led to more and more cases and more expertise with time. Other programs had a bad experience initially. They were therefore less eager to increase their blast cases. Once something does not go well, especially in medicine, it’s really hard to go back to it.

Why would there be different experiences in different programs? Hard to say. I am prejudice in favor of the NYU lab, the people are all excellent, but there are other good labs around.

It may have something to do with the media. Media is the nutrient juice we grow your embryos in. We used to make it from scratch (what a pain), but now we buy it. An important factor making blast possible is the media. The old types of media could only support an embryo in culture for 3 days, and some very important changes in media composition were necessary to allow the embryos to grow 2 more days in the lab.

Initially, there was some variation in the new blastocyst media composition and quality, and there were batches that did not grow blastoctys well. So if you were an IVF lab who just happened to start out with an inadequate media batch, your outcomes would be lower, and you would be reluctant to explore blast culture further. Thanks to your lab directors and staff, we had a very careful process of testing media and analyzing which worked best. This allowed up to keep up the embryos quality in the face of variable conditions.

Among the programs that go to day 5, there is considerable variation in their criteria for going to blast. Some IVF centers need you to have 10 nice embryos on day 3 before they will consider growing the embryos longer. Others need you to have 6 day 3s, some 5, etc etc. Programs also put age in the mix; in other words less likely to go to day 5 the older you are. The more comfortable a program is with blastocyst, the softer their criteria will be.

Our criterion is that if you have more embryos than we want to transfer, you go to day 5. We transfer 2 embryos in most women which means if you only have 2 viable embryos on day 3 we do the day 3 transfer. If you have 3 or more, as is usually the case, you go to day 5.

Naturally, the obvious by-product of a good blast program is a lower multiple rate. Getting you better selected embryos, will help you become pregnant with fewer embryos. We started with blastocyst transfer in 1999. At the time we had a 20% of women under 38 had 3 embryos implant and now the rate is 1.9%. And many of those women had 2 embryos transferred, but had one of them split into identical s.

We went from putting in an average of 3 embryos per patient to two. Our pregnant rates would not be as high as they are if we put 2 embryos in on day 3. It’s just too hard to tell which are the best ones on day 3. Besides we have numbers to support our work. The implantation rate per embryo (this is a number that is used a lot. It’s the odds of each embryo sticking) was 34.5% in women under 35 and now its 43.4%.

So if your program is not doing a lot of blastocyst, does this hurt your chances? It really depends on the published pregnancy rates from your clinic. If they have great rates, but don’t do much blastocyst, that’s not so bad. Unless of course they are putting in more embryos per transfer to maintain the higher pregnancy rates. It’s not always easy to predict who will not get pregnant and who will get pregnant with triplets or quads. If you want to avoid 3s and 4s, your best bet is to not take the risk.

Sometimes there can be a diagnostic advantage to blastocyst transfer. If you are not getting pregnant with day 3 transfers, it may be time to try blastocyst. Occasionally, the embryos look much worse on day 5 than they did on day 3. This would not be not good news but at least you would know where you stand. It is also possible that they look just ok on day 3, but perk up very nicely by day 5, and this information might be of help to you.

Thanks for reading, and please see disclaimer 5/17/06.

Dr. Licciardi

Meet the Blastocyst

Hello everyone, this blog will describe the blastocyst. I will show you some pictures and tell you what is good and what is less good. Next time I will tell you a little about our blastocyst experience at NYU.
Let’s start with an easy one, a nice one. This is a very nice blasotocyst.


This is the type of embryo you may see on doctor’s web sites.

So what are we looking for? In no particular order, one is the thickness of the zona. This is the thin membrane around the embryo; it looks like a clear plastic shell. The thinner the better. As the embryo grows, gets larger, and becomes ready to pop out of the zona. The zona gets thinner, and this is a good sign. We don’t measure the thickness; we just look at it and make a judgment. The bigger embryo in the picture below has a really thin zona, almost impossible to see, which is a good thing.



This embryo has a much thicker zona, not as good.



What else are we looking for? We look inside the embryo. You may not be able to tell by looking right away, but the inside is hollow. Thus the name blastocyst: the inside is like a fluid filled cyst. That’s a good thing. So the next embryos have a lot of space on the inside, the cavity (the space inside) is large, another good thing.



This familiar embryo has a smaller cavity, not as good, but not a terrible embryo overall.

What about the cells of the embryo? There are 2 types. There is the inner cell mass and the trophectoderm. The inner cell mass goes on to become the fetus/baby, the trophectoderm cells go on to become the placenta. Many more cells are designated for the placenta than are for the fetus. Ideally, the inner cell mass (ICM) is easy to see as a clump of tightly bound cells more towards the center of the embryo. Here is the nice embryo we saw before with a nub of cells at about 8 o’clock. This is a good-very good inner cell mass.

These embryos have ICMs that are smaller; in fact it’s hard to see the ICM in the bigger embryo.

Next we move on to the other cells of the blastocyst, the cells that make up the outer area. These are the trophectoderm cells, troph cells for short (really sorry about all the terminology, it just goes with the territory). Cells that are more plentiful and smaller make a better embryo. The larger embryo below has very nice troph cells (and the ICM is really nice too).

This embryo has troph cells that are not quite as good: they are larger and fewer in number.

The embryo on the left below has just a few troph cells and they are really spread out, not so good.

The next embryos are not very good looking. The top left does have a cavity, and the cells are not very good. The top right has a very small cavity. The bottom embryo looks like there is no cavity.

The next embryos have cavities, but not the nice ICM cells and troph cells we have previously seen.

These embryos have thick zonas, the lower left has no cavity, and the upper right has a small cavity and few large cells inside.

This poor embryo has a nice thin zona, but just a few cells inside. The troph cell at 4:00 o’clock is just spread so thin, across almost half the embryo. The ICM at 11 o’clock is tiny.

So now you know more about blastocysts than the average person undergoing infertility. I realize that some of you are not as interested in the details, and others really use the details to get through the infertility day.
Next time I will talk a little about the numbers we assign and a little about the NYU blastocyst experience.

Thanks and see you sooner next time,

Dr. Licciardi

Infertility FAQs

Hello Everyone, catching up on the questions again. I know the topics are popular and I owe you one for next time.

I changed the format a bit for this time. I have the answers in more of a FAQ format with a little less verbage. I go through the question and try to distill out the major point. Hopefully this will be more efficient and informative, plus it allows for me to get to more issues more quickly. Let's see how it goes. Next entry will be a topic.


Do you need to remove Hydros? I am assuming your RE made the tubal surgery an option; some people can get pregnant with hydros in place. I make it an option with most of my patients. Of course you need to discuss this with your doctor, he knows your case better than I. It’s too early to tell about the Essure.


Is a high estrogen bad for implantation? I have not seen this to be the case. It is very true in mice, but mice are very different.


Why would someone who is 33 have 2 kids then 4 miscarriages in 15 months? If your workup is negative, we don’t know. It is important to have a hysterogram. I have had women with 4 miscarriages go on to have more than one child.


Is the estrogen prime good for low responders? It is no worse than anything else. If other stimulations have failed, give it a try.


If you make a lot of eggs does that mean you have PCO? It does not. It could mean you just make a lot of eggs. We see this all of the time.


If you are discouraged because you failed you fresh DE cycles, should you bother with your frozen? Believe it or not, we have some women who did not get pregnant with their fresh de embryos and have not returned for their frozen. Now there may be many reasons for this. If you would like to be pregnant, get up the nerve for the frozen cycle.


If you do not ovulate with clomid, should you add metformin? Consider the other option of very low dose injections. Metformin an option, but it may take months to get results, and in many cases ovulation dose not occur even with metformin.


Will acupuncture help? We don’t know, but I have many women doing it. In fact, in our office we provide acupuncture services, and the patients are very happy we do. We also provide Yoga and Mind body and psychological services. It’s all under the NYU Fertility Center Wellness Program.


FSH on day 2: should you wait for a lower number? Not sure. We prefer if our patients start with a number less than 13.4.


Can coasting have a negative effect on egg quality. Absolutely. Probably less so if the coasting is 1-2 days, but longer coasting is at times very bad for egg quality.


Can someone be prone to chromosomal miscarriages? Yes, there are some women who have a high proportion of chromosomally abnormal embryos.


Septum and PCO, which to fix first? Yes there are women with a septum who have had normal fertility and pregnancies, although I would be hesitant to leave a septum in because of the potential problems. It’s between you and your doctor. PCO is always fixable.


Is obesity a problem? No hard data, probably leads lower IVF rates. It’ more of a problem for pregnancy because of harm to the fetus. 11 eggs is ok, a few more may be better, ask your doctor about increasing your dose.


Should infertile women have a laparoscopy? Very few of my patients get a laparoscopy. If the only thing your insurance will cover is laparoscopy, then it’s a more reasonable approach. However, if there is no pain, no cysts and open tubes, the odds of a laparoscopy helping anything are low. Yes there are some women who everyone thought were fine who were found to have bad endo, but these cases are rare and usually there is a sign of the problem pre op.


Low sperm morphology: Usually not a factor. Some exceptions exist.


PCOS-like. I am happy that your doctor put it that way. Too many women are labeled with PCOS.


Temperature charting was good for the cave people. Please use a predictor kit.


What are the chances of conceiving with Clomid at age 40? Probably around 3-5 % per try.


Sperm clumping is probably not a problem. If anything, it should be solved with iui.


Stay with Clomid? Getting pregnant with clomid, but 2 miscarraiges. If you are getting pregnant, there is more of a reason to stick with it. I don’t think the clomid is causing the miscarriages, so getting pregnant with the injections amy be no different. See what your doctor thinks.


BPA leaching from cans an interfering with implantation? I wouldn’t worry about it.


Can a 34 yo with a poor response to the drugs become pregnant with IVF? Yes. At your age you only need a few eggs. Now more eggs would be better, but the odds are still very good with few eggs.


How to deal with antisperm antibodies? IUI or IVF.


Polar bodies are different than pronuclei. They both contain chromosomes. The polar bodies are the cells garbage. The pronuclei stay inside the egg and fuse the day after the fertilization. They come together to become the complete genetic material.


Is going for more than 9 eggs at 34 greedy. No , if your doctor thinks adding more drug will safely get you a few more eggs, that’s not so bad.



Is a lining of 16 mm too thick? It is if there is a reason it is thick. That is to say, if there are polyps making it thick, that’s not so good. If the lining is perfectly normal, and it’s thick, that’s ok.


Nuclear transfer and cytoplasmic transfer are not allowed in the USA. Just like many things in medicine, some preliminary results looked ok, but no one ever proved any benefit.


Does thyroid disease, like Hashimoto’s, cause miscarriages? This has been debated for the last 20 years, and there is no good evidence that it does. We are trying to do yet another study to look at the problem.


Does age matter for frozen embryos? No it’s the age you were when they were frozen, not the age you are now.


How come I became pregnant easily at age 23 and am having trouble now that I am 39? This is not uncommon, 16 years is a long time. A lot can happen.


Can you have regular cycle and not ovulate? I don’t think so. Ask what your progesterone levels are, even if they are over 3, you are probably ovulating. If you are not, well then it’s time for induction of ovulation.


Will DHEA help? It might, and if you are making a very low number of eggs, it may be worth a shot. I have had mixed results.

If you have frozen embryos, should you use them or jump into a fresh cycle? It is easier to use the frozens, but if you want the higher pregnancy rate, do the IVF again. If you only have 1-2 frozens, it may be better to do another fresh because not all embryos survive the thaw well.


Can a chromosomally abnormal embryo look beautiful? Absolutely, we see this every day.


What is the optimal TSH level? It depends who you talk to. The endocrinologists are going crazy trying to get everyone’s under 2. There is no real conclusive science showing this is important. Probably ½ the population has a TSH over 2, and ½ the population can’t be abnormal.


Can antidepressants interfere with FSH levels? Probably not.


Will assisted hatching reduce miscarriage? No it will not.


Can you have too much progesterone? No.


Does everyone with endometriosis need IVF? No. It depends on the status of your tubes. If the endo is causing scar tissue around the tubes and ovaries, than yes, IVF may be the best option.


Is a 12 cell embryo on day 3 a bad thing? The embryologists seem to think so. You cannot say you have a serious egg problem after 1 cycle.


Are fragments removed? They are typically removed f you are having hatching because the same little tool used to hatch can be used to suck out some fragments (unless you are having laser hatching). However, no one has ever showed that fragment removal makes a difference. Same goes for assisted hatching.


How do you define poor egg quality? I would say embryos that look less good than average. Embryos that are fragmented more than 20% are poor, even 20% is not great. Slow embryos are poor. However if you just did one cycle, you cannot be given the label until another cycle is performed.


What’s better, a frozen cycle with estrogen, or a natural frozen cycle? They are about the same. I find that sometimes the natural cycle gets a little confusing with the timing, and a small number of people ovulate earlier than expected, so if you do a medicated cycle, less is left to chance. However a natural cycle FET is a very acceptable practice.


See next time. Please read disclaimer 5/17/06. Dr. Licciardi

Back to More Fertility Questions

There will be 1-2 more for the blastocyst, but I will answer a few questions first.

Sorry, some of these questions were asked a while ago and my responses may be a little late if immediate action was necessary. I will still answer many of them hoping the answers will help others. If I skip your question, it does not mean it’s a bad one, it just means I cannot comment, or I just don’t have anything additional that will help.

There are a number of women who have tough stories about failing many IVF cycles and being faced with the donor egg decision. I always feel I want to recognize the problem by commenting, but my responses have been similar. Usually, it’s just up to you. The boring answer is get tot the best clinic possible and weigh your options. If I see anyone who I think is getting pushed to donor egg too soon I’ll comment.

Jennifer was discouraged because on clomid she found it difficult to time her intercourse because the cervical mucus remained thicker.
You should use a different method of checking for ovulation, namely the ovulation predictor kits. Clomid does make the mucus thicker, but not in some and partially in others. You can get pregnant if the mucus is thicker, but it depends how thick. This is another reason to consider insemination in order to remove the mucus from the equation.

Muriah had septum surgery but the HSG post op showed some septum remained. Why?
This is more common when the septum is very large. With a large septum, there is quite a bit of cutting. Of course we don’t want to cut too much, so at the top it may look like a dramatic improvement, but in reality, a little more should have been cut away. It is also possible that the doctor saw that there was a little left, but felt he had cut enough, but did not. It is also possible that as the uterus healed, it scarred a little at the top, making it look like the septum remained, when in fact it was cut properly but did not heal well. In any event, when I have a patient with a large septum, I do say that a second procedure may be necessary, although it has not been necessary in years.
It is also possible that there is a little left, but it’s not clinically significant. This is very common. I sometimes see a bit left and I say it’s not enough to worry about.

Jamie has spotting being treated with progesterone.
Just make sure your uterus is normal. Make sure you have a thorough ultrasound and HSG, and maybe a sonohysterogram, to be sure there are no polyps or fibroids. Some women need a biopsy. Otherwise, some women spot for unknown reasons and progesterone, sometimes with estrogen, fixes the problem.

Ruby’s husband has anti-sperm antibodies. I do not think this means anything.

KSNYC makes a few follicles but only makes 2 eggs Why? We do not know. If you had only done 1 cycle, we could say it’s just one of those things, try again. But after 4 cycles with varying protocols, and consistent results, well, that’s how you behave. I would say that at age 34, you should not give up yet.

Ronni is 40, makes nice eggs and embryos, has severe male factor, and is being told to do DE after 3 failed cycles. She is being told it’s an “egg issue”.
It’s up to you. Of course your problem is an egg issue, but you eggs can still give you a chance. I am going to guess that your odds are 15-25% with your eggs. You may want to consider traveling farther for a better clinic.

Amanda was on clomid, and injections are being suggested but is worried about multiples/hyperstimulation. Yes minimal stimulation is the way to go. We use anywhere from 37.5 -75 units.

Katrina’s husband has zero morphology. There is not much that can improve morphology. Spotting may or may not be a problem. See the post above.

Flycat is Catholic and does not want IVF or IUI. My suggestion is for you to speak to your priest/pastor. You never know, they may be more permissive and sympathetic than you think.

Helen has a bleeding cervix. You are right, cautery or freezing may scar the cervix. Get another opinion.

Lazarus is 41 and has failed a few cycles. Her doctor does not want to use the estrogen pirme. I say why not? It may or may not help, you just need to see.

Mina is 33 and was told she is in premature ovarian failure. You need to repeat the FSH and estrogen levels every 6 months, and least for a while. Sometimes things get better. However odds are the numbers are accurate and your doctor is correct.

Tracylayne’s husband has a translocation and 6 sperm. It seems that your advice is accurate. We do not know with certainty about odds of pregnancy and miscarriage.

Rehab nurse is considering reversing her tubal ligation. You are right in that you need to get to the right doctor, but it is hard to know who that person is. Some states have insurance companies that cover the procedure so doctors there have more experience because they do more. It’s the balance between reversing the tubes and just doing IVF. Some women prefer the IVF because they can still have contraception after the baby is born. The operation may cost more than one IVF cycle, however it may take more than one IVF cycle to get pregnant.

Chris has severe endometriosis. She has done 2 retrievals , makes a good egg number and has nice embryos. She has also done frozens.
Make sure you don’t have a hydrosalpinx (blocked swollen tube). Assuming you do not, it may just be a matter of trying again. Your history does sound like there are many positives that can work in your favor.

Karen has triplets and the new fertility clinic is criticizing her for wanting another baby. Go elsewhere, their attitude is not appropriate.

Heather wants to know if she should do back to back iuis. It probably is not necessary, providing the timing of the one iui is proper. If there is a question about the timing, use the 2.

The Kinsleys had a nice fresh cycle that failed and are worried that their frozen cycle will fail too.
There is not much to worry about. If they thought the embryos were good enough to freeze, they are probably more than good enough. This is one of the main reasons we freeze, if the fresh fails, you have the backup. It can work.

Curley wants to know if poor sperm can cause embryo quality issues. This is tough one. Usually not. However, I have seen a few cases along the way. The big problem is how to find out. If you make 20 eggs, you can feel better about splitting the eggs and using 2 sperm sources. If you have make 4 mature eggs, the experiment may not give you the answers you need. Most of my patients will try a few IVF cycles first, and then be forced to make a decision. May do not opt for the husband/donor split.

Just Before Blastocyst: The Morlula

So what happens after day 3? Two days later we would like it to be a blastocyst. The day before it becomes a blastocyst, it should be a morula. A morula forms when the 8 cell embryo divides further, and at the same time the cells become very close to each other. Here it’s difficult to see the borders of the cells, so the morula looks like one big blob. It ‘s solid in the middle. It’s still inside the shell. There are about 12-30 cells in a morula.
Here are some pictures:

Here is a nice looking morula.

Here are a few others . The top right looks nice, the others look OK, the bottom right looks the worst.

Most morulas (some write the pleural morulae, but most write it morulas) look about the same, so we don’t give them a number or a grade. We may say “nice” for a good one, but that’s about it.

Is it ok to transfer a morula? If your doctor wants to transfer your embryos on day 4, you will probably have morulas, but it will be hard for you to get a handle on quality. Most programs transfer day 3 or day 5. Day 4 transfer is ok, but most of us would say if you are waiting till day 4, just wait till day 5 so that the embryos have more time to grow, and quality can be better assessed.

What if on day 5 you are told the best embryos are morulas, not blastocysts? Not so good. I have had patients get back 2 morulas and become pregnant with twins. However the chances of pregnancy are much higher if you have blastocysts.

If there are morulas on day 5, isn’t it better to wait another day until they are blastocysts? No, because even if they become blasts on day 6 they are still a day behind. Rarely, we transfer on day 6. This may happen if , for example, there are 4 morulas and we want to give them, one more day to see which ones, if any, develop a little more.

Can we do anything to make the embryos grow faster? The same answer as last time. We try to change things up a bit next cycle, but there is no special drug protocol for slow embryos. Its just a matter of trying again and hoping for a better outcome.

Thanks again,

Dr. Licciardi

More About Embryos

The questions: at the time of this writing there were 84 questions to answer. I will read through them and get to most, but probably not all. I am sure this is most difficult for those who write about the here and now, i.e. questions about a cycle in progress. Many of you have commented that the topics are more helpful than the questions, so I want to continue with the embryo blogs, and then go to more questions. I do like answering the questions.


The egg is one cell, the fertilized egg is one cell, and then the egg divides, becoming 2 cells. The 2 cells are smaller than the one big one, and with each division, the cells become smaller. After 2 they become 4. Actually many times they become 3. Both the 2 cells may not divide at the same time. That’s why an embryo can be a 3, 4, 5, 6, 7, 8 or other cell number. It does not need to be an even number.


So here are pictures of 2 cell, cell 4 cell and 8 cell embryos.

The overall size of the embryo does not change. The zonna pellucida stays the same size, so the cells need to fit inside. Just like a developing chick can’t be bigger than the egg, till the end.

These are pictures of perfect looking embryos. Most embryos do not look like these, and that’s ok. These are the typical embryos you see on web sites.

Most of the questions about embryo development we cannot answer. Why do some embryos look prettier than others? Why are some embryos slower than others? Why are some embryos fragmented? We are not close to understanding these questions. We prefer if an embryo looks “better”, meaning the cells are dividing at the right rate and there is minimal fragmentation.

How quickly should an embryo grow? 1 day after the retrieval, they are still one cell, but the next day division should take place. A 4 cell may be the best, but a 2 or 3 may be ok. And of course, they have to keep growing, so that the next day, day 3, they should be 5-8 cells. A 4 cell on day 3 is really slow. Certainly, as with many other slow embryos, a baby is possible with a 4 cell on day 3, but it’s better to have an embryo that is more advanced. The closer you get to 8 the better, 6 is the minimum “good” number”.

Most clinics have their own classification system for grading embryos. Some labs call their best embryos A’s. Some 1’s, some 5’s. There is a reason for this. IVF is a relatively new science and many of the lab directors who started 10-20 years ago had little human IVF experience. There just were not a large group of scientists who previously worked in IVF labs. They had backgrounds in brain science, animal science and all sorts of other areas. Some of them turned into great lab directors (hats off to our lab director, Dr. Krey), but there was not grading system that the whole country followed. Each program just made up its own system for grading day 3 embryos. We could all get on the same page, but now it’s too hard to go back.

It would be really difficult for each program to go back through 20 years of charts and change the numbers assigned to each embryo. Plus if we all change now to a new system, it’s hard have some embryos graded one way and some another, especially for research purposes. So things will stay as they are. It just makes it a little difficult when you talk to your friends to compare embryos. To jump ahead a little, there is a system most of us follow for day 5 embryos.

What is fragmentation? Fragments are little pieces of the cell that break off as the embryo divides. A little bit of fragmentation is normal. As the degree of fragmentation increase, the odds of implantation go down.

Let’s look at some day 3 embryos to see varying amounts of fragmentation.
This close up shows the normal larger cells, and some smaller round “fragments”.

Here is a group of embryos from the same woman. The embryo far right is the best. It has very few fragments. The top embryo looks good too. The bottom middle looks ok, but is a bit more fragmented.

This embryo has a high degree of fragmentation (compare to the nice embryos at the begining).

In this picture, the far right embryo is full of fragments.

We frequently assign a fragmentation score by estimating the percentage of the embryo volume that is replaced by fragments. 0% is actually rare, some fragments are expected. 0% is ok, but it does not happen much. We consider up to about 10% to still be very good. 10-20% is still OK, not quite as good. More than 20% is more abnormal, we consider the embryo to be of poorer quality. Pregnancy can occur with a fragmented embryo, but the odds are lower.

Sometimes fragments are removed from an embryo in the lab, by making a small hole in the shell and sucking out the fragments on day 3. This is done at the time of hatching since the hole is the same. The embryo can look much better, but we do not know if it means the embryo is really in better shape.

Can we reduce a woman’s chance of producing fragmented embryos? We try, but we never know if our efforts helped, or things improved as a result of chance. We add lupron, remove lupron, add LH, remove LH, lower doses, increase doses, give few days or more days of stimulation, etc etc.

So what’s worse, a slow embryo or a fragmented embryo? Of course it depends on how slow or how fragmented, but basically, it’s a tie

An important issue here is that if you have done 1-2 cycles of IVF, and you make eggs and embryos and have fragmented embryos, donor eggs may still not be necessary. Get a second opinion at the best program possible. Maybe DE is the best thing for you, but maybe another try under different conditions will do the trick.

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

The Road to Blastocyst: Eggs and Embryos

This is the first installment of blastocyst blog; but it's a bit of a pre-requisite. To give you a feel of where we are going, I will start with pictures of eggs and embryos and then blastocysts.

This is an egg. I doesn't really look like an egg. Part of the reason for this is that in this picture there are hundreds of cells, but just one that is an egg. The dark circle in the center is the egg. You can see how big eggs are compared to the rest of our cells. The surrounding specs are granulosa cells. These are the ovarian cells that line the inside of the follicle. Prior to ovulation, the egg's position in the follicle is along the edge, so the granulosa cells that are growing along the inside of the follicle surround the egg. When the egg ovulates, it carries some of these cells along. When an egg is retrieved during IVF, it is also surrounded by granulosa cells.

The granulosa cells make the estrogen (estradiol). So as the follicle grows, more granulosa cells form, and estrogen rises. In an IVF cycle, the more eggs there are, usually the higher the estrogen levels.

This is a picture of an egg a few hours after retrieval, after the granulosa cells have been removed.
In the case of IVF using ICSI, the embryologist needs to remove the granulosa cells a few hours after retrieval. This is necessary so she can see the egg and to properly inject the sperm. If ICSI is not necessary, we can mix the eggs and sperm together, and the sperm will swim through the granulosa cells to get to the egg.

The little round object on the top is the first polar body, and this is an indication that the egg is mature. The first polar body contains chromosomes, as does the larger egg cell. For the egg to accept the DNA of the sperm, it needs to dump some of its own DNA, otherwise there will be too much. So the egg unloads some of the DNA into the polar body, which just withers away. Sometimes testing the DNA of the polar body can tell us about genetic diseases in the egg. For the most part, we can not use an egg that is not mature. There is some encouraging research looking at maturing eggs in the lab, but so far the process of maturing eggs in culture has not been widely accepted.

This is what we call a 2 pn zygote (or 2 pn embryo). The picture was taken one day after the retrieval. You can see a few granulosa cells still hanging around.
The halo around the embryo is the zona pellucida. It's the shell of the egg. It has the consistency of a thin vitamin E capsule. Inside is the egg (or oocyte). In the middle of the egg, you can see 2 little round objects, and these are the pronuclei (pn). One contains the genetic material from the egg, the other from the sperm. In some animals we can tell which came from where, but not in the human, although as our microscopes improve, I suspect we will very soon be able to tell. So if we expose eggs to sperm, and look the next day, and do not see 2 polar bodies, fertilization has not occurred. Sometimes we see one, and this means fertilization possibly occurred. In this case we may or may not see 2 later in the day. The 2 pn will combine to complete the fertilization process.

Dr. Licciardi

Stories of Persistence

I know you are waiting for the blastocyst blog. I am just getting some photos together and will have it ready for next time.

Like it or not, the holidays are here. Maybe it’s a good time to spread a little message of hope. Now hope isn’t for everyone, but let’s face it, it’s probably the number one thing that keeps us going. It’s an emotion than can be applied rather universally, applicable to mostly all of our basic functioning.

Anything we need or want, we hope for.

As stories from the internet have shown, some women with low chances can become pregnant.
Here are a few of my own. And these are only a few out of many others, these just came to mind.

Ms. A was 38 when we met. Her FSH was 22. She was “dismissed” from another program. 2 years earlier she delivered, but this was after trying for 18 months. The sperm motility was a little low, but the sample was close enough to normal, ICSI was not needed.
She first tried a day 2 start, her FSH was 13,4, and was cancelled and converted to IUI because there were only 3 follicles. The plan: keep trying. Her second cycle never got off the ground because of a day 2 FSH of 17.7.
Her FSH was 11.9 on her 3rd attempt and she went on to make 4 eggs, 4 fertilized . On day 3 one looked good, the other fair. This ended in an early biochemical loss.
Her next cycle we changed up the protocol a bit. She had 4 eggs, and 2 embryos transferred, both looked good. This worked, and she just delivered.
So here we have a woman who most doctors would tell there is no chance, but she persisted.


Ms. B was 35 when we met. Her FSH was 14. Her resting follicle count was less than 5. She started a cycle with an FSH of 12, got 6 eggs, poor fert and a cancelled transfer for arrested embryo growth.
Her second cycle was cancelled for no response (not one follicle).
She got pregnant on her own. This theme is an internet favorite. Buy the way, she did not use DHEA.

Mrs C. was 36 and suffered from severe edometriosis. She did 2 IVF cycles before we met.
She did 3 more retrievals with me, always making a good egg number and having good embryo quality. She travelled long distance to get to NYU. On her 3rd cycle (5th total) she became pregnant.

The next one goes under the dumb doctor category (that would be me). Mrs D, a 38 year old from overseas, e-mailed me and told me about her FSH of 25. Realizing she was from far away, I tried to save her some travel time and money and told her IVF was out, but donor egg was in. The couple came to see me, heard the donor egg schpeal and as I finished the husband looked up and said that his wife was going to be day 2 in a few days, could they try IVF while they were still in the States? Without boring him with the low odds speech, I just said, “sure why not.”
Sure enough the FSH was 12, she made 9 eggs and delivered twins. I think they are happy with me, but I am sure they have their reservations.

How can we put these all together?
1) They about women under 40. I don’t mean to exclude the 40 and over crowd from the hope discussion, as there are plenty similar stories about women in their 40’s, but the facts support that it’s easier to beat the odds when you are younger.
2) FSH may not be as important as we once thought. Again, a bad FSH is better under 40. Every so often there is a paper or abstract reminding us that pregnancy rates shoot down with increasing age and FSH levels. Which leads us to the next point:
3) Some infertile women can at times become pregnant on their own. We do use this fact when recommending that some women cancel their cycle or give up on IVF. We say yes you can get pregnant with IVF, but your odds are low, about the same as getting pregnant on your own. Of course this is much more difficult concept to accept when there is a severe male factor.

So for Mrs. A, C, and D, their persistence is what lead to their success. They did not accept the advice of a doctor; they did what they felt they needed to do. Of course we have to keep in mind that it is also true that there are women who try and try unsuccessfully.

Sometimes the fertility establishment is criticized for giving a bit too much hope, while profiting nicely from tons of women who are needlessly spending tons of dough. And sometimes we are criticized for not giving an infertile woman the chance she deserves.

But it will always be true that for most women with low odds, there is a small chance, and sometimes their only chance, using IVF. So it all goes back to getting to the right clinic and getting informed about your odds. After that it’s between you and your doctor, sometimes with a little tug of war.

Dr. Licciardi

A Marathon of Infertility Questions

As this Sunday was the New York City Marathon, I figured I would have my own little marathon and answer all of the outstanding questions. Here it is.
It took me a few days to cross the finish line, but I was able to eat and sleep along the way, possibly experience some weight loss, and I seem to be injury free.


From October 4th

Niki has had a very tough time trying to have a child. She has had a number of bio-chemicals and worse (see her post). Her basic questions are 1) is a thinish lining the reason, or is it an immune problem, or some other problem we just don’t know about?
I also do not buy into the immune issues. These have been studied now for many many years and never has anyone produced a quality study showing they mean anything. However, you have few choices, so it may be reasonable to consider getting tested and treated, if something shows up. I am not recommending one way or the other. You should give equal consideration to a carrier.

Esther had open tubes on hsg and a few weeks later had both tubes blocked at laparoscopy. She is being told she needs IVF.
I am not so sure. When I have open tubes on HSG, I don’t even check at laparoscopy. Why? Because it is common for tubes to be open on hsg and closed at laparoscopy. It’s a mechanical issue. Sometimes the doctor just has trouble getting dye out the tubes at laparoscopy. Now it depends on where the blockage is. If you have proximal occlusion (blocked at the uterus), this may be a false finding. If he says you have bilateral hydrosalpinx (blocked near the ovaries) that’s different and real. If there is any question, the answer is simple, just repeat your hsg. If the tubes are open on your next hsg, there were not blocked at your laparoscopy.

Mosche and his wife need IVF with ICSI due to male factor, however even with ICSI, there was no fertilization.
I have only had one young patient make many eggs and not fertilize with icsi. So it can happen, but it is rare. It’s a little more common when there are also issues with advanced maternal age and low egg number.

Ruby asked about sperm antibodies.
I do not believe in them because no good recent scientific paper written showing me that sperm antibodies are relevant.

Angie did a clomid IUI cycle, and the sperm count was 18 million with 56% motility.
The count sounds reasonable for iui. Although you should still ask for the total motile count, and look for that to at least be over 5 million, preferably over 10.

Tabi did 4 IVF cycles, 3 with lupron, one without. The non-lupron was her worst.
We don’t know if it was the no lupron, or was it just going to be a bad cycle for you that month, independent of your stimulation protocol. It may be that in your case lupron is better. For most women who make few eggs, this is not the case, but not all women are the same. I don’t think you are declining.

Ali did IUI. The sperm count was 143 million with 48% motility. However for the iui, only 3 million were recovered.
This is strange and does not make much sense; unless the initial volume was very low (2cc is normal). I am not worried about his morphology. “Abnormal” sperm are not removed when preparing for iui.

Manny and his wife are trying to conceive. He is asking if the lining could be an issue, especially because she takes anti-migraine medication that theoretically could restrict blood flow to the uterus.
The question is interesting, but unknown. One option is to measure the lining on and off the medications. Or, try to conceive off the medication. Another option is to look elsewhere for a potential problem. Do the basic workup i.e. semen analysis, HSG, day 3, to see if there are not bigger problems with more known quantities.

Anonymous has PCO and 2 weeks of bleeding after clomid.
This is not normal. Actually, the first cycle sometimes the bleeding can be unusual, but once you get into a pattern of periods, they should not be 2 weeks long. You need a good exam and ultrasound and maybe an endometrial biopsy.

Anonymous is 42 yo with 3 failed IVF cycles. Some borderline FSH levels and 1, 1 and 3 embryos available for transfer. Should she stop?
Your odds are what they are, low. It depends on your clinic, but your chances are probably about 5-10% per try. Many women, probably most, would stop here. But some persist, and a few get pregnant. As you know there are emotional, physical and financial issues to wade through. You can’t say you didn’t try. I hope it works out.

Mark is asking if he and his wife should consider natural cycle or minimal stimulation IVF vs. the standard IVF using more drugs.
You will need to decide. My only comment on your post is that it is not true that fertility drugs for regular IVF will ruin the eggs forever. But the opposite is also true. If you do a natural cycle, you can always do a regular cycle later. Regular IVF may not be for everyone, however, for most people, it has a higher pregnancy rate, which means a better chance of having a baby. The cost is less for natural, but with its lower pregnancy rate, it is common (not in every case) to spend at least as much money because the cost of multiple cycles really adds up fast. If you get pregnant early, great, you were the lucky one.

Erika has had 9 pregnancy losses and IVF is now recommended.
I understand the theory; if you put more than one embryo in, maybe if one fails another one will stick and you can have a normal pregnancy. Certainly, your odds of loss will be higher than the average person, even with IVF. I don’t think we can tell you that your odds of loss will be lower than from a natural pregnancy. However, your options are limited, so it may be worth a try.

Dizzy has totally unexplained infertility. All tests are very normal and she is 31. She has done 6 FSH iuis and is considering IVF, but insurance does not cover.
IVF is the next step. No one will be able to tell you why you are not getting pregnant, but IVF has an excellent pregnancy rate, even if you have failed FSH iui. You odds with FSH iui are now going down, because it has not worked. Of course you could do more FSH iui, and it may work, but it may be more of the same.

Purple Mocha has a 3 mm lining on clomid.
Sounds a little too thin. You can try again, or change to FSH. You could also check you lining in a no drug cycle to see what your baseline is. Of if you want to get going, just go to the FSH.

Mtroth has some endo and failed one IVF cycle, which was complicated by hyperstimulation. She has frozens. Did an undiagnosed biochemical pregnancy lead to her hyperstimulation?
You may have had a biochemical, but probably had plain old hyperstimulation. Your estradiol was high and you needed to be coasted. I do not think the endo was an issue. You can’t prepare for the FET. The good news is you seem to have nice embryos and should do well.

Athena has 8 months of infertility, short luteal phases of about 10-11 days, and serious pelvic pain. Her doctor will not see her until she has a year of infertility.
Maybe you have insurance that will not pay your doctor until there is a year of infertility, or maybe he is not a nice person. See which it is. If you think your timing has been good, it would be better if you saw him or another doctor soon. In general I do not believe in luteal phase problems, but you may be an exception because your luteal phase is so short. But do not only get that treated; work on other things at the same time. Get the hsg and ultrasound to look for cysts and endometriosis. Get the sperm checked.

Anonymous is an over-exerciser and because of this does not get her period on her own and does not bleed after provera. Because clomid starts after the period she does not know that do about starting the clomid.
You can start the clomid without a period, providing you get a pregnancy test. I am fine with you trying the clomid, but may women like you do not ovulate on clomid because, due to the exercise, your pituitary does not have much FSH or LH, and clomid works by releasing FSH and LH from the pituitary. Most of time, injected FSH is necessary to get you to ovulate. But you can try, sometimes it works.

Milka is 37 and her doctor told her her IVF failure was age related. He also wants to repeat her sonohyst and cultrures
I do not repeat those tests unless there is a good reason. Failing IVF is not a good reason. Your failure was not age related, you are young compared to many fertility patients.

From October 15th

Niki wrote back and did her IVF cycle, froze all due to lining issues. She is considering a carrier and does not want pgd.
It all sounds reasonable to me. It will have to be your choice.

Anonymous has pco and endometriosis. She did 8 clomid cycles and is in her last FSH iui cycle. Should she do IVF?
If you have done 2-3 FSH iui cycles, IVF is the next step. I like the way your doctor is doing the FSH iui. I am very optimistic. You are 28 and have eggs, that’s all it takes (in most cases). I expect you to do well and get pregnant quickly.

Anonymous is 33 and has had 3 miscarriages.
You odds are still excellent of having a baby in your nest pregnancy. Your doctor needs to do a miscarriage workup.

Anonymous has a normal pap with some cells missing and burning and numbness in her vagina.
As long as your doctor and the report say the pap is normal, it’s normal. I do not think the burning is related to antibodies, and it’s not due to the pap.

Diana was diagnosed with a septum and that was corrected. She then had to delay fertility treatment for treatment of thyroid cancer. New she is trying again without success. She is 35.
Give it the 3th month, but start making plans if things do not work. As far as your next steps, you know the drill. Get the options, get the pregnancy rates, and then decide which treatment sounds best for you. Be sure all of the septum is gone. I see many patients who have had septum surgery, only for me to tell them their doctor left a lot of septum still in place.

Anonymous does not get her period and is starting with a SIS.
I does not matter if you see her or a RE, but you need assistance ovulating ASAP. I don’t get the SIS, unless she sees something suspicious on ultrasound. You need to ovulate and this will probably require medication. Ask the doctor about getting the HSG before you try, or trying a little while (with ovulation) and then getting the HSG.

April did an IVF cycle with some immature eggs and late icsi. The embryos did not look good.
It sounds like there were a few issues with your cycle, but they seem correctable in the next try. It’s hard to tell if there was a problem with your IVF clinic, or things just want bad on their own. If you think you are at a very good place, give them another try. If you have reason to believe there is a better clinic near you, make the switch.

Shari in Chicago has endometriosis. She was treated with lupron and is waiting a long time for her period to return.
It works like this. The lupron is given every month (unless you have the 3 month version), and that lasts about 5-6 weeks in your system. Then you need to start your cycle again, and most women ovulate 2 weeks after that, and get a period 2 weeks later. That means you get your period about 8 to 10 weeks after you last shot.

Christine asked if IVF babies were born earlier and or smaller than non-IVF babies.
The answer is maybe. Some data suggests this is the case. However not all studies break out singletons from multiples, which usually deliver early. If there is an association, it may be due to the fact that some women with infertility may have uterine abnormalities that cause premature delivery. It is also possible that infertile people are more likely to have subtle genetic issues interfering with the length of pregnancy or the size of their babies. Or it may be that there is no difference at all and the right studies have not yet been done. Or maybe the IVF process is flawed and babies are smaller and deliver early. At this point, if there is a difference it does not seem to be great.

Alesha is trying to have her second IVF baby. Her first was at age 32, she will be 35 in January; her FSH is normal. Because she is a teacher, she wants to wait till summer to try. Her doctor says try now; her ovaries may change in the next 7 months.
It will be a little harder then, but if you are very fertile now, you will be very fertile then. Although there is a small chance he is right. Don’t forget you will be 3 years older than you were at your first try. I think it’s up to you, but consider this. Many women become very sad when they get pregnant on their first try, but not on their second, because it seemed so easy the first try. This could happen, and your following cycle will need to be during school, which is what you were trying to avoid. Therefore, why not just do one during school now. The logic is a bit of a stretch but I hope you get the point.

Leila has endometriosis and a fair response to meds. Her first 2 cycles yielded few eggs, and she did much better with a day 2 start than with lupron or microdose. If this fails, should she try again?
This cycle was very encouraging. You are only 36 and make 11 eggs, not bad at all. Question for your doctor: do you really need icsi? It sounds like you are on the right track. Consider the same protocol or estrogen priming.

Anonymous asked why go to FSH iui after 6 failed clomid cycles? Why not go to natural iui?
For younger patients, natural iui has a 5% pregnancy rate and FSH iui has a 20% rate. You can do whatever treatment you are comfortable with, just know the odds.

Anonymous is 42 years of age and has a FSH of 18. She failed a response using 14 days of lupron and 750 units of FSH. Should she stop?
It really does not sound encouraging. If you really wanted another try, ask your doctor about the estrogen priming protocol. Lupron is not the best for poor responders.

Anonymous has irregular cycles and is trying with clomid. She is using cervical mucus to time things.
Use an ovulation predictor kit instead. You can get pregnant with mucus that is thicker, but, if the clomid does not work after 3-6 times, ask your doctor about FSH. You may get pregnant before you get to the FSH.

Anonymous did 2 clomids, 3 FSH iuis and one IVF. She made 9 eggs but had slow embryos.
Get yourself to the best IVF clinic available. It may be where you are, or you may need to switch. Check rates at SART.ORG. Use a different protocol. I hope it works out.

Beth was diagnosed with endometriosis and is not ready to conceive. Should she go on Lupron for 9 months?
9 months sounds like a long time to me. The pill is definitely an alternative to lupron. Ask your doctor or get a second opinion.

Amila had an iui, had intercourse that evening and then had an iui the next day. The second iui had a lower count.
Probably too much. Stick to the iui’s.

Jesse b: Wife 30 he is 34. They just started the workup and were found to have one blocked tube and a low morphology. Their doctor is already talking about IVF.
Wow, they are going fast! First of all, if the tubal blockage is “proximal occlusion” a laparoscopy is aggressive. It is an option, so is repeating the hsg. It may have been spasm. If it shows distal occlusion, maybe surgery is more indicated. The morphology is probably not an issue. I don’t why they don’t just consider clomid first. Even if one tube is blocked and one is normal, it may be worth a shot with clomid. Of course, ask your doctor or get a second opinion.

Anonymous is 37, has a bicornuate uterus and a poor response. 4 failed ivf cycles, 0-6 eggs each. Her husband had a vasectomy.
Since your last protocol seemed to work best you could try one more cycle. You could also consider stopping. If you do another, consider the same protocol you just used. The reversal is not a bad idea, because at least you can try every month. But, they don’t always work, or they work but the counts are low.

Lisa tried many natural donor sperm cycles then used low dose FSH and got only 1 egg. She is worried that if she made only one on FSH, maybe she made none on her own or on clomid.
I believe you made one on your own and one or more on clomid. Your doctor did the right thing trying to control your dose, but now it seems you need a little more. It can work with the one. If not you may need a little more drug.

Anonymous has a doctor who wants to do an endometrial biopsy the month before the IVF cycle to promote a better lining.
Most of us do not do this. If your doctor can do a study, or maybe he has seen such a study proving it works, fine with me. But I am not aware that this method is of any value.

Kate is 31 yo and she did 2 IVF cycles. Her response is fair, 5-6 eggs, and after her first cycle her embryos did not look good. They got rid of the lupron and in her second cycle she had nice embryos. A pregnancy ended in a miscarriage at 6 weeks. She was told she has bad eggs.
I do not see that you have bad eggs. Your last cycle gave you nice embryos, and it almost worked. I think your chances are still very good. You could change to a microdose, or you can stick with your last stimulation, or you can consider an estrogen prime protocol. They will all be similar, it’s hard to say which one will be the best for you. Check pregnancy rates, if their results are good stick with them.

Murgdon’s husband has very low counts and her RE and urologist feel there is nothing practical that will raise counts, leaving them with IVF as their only option.
It’s hard for me to give specific advice about your husband’s condition, but in most cases, the advice you have received is correct.

Indigirl is 40 with a couple of cancelled ivf cycles for poor response. She switched to the estrogen prime and had 10 eggs. Her FSH is 10-12 and she has a bad AMH level. Is 10 a bad count?
10 is a very nice number, definitely enough to work with. We do not know enough about AMH to know if a bad level means pregnancy is not possible. Right know it’s a guide. The technology of PGD changes for the better every day, but ask your doctor what he thinks about not doing PGD. There is an element of embryo damage that can occur. PGD may be the best thing for you, but double check.

EAS is considering IVF with PGD because she has had a biochemical, 6 week misc at 6 weeks, and now a beta that does not look promising.
As long as you are informed about the pros and cons of PGD, then the choice to use PGD is reasonable. I just get upset when patients are led to believe that PGD is a perfect science.

Anonymous is 27 and does not ovulate or get her period, even with provera and clomid. What should she do? Her doctor is suggesting metformin.
Some women go great with metformin, but they are a mininority. The down side to metformin is that you need to wait another 3-6 months to see if it works. Certainly, it’s less expensive than getting FSH injections and monitoring, and you don’t need the doctor’s visits. It is a less aggressive way to go. Weigh your options.

Kahla’s husband has a low count. They got pregnant and had a baby on their first IVF try. The next 2 cycles failed and she had a 6 week miscarriage on her 4th try. She has had it and is considering iui.
It depends on the sperm counts, and you need to know your odds with iui and IVF. Most people find it really hard to go back to iui after doing IVF. But, if the counts are at least adequate for iui, you could do iui, and IVF later if necessary.

Jennifer’s mom has the BRCA gene discovered after being diagnosed with breast cancer twice. Should Jen take clomid?
Maybe you should get another opinion. Clomid is not that different than tamoxifen, a drug used to treat breast cancer. However, breast cancer is not my area, so I will defer. You could use letrazol to stimulate ovulation. This can cause ovulation, but is also used a breast cancer drug. Make sure you are not pregnant if you take it. Make sure you are fully screened for cancers before you try.

Elize has had enough history for 5 women. Check her entry for details. Now she is left with multiple major surgeries, miscarriages, and a uterine scar.
Much depends on how much scar there is. If it’s a little area, and most of your uterus looks good, and your normal endometrium looks thick enough, you may be ok, even if the scar comes back. If scarring returns after the first surgery, the odds of a second of third operation permanently removing the scar are much lower, especially if the scar takes up a large amount of the enodmetrium. We are not sure why you had the miscarriages, so I can’t say that you are at high risk for another miscarriage. Rupture is really rare, more common if you needed to have a large uterine incision for your myomectomy. A scar will incresase your odds of miscarriage and premature labor, but again it depends on the size of the scar. Scar will increase your odds of placental problems such as increta (where the placenta grows too deeply into the uterus)

Jesus my best friend has a unicornuate uterus with an open tube, and was encouraged to try on her own.
It sounds like a good plan to me.



OK, see you next time with a topic, probably blastocyst.
And please see disclaimer 5/17/06.
Dr. Licciardi

Infertility Questions and Answers: Almost Caught Up

Anonymous asked about really trying to nail down the best progesterone for her IVF attempts. She failed one fresh cycle and 2 frozen cycles. She tried the injections and cream and Crinone. Her latest problem is she bled on Crinone, and had a thin lining in the luteal phase, and now is scheduled for a biopsy on Crinone.
Why? Crinone may be a good drug for some, but in your case it does not work. Why do a biopsy when you already know this drug gives you problems? I have never done an ultrasound in the luteal phase to check the lining. Maybe your doctor is on to something, but for most of us it’s all about the lining before your progesterone(ie we check in the follicular phase). Your problem highlights the reality that progesterone in oil, as difficult as it is, gives consistent results. If vaginal progesterone is your only option, and Crinone does not work out, you can consider old fashioned progesterone suppositories.

Anonymous asked about not getting her period after lupron.
This commonly happens. You odds of pregnancy will be based on your clinic’s success rates. Remember it’s the age you were when the embryos were frozen, not your age now.

Wannabmomma has PCO and has tried 5 clomid cycles with intercourse, no luck yet. She is 26 yo.
It is almost time to move to the injections. Most of us make your limit 6 cycles, fewer if you have regular cycles on your own. But, you are only 26, so you could consider a couple more with insemination. I really think this can be up to you.

Big Childwish has a significant miscarriage problem. She has had 4 consecutive miscarriages at about 7 weeks, all with a sac but no fetal pole. All of her testing is normal. She tried the blood thinner.
I am assuming you had a hysterogram, if not you need it. I am not sure if you have had a d and c with any of the pregnancies? This would tell you about the chromosomes of the fetus, possible giving you more information about the causes of your problems. Otherwise it may depend on your age. If you are younger, your chance of a baby in your next pregnany is still over 50%. If you are older, your odds are much lower.

Katie has PCO, did an IVF cycle with 7 eggs, 5 fertilized and 2 embryos for transfer on day 3, one 4 cell and one 5 cell.
OK, there are some positive things here. I like the way your doctor was cautious stimulation, and you do make eggs and embryos. You can use the information to improve your next try. First a little more drug will be OK. You don’t need to make 30 eggs, but 15 may be better than 7. If you are at a clinic with a 26% pregnancy rate, but can travel to a clinic with a 49% pregnancy rate, I say travel. If your clinic treats 100 patients, 74 will not get pregnant. If the other clinic treats 100 patients, 51 will not get pregnant. That’s a big difference.

Alibee has a complicated history. She has a unicornuate uterus with a normal tube and 2 ovaries. She has a fairly large fibroid. She has done 5 FSH iui cycles and 1 fresh IVF cycle and 3 FETs, and maybe more more fresh IVFs?
It sounds like your fresh IVF cycles were excellent because you had so many frozen embryos. It’s hard to prognosticate your future after failing frozen cycles. They just do not work as well as the fresh. They are worth doing, but if they don’t work, it’s hard to say things are bad. Your last fresh IVF cycle yielded very nice embryos. So why no pregnancy? Can it be your uterus? Possibly. Most women with a unicornuate uterus are not infertile, but there are a few who have trouble implanting, we don’t know why. Is it just bad luck with IVF? Possibly, but why are you not getting pregnant on your own? This is going to be a case of trying again, if you wish. Should you consider a carrier? It should be a consideration, but of course even that is not a guarantee.

Emily has unexplained infertility and has started clomid. Her first try did not work. She asked about some recent press concerning a terrible article about clomid not working for unexplained infertility.
That will be another blog, but they are wrong. There have been many many studies showing clomid does work. Just remember the odds, which are 8% per try in women with regular cycles. So you are on the right track, I hope it works out.

Jen seems to be hanging in there with her endometriosis progression and pain. Keep us posted.

Anonymous is concerned because her first IVF cycle worked and her second did not. She is worried about the 8% morphology.
This is not the issue. Morphology will not lower IVF pregnancy rates. It’s common that success in the first cycle causes fear when the second cycle does not work. Stick with it. Even in the best clinics, odds are 50% for young women, meaning it’s a 50% failure rate.

Amelia’s husband has an inversion in chromosome 1, causing low sperm counts. She asked about IVF with PGD.
This all depends on what your needs are, and the advice of a counselor. Of course you need to ask about the problems associated with this inversion. Is it just a low sperm count, or are you at risk for a miscarriage or even an abnormal child? You also need to be informed about the costs and success and failure rates of doing the IVF with PGD. In addition, you need to ask about the error rate of your PGD procedure.

Singh did 2 IVF cycles. The first resulted in 10 eggs, but 8 fertilized with more than 1 sperm (polyspermy). Her second cycle she did ICSI and did not have polyspermy. She is wondering if the polyspermy means her overall egg quality is bad, leading to a failure in her second IVF cycle.
We do not know if your problem is egg related, or related to a lab issue. Since you say you had nice embryos in your second cycle, your eggs are probably fine.

EMLU has severe endometriosis. Had Twins with her first IVF cycle, but has since had 2 fresh cycles, and then a frozen cycle revealed fluid in the uterus so the cycle was cancelled. She still has fluid in her uterus and a biopsy revealed endometritis.
Fluid in the uterus is a very difficult problem. I have a few patients with this and it’s tough. In your case you may want to a have a hysterogram (after the endometritis is cured) to be sure you do not have a hydrosalpinx, as this is the most common cause for fluid. You have another possible cause: endometriosis. Some women with advanced endometriosis also have adenomyosis (endometriosis of the uteris) and this can cause fluid. Definitely get treatment for your endometritis. However, most cases on biopsy are not really endometritis, it depends how quick your pathologists are to make the diagnosis. Some overdo it.

Anonymous has unexplained infertility and failed 6 months of clomid.
I would say that’s enough clomid, and you should consider FSH iui or IVF.

I agree with Christine

Beth asked about clomid for raising sperm counts.
It depends why the sperm counts are low. If his FSH is present but low, clomid may help, but that’s a really rare cause for low sperm counts. If his hormones are normal, clomid probably will not help. In fact some doctors think clomid lowers sperm counts by raising men’s estrogen levels. In any event, it’s ok to try some of these things, but don’t waste time waiting for results. Move on with your plan of action in the meantime.

Anonymous had a low progesterone and was put on clomid. So far so good. Then her luteal phase was only 10 days on clomid, and now she thinks she has not ovulated on clomid.
OK, see if you can get office monitoring on the clomid. Ask about getting an hCG shot once your follicle has reached 18-20 mm. This should straighten everything out. If monitoring shows that your cycle is not behaving properly, switch from clomid.

Anonymous is 27, but only got 3 eggs at her IVF cycle. Her doctor was overly cautious with the dose of drug.
OK, so now you know, you need more drug. It sounds like you had at least one nice embryo, so with more eggs you will get more nice embryos and have a much better chance of pregnant. I am optimistic.

Anonymous had infertility, tried clomid, and got pregnant with FSH iui. She miscarried twins at 6 weeks. She is a carrier for factor V.
It sounds like you are doing all of the right things. You just have to wait for the results of all of your tests. I hope it works out.

Mrs C was told she needed IVF because her husband had 1% morphology.
He was wrong, she was right. She got pregnant on her own.

Pam is 40, and failed 2 fresh donor cycles, with 2 good donors and nice embryos. She failed the frozen cycle and has 3 frozens left.
This could be bad luck or fair medical care. I can’t tell. You want to be sure you have had a hysterosalpingogram after your myomectomy. Make sure your doctor reads the films. After that it’s too hard to say form the blog what’s going on with you. Check the delivery rates form your clinic for DE. Most good centers are at least 50-60%.

I can’t comment on one article showing success with a strange therapy in a small number of patients. Let’s give it more time.

MiraclesdDHappen: 26 yo, trying for 7 years, 6 failed clomid.
We are all sorry to hear your still are not pregnant, but it’s time to move on. It’s either FSH iui or IVF. It can happen, it’s just going to take more work.

See you next time, and please read disclaimer 5/17/06/.

Dr. Licciardi

Answers to Infertility Questions

Mas asked about Rogaine and low sperm motility. My urologists tell me Rogaine has no effect on sperm production or motility. However, just like everything else, maybe he is the one out of hundreds whose system is very sensitive. See if stopping the drug changes anything.

QVC has had elevated FSH levels but recently had a 1.9. Make sure there was an estrogen level done at the same time. Once the estrogen (or estradiol- same thing) goes over 50, it will artificially make your FSH lower. Once the estrogen is over 100, levels like 1.9 are common. You should still be on a protocol designed for women with high FSH levels.

Stephanie had a low egg number using a long lupron protocol. I suggest removing the lupron. I rarely use lupron anymore. I have also started using the estrogen priming protocol. So far I can’t say it’s better, but it seems to be at least as good.

The infertility acupuncturist asked about progesterone after IVF. There is a theory that you need more progesterone for IVF because the follicles, which become the progesterone producing corpus lutea(CL), become disrupted by the needle at retrieval. This may not be the case, but we are not sure. I would think that even in this is true, there are so many CL with IVF, progesterone production should be just fine. However there is more to the story. IVF drugs, especially lupron, but possibly antagon or cetrotide, may lower progesterone production. This is because lupron stops your pituitary from making LH, and LH drives progesterone production. Once you stop lupron, LH function returns, but it takes a few days and by then it may be too late. There are many studies showing if you use lupron, pregnancy rates are higher with progesterone. I don’t believe such studies have been done with antagon. Most studies show no improvement in pregnany rates with fertility drugs and iui. This may be because Lupron or antagon are usually not used for iui.

Melinda asked about ectopic pregnancy. She had one and is worried about another with IVF. Yes you are at increased risk, however the odds are still low, even lower if they took out the tube with the ectopic. I do not know the status of the remaining tube. Your odds could be anywhere from about 2-8% for having another ectopic. It’s good that they told you about potentially having an ectopic, but ask them to check their numbers.

Hopeful in Arkansas asked about clomid iui with male factor. It depends on the total motile count. This number is arrived at after the wash. It’s the total number of sperm you are getting back. The higher the better. Less than 5 is bad, 5-10 is ok, 10 or more is good. If you are getting low number back, consider IVF. If you are getting good numbers, then it’s up to you.

M asked about embryos that were frozen when her husband was drinking excessively. There is just not enough information out there to answer your question. Sorry, I wish I could help you with this one.

Helen asked about taking estrogen pills during her cycle. It is not a good idea to take estrogen pills as part of a natural cycle. It will interfere with ovulation, making it come early, late, or not at all.

Michelle asked about her iui cycle # 12. I am sorry you cannot afford IVF right now, I hope you can find a way. I hope this iui works.

Aimee asked about the necessity of an HSG. I skip it in only a few patients. I have to be really comfortable with their age, history and ultrasound to let it slide. If your doctor is even hinting at it, get it done. You will know soon if your first doctor was wrong. Odd are he was right, but you will see.

Nina asked about extra fertility testing before getting further treatment. I can’t really know what you specifically may need; however for most people the testing is pretty basic. It’s a HSG, SA and day 3 bloods. After that it’s all about your history and the philosophy of your doctor. You can waste a lot of time and money on tests that are not mainstream. Progesterone problems are rarely the cause of infertility. Remember, they go up and down throughout the day. Ask your doctor, taking some extra may not hurt, but don’t go on progesterone for 6 months without doing something else at the same time.

Della hit the jackpot! Very nice.


Julie has immature eggs. DO NOT GIVE UP!! Get a second opinion. I am not sure if you had the same problem both cycles. Taking more HCG may be the answer, but not if your levels were high enough. Let another doctor look at your records. Some women make a huge percentage of immature eggs no matter what we do, but even they can be successful with persistence.

Jen-Jen is 42, PCOS, considering IVF. Well, the good news is that you have PCOS. So many women think this is a bad thing for IVF, but it is a good thing, and as you get into your 40’s it’s a great thing. If the diagnosis is correct, you will make many eggs. IVF success in your 40’s is increased but getting high egg numbers. On the other hand, iui should make many eggs and your odds may be higher than expected. But, IVF rates are always 2-3 times higher than iui. So if you are considering IVF, do it soon, because you will never be younger.

Stacey came to see me and has 3 year old twins. Thanks for writing; let’s hope for good luck to all who need it.

Dove has a very high estrogen from IVF drugs. I am sure you had to make a decision before today. I hope it worked out.

So there it is. See you soon. Read the disclamer 5/17/06.

Dr. Licciardi

More Fertility Questions Answered

Courtney has a problem with Clomid and Femara because they make the lining of her uterus very thin. Should she switch? Yes indeed. It’s time for the injections; hopefully you will see a difference.

Anonymous asked about recurrent aneuploidy and miscarriage, PGD and donor egg. Check my blog on PGD. The answer is going to have to come from within, and you understand your obstacles. Even though I am not big on PGD, there are some cases where it should be considered. It may depend on how many miscarriages you have had, your FSH levels and your response to the medications.

Amina has severe anemia and an abnormal uterus and is considering pregnancy. The sickle/thal combo can be very dangerous during pregnancy. You need to sit down with a high risk doctor before you conceive. It’s hard to say what your uterine diagnosis is. If there is a big difference in the sizes of your uteri, it is more likely to be a unicornuate with a rudimentary horn, but this is just a guess. You need an MRI to get all of the facts. And you need the right person (maybe more than one) to read the films.

Jenn is having success taking long term Femara for endometriosis. Your story is giving me and patients important information. Thank you.

Amy M has a short luteal phase and is worried her doctor is not treating it correctly. She is getting Clomid, but not progesterone. I am not worried about your progesterone level of 11. I would concentrate on the length of the luteal phase on Clomid. If you get a 13-14 day luteal phase, you are probably ok. However, I also don’t see a problem with taking progesterone. I don’t know if raising the dose of Clomid will increase the progesterone level.
Sarah 23 asked if the endometrium can be too thick. I have not had problems with a very thick endometrium, providing there are not polyps or hyperplasia. These are things that can make the lining look thicker and could interfere with implantation.

Penny asked about potential problems associated with poor blood flow to the uterus. I don’t do this test; I have not seen any good literature supporting its use.

Jen has an IVF baby, but 3 nice IVF cycle have failed since. She is 35. It sounds to me like the last cycle was fine. It’s hard without seeing all of your records. You need to keep trying. You may not be able to due to finances or other reasons, but if your only barrier is emotional, you must try again. I suspect you are ready to do so, but want to do everything you can in your power to bet it right. Again, I don’t know everything about you, but I have to remain optimistic. It worked once; you make many eggs and get good embryos. Ask about repeating your hysterogram.

Anonymous has bilateral hydrosalpinx and a male factor. If there is some live moving sperm, IVF can work for you. If there are no sperm, you are right, no sense in having your tubes removed. The easiest question is the one about your doctor who is not giving you any information: just get another. There are many doctors out there who can’t wait to see you.

Anonymous asked about Femara. I am sorry but I don’t use it. I just get worried about that one person who takes it while pregnant. If your FSH is high, you know what the deal is. If you want to try it, it will not hurt you, or change you FSH levels. Clomid is not really bad for high FSHers, it is just not very effective, even in young women with normal FSH levels, although of course we use it regularly.

Jill is an excellent responder who has not yet become pregnant. Her doctor is adding metformin. I think this is fine. I did more of the same in the past, but less do lately. I have just started giving less fertility drug instead. I see you will be on less drug and this too should help. I have personal thoughts about long lupron in women with PCO. I think it prolongs the cycle. A no lupron cycle may be 1-2 days shorter, and this may be good for a woman whose estrogen skyrockets. This is just an opinion at this point. Ask your doctor.

Catherine is 40, and has trouble with her health care providers. They aren’t letting her do IVF. Yes you can get pregnant with 4 months of unmonitored Clomid at age 40, but come on let’s get real. Time is the problem. Your odds will be less than 5%, and your odds with FSH iui will be about 10% and your odds with IVF will be higher, although that depends on the success of your IVF clinic.

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

Dr. Licciardi

A Big List of Fertility Questions and Answers

Hello Again to Everyone.

Monica asked about DES exposure. Most women who were exposed to DES do not have any problems with their uterus or cervix, but a very small percentage of exposed women do. You definitely need a HSG and may need to be followed by a high risk OB if the cervix or uterus is abnormal. The older fertility doctors have a little more experience, as DES was mostly phased out by the early 70’s.

Sophia asked about what to do next after 6 failed ICSI attempts. You need to be in the best clinic available to you. You could consider travelling for a second opinion.

Mandy asked about Clomid vs Metformin. In general, I use more Clomid than Metformin. If you do not ovulate, but do on Metformin, and got pregnant easily, great, sounds good, use it again. If it took you a while consider Clomid. Doctors differ on when to stop Metformin during pregnancy, and it may depend on the severity of your case of PCO. I do not think you caused the miscarriage by changing the Metformin dose.

Laura asked if ICSI is safe. We will not know the specifics for decades. So far it looks relatively safe. You need to speak to your doctor and carefully read the consent forms.

Niki asked about her lining. Really sorry to hear of your struggle. If it’s 6, it’s 6. It probably was not much different when you last became pregnant. It can happen.

Gosiael asked about a short follicular phase and IVF. It seems you need a different protocol. Ask about trying something completely different. Lupron, low or microdose is a good suggestion. Do not give up yet, it’s too soon.

Sperm of 20 million and 20% motility: repeat the test. You have all of the options available to you. IVF may be your best shot if the sperm counts remain consistent.

Veronica asked about ICSI in a natural cycle. You can do whatever you want, but a natural cycle, while it may be successful, has a very low pregnancy rate. Your lining is fine. If your last protocol gave you your best results, yes do the same again.

M asked about IVF for a low sperm count after vas reversal. I think the microflare is a good protocol. It’s hard to say if I think it’s best for you. It seems you did pretty well with your last, but without seeing the whole cycle I can’t say for sure. To go from cancelled to 12 eggs is quite good. Ask your doctor about keeping the same protocol but going a little longer before your hCG.

Anonymous asked about a strange clomid cycle. I agree, your cycle is off, I don’t know why. Ask your doctor about moving straight to the injections.
A period after taking injectables, for IUI or IVF, can be heavier than usual. This is because the injections give you more follicles, which raise your estrogen, which gives you more of a lining to shed.

Rachael asked if it’s ok to do acupuncture. Fine with me.

Emily asked about being on Metformin for 8 months. What’s the crime in putting you on clomid? You can take both. Most doctors do not follow insulin levels in their Metformin patients. Sounds like time is just passing buy.

Blastocyst is coming.

MK: Yes, FSH levels drawn on day 23 are not useful. Your later progesterone levels look fine.

Sandy asked about PCO and miscarriage. For every doctor who says there is a connection, there is another who says the opposite. If you ovulate regularly on your treatment and you easily conceived, there is no reason to believe it can’t happen quickly again. If it took you a long time to get pregnant, you can consider getting more aggressive this time.

Kristina asked about mildly elevated THS levels, otherwise known as subclinical hypothyroidism. Your doctor is probably right, your levels are not a problem. However there are tons of endocrinologists who disagree, and would treat you with thyroid medication. In the past I did not give medication to people like you, however I got so much flack from the endocrinologists I just gave in and started treating. You can see an endocrinologist for a second opinion.

Mr and Mrs Oldham have a sperm count of 6.5 million. If your count remains in this range, IVF is by far the way to go. You can explore other options, but your highest odds will be with IVF and ICSI.

Christine got 3 opinions and it paid off! Thank you Christine for your kind words. This is the reason I do the blog. Spread the word.

Arpee: Thank you, a search function on the blog is a great idea. I will give it a shot.

Megan has had 3 miscarriages. She has 6 frozen embryos, but had become pregnant on her own. She doesn’t know if she will have a lower chance of miscarriage if she does the frozens or tries naturally. Theoretically, in a frozen cycle you are putting more than one in, so if one embryo is abnormal, maybe one of the other ones are ok, lowering your odds of miscarraige. This effect is probably minimal but may hold true. In general I don’t like PGD, but you may want to at least consider this for your remaining embryos to lower your odds of miscarriage. No matter how you become pregnant, unless there is something else in your history, your odds of having a baby in your next pregnancy are 70% (unless you are in your 40's, then your odds are a little lower).

Chris was told to take 6 months of lupron for her adenomyosis. Get another opinion. It depends on the severity of your case. I would give 6 months of lupron only in the most extreme cases. 6 months is a lot of time to lose.

Trixie has a 10 day luteal phase. This is probably too short. A little progesterone may do. Ask your doctor.

Rose has a high estrogen on day 3, but has been taking estrogen. I don’t know if you need estrogen, but if you do, try repeating your bloods on day 4 and maybe 5. You may be able to start your cycle even though it’s later than day 3. You may have estrogen in your system left over giving you this high reading.

Someone with Klinefelters has never had a semen analysis. Yes, you need this test. If there is no sperm, find a good reproductive urologist and consider the biopsy. Ask about doing the biopsy and IVF at the same time. Many times there is a minute amount of sperm, enough for icsi, but not enough to freeze.

More to come, and please read disclaimer 5.17.06.

Dr. Licciardi

Polyps

It looks like vacation is over and I have a little catching up to do. I will try to get to as many questions as I can. The first question was about polyps, so here we go.

First a little story. I had a patient whose uterus looked fine on her initial ultrasound and HSG. She started an IVF cycle and lo and behold, a day before her hCG, a couple of polyps were discovered in her uterus. They were just under 1 cm each.

We had a few of options. First we could have canceled the cycle, removed the polyps, and restarted a cycle in another month. The second option was to continue the cycle, freeze the embryos, remove the polyps, and then do the frozen cycle. The third was to do nothing, continue with the retrieval and transfer and see what happens. We did the last, and she became pregnant and delivered twins.

What are polyps? Going back a little, uterus is composed of 2 basic parts, the first being thick outer muscular layer; the myometrium. The second part is the innermost layer made of glands; the endometrium. Most of the endometrium sheds every month with menses. Polyps are little balls, usually round or oval, that are overgrowths of the endometruim. So they grow on the inside of the uterus. They are not shed every cycle, they stick around each month and can get bigger with time. Sometimes I explain they are like skin tags, except inside the uterus. We don’t know what causes them.

Theoretically, they interfere with implantation. How? One possibility is that because the glands are growing in an abnormal way, an embryo may not be able to attach if it tries to stick on top of the polyp. This is probably because the embryo will not be able to receive proper nutrients and blood flow. Also theoretical, a polyp located in one area of the uterus can make even the normal areas inhospitable because the polyp may create a generalized inflammation in all areas of the uterine lining. This inflammation could interfere with any of the many very complicated implantation steps.

Should polyps be removed? It depends what you call a polyp. Some doctors see a little area of irregularity in the uterus, which can be normal, and call it a polyp and want it removed. Most doctors are more reasonable and agree that we don’t know much about small polyps, and we don’t know if they interfere with conception. There are many women with polyps who get pregnant all of the time, but when we have a patient who is not getting pregnant and has a polyp, we at times want it removed.

The smaller a polyps, the less we worry about them. We really don’t have a size chart to tell us what’s too big. In general, polyps less than 5 mm are really small and rarely removed. Polyps 5-10 mm are a little more of a concern, but your doctor may see one of these and not worry. Larger than 1 cm is more significant and more doctors would recommend removal. 2 cm is pretty big; too big.

Most women do not know they have polyps. Occasionally they cause pre menstrual, or post menstrual spotting, sometimes mid cycle bleeding or spotting. Larger polyps can make the period very heavy and long.

So what do we know? We know if there are one or more large polyps, and everything else is normal, women have a good chance of getting pregnant after the polyps are removed. The effect of smaller polpys on infertility is less known. Some women get pregnant after having small polyps removed; some women get pregnant with the polyps in.

Doctors and patients have their breaking point for polyp removal, but the thresholds can be different from case to case and from practice to practice.

Polyps can grow back. Sometimes they are completely removed the first time, and they grow back anyway, or there is a new one that develops. Sometimes the first polyp is not completely removed. Many polyps grow from a stalk, so that if the polyp is removed, but the stalk is not, it is more likely to come back.

This is one reason that a hysteroscopy is mandatory for proper polyp removal. A standard D and C, where the doctor does not actually look in, is not the right surgery, and in many cases leads to failure and a repeat procedure. During this procedure, the doctor scrapes “blindly”, not seeing where the curette (scraper) is going. Here it’s common for the polyps to be pushed aside, but not removed. Looking in with a scope to be sure all of the polyps have been removed, including their stalks, is the way to go. During hysteroscopy the doctor can slide a tiny grabber through a narrow channel in the scope, and target and directly watch the polyp removal.

Can polyps be cancerous? Very very rarely. You can discuss this one with your doctor.

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

Dr. Licciardi on TV

This week I was on live national television; The Early Show on CBS. One segment was Monday and one segment was Tuesday. You can view the pieces by going to:
http://www.cbsnews.com/sections/earlyshow/main500202.shtml
On the left margin look for Videos, and then click health. You will see videos, click more videos. The 2 segments are “Being a Mom with Breast Cancer” and “Pill Giving Women a Chance”.
I would just give you the video's URL, but for some reason it is not working for me.

Dr. Licciardi

The Endometrium Part III

Last time we went over some of the conventional methods used to increase the lining thickness. What about the less conventional?

Well there’s Viagra. I had a patient try it and she had a baby. I have had many others try without success. The linings measured no thicker on Viagra than off. As with many things there was some initial interest when it was first described, but we never were able to conclude that Viagra does anything. I do not suggest it to my patients.

What about baby aspirin? The studies are also limited, but the results are not compelling enough to convince us that baby aspirin is worth anything. I have heard that some doctors have all of their patients take it regardless of history. Why I don’t know. It seems benign enough, and is probably used by many women who keep it a secret.

What about using blood flow as an indicator? Why look for bad news? If someone could tell you it’s almost impossible to get pregnant with a certain blood flow, fine, but they can’t, so why torture yourself. We don’t know enough about this.

Is there a minimal acceptable thickness and is thicker better? My colleagues and I did a study looking at donor egg recipients and compared pregnancy rates in women with thin and thick linings. The pregnancy rates were the same in women with linings less than 6 mm compared to women with linings 7 mm or greater. Dr. Noyes also did a study looking at recipients and found that there were plenty of pregnancies in women with thin linings, but the rates were a little higher when the lining was greater than 9 mm. Other authors have shown there is no correlation between thickness and pregnancy rates, and others have shown that the pregnancy rates are higher with a thicker lining.

I do not think the pattern matters. The odds of pregnancy don’t seem to be different if the pattern is ring (or triple) or homogenous. I have found that if the uterus is sharply retroverted, the pattern is commonly homogenous, probably just having to so with angle of the ultrasound waves.

If I had to summarize the general feelings of most infertility doctors, I would say that we are a happier then the lining is thicker, and we may try things to thicken things up a bit, but in the end we take what we can get. Many patients have told me they heard that the target lining is over 9 mm. This I can say is not the case at all.

So let’s say for example I have an IVF patient whose maximum lining is 6 mm. I am not overly worried about this, but will review things and see if there is anything that can be done. I may mention to her that the lining looks a little thin, but would also say it’s not a cause of great concern. Any thicker does not even get a mention. Thinner will get more of a discussion. If her cycle does not work I will try to get it thicker next time, probably using estrogen patches early in the cycle. In many cases the lining remains the same.

For IVF, some doctors freeze all of the embryos and try to get the lining thicker in a high dose estrogen frozen cycle. I have never done this because I do not think it helps. I think you may hurt some embryos with the freeze, and I doubt the lining will get much thicker or much better in the frozen cycle.

This all sounds OK until we have a patient who is not getting pregnant, and also has a thin lining. Question: is it really the lining? Maybe yes and maybe no. I currently have a woman who has tried IVF 5 times with average embryos and a 9 mm lining. Why isn’t she getting pregnant? The point is some women have a thin lining, but a different reason for not getting pregnant.

Some women bail out and go to a gestational carrier, and are successful. In their case it seems the problem was the lining. But few women want to or can afford to go with a carrier.

In summary, the thickness of the lining is not as important as many doctors and patients make it out to be. However, there are some women with thin linings who cannot get pregnant, and for some of them, the lining is the reason for their infertility. Because the treatment of infertility is a game of odds, trying, even when it looks like there are factors against you, is the best thing to do. After that, it’s time for third opinions and opening up to the less conventional options.

That’s it for now,

Please read disclaimer 5/17/06.

Dr. Licciardi

Improving Endometrial Thickness

Today’s case: I have a patient who is doing a frozen embryo cycle, so we are preparing her uterus by giving her estrogen pills. She completed 2 weeks of estrogen therapy and her uterine lining was 6 mm, a ring pattern (also called a triple pattern). We decided the 6 mm was a little thin, so we kept her on the estrogen for 1 more week. I scanned her this morning and her lining was 8 mm. As this was a more acceptable thickness, we didn't need to wait any longer and we have now scheduled her transfer.
Is this a typical response? Did waiting help her cause? Let’s go over a few things.

Can your doctor do anything to improve the thickness of the lining? First let’s start with things I try. And here I am talking about a “medicated cycle”, one in which a woman is asked to take estrogen to prepare the lining for a frozen cycle or maybe in preparation for a donor egg cycle. These are cases where the ovaries are not stimulated by fertility drugs, there is no egg production and therefore the ovaries do not make estrogen. All the estrogen comes from medications.

One way to try to improve a lining is to just take more estrogen. There are different ways to get estrogen into your body: pills, patches, vaginal pills or suppositories and injections. All work well and none have been shown to be superior. When you are talking purely about estrogen levels, usually the shots and the vaginal pills lead to the highest blood levels. Levels with the oral pills and patches give levels that are a lower, but usually these methods supply more than enough.

What is the minimal acceptable level? I shoot for at least 200 pg/ml, but probably a little lower is just fine. No one has ever shown that 400 is better than 200, or 1000 is better than 400. Therefore, most of us are not overly concerned with the levels as long as the minimum is reached.

So in the case above, we didn’t even add any more, we just gave the uterus more time, and it seemed to work.

I start with estrogen pills, because I think it’s easier for the patients. Some women get bad rashes from the patches, and we all try to avoid injections. The other thing I don’t like about the injections is that the estrogen stays in your system a long time. So if you are not pregnant you need to wait longer to start again. But if you doctor has another preference, fine with me, they all work.

Some women do not absorb the pill well, and other women get low levels with all of the estrogen methods. We don’t know why. Maybe they metabolize the estrogen quickly (their lever breaks it down quickly).

If the pills are not working well, we can add a patch, so the patient is taking both. Or we can add the vaginal pills, injections or all of the above.

Case 2. I had a patient years ago who did one IVF cycle with a lining of 8 mm. She got pregnant and had an uncomplicated vaginal delivery. Nothing unusual happened at all. Then she came back for her frozen embryos and her lining would not go above 4 mm. We added everything, still 4 mm, despite very high blood levels. We cancelled the cycle, and tried another fresh IVF cycle, thinking maybe her uterus would respond better to the ovaries making estrogen, and still 4 mm. We do not know what led to the change.

The point here is that only some women respond to extra estrogen and or time. Most of the time, if you have been on some form of estrogen for 10-14 days, that’s it. What you have you have, there is no improvement later. Or maybe there is a minimal increase the lining thickness.

In many many cases, the “feel sorry” factor comes into play. This is when the doctor does the scan, finds a thin lining, and then looks and looks and looks trying to find you an area that is a little thicker, and usually finds a better spot, even if it’s 1-2 mm extra. When the lining is obviously thick, it should take the doctor about 2 seconds to measure the lining. If it’s thin, but it’s a little early, and we know you will be coming back, same thing. But if you now have had extra time or been on extra estrogen, there is nothing else to offer, and we look and look.

The point here is I don’t know if the lining actually improved. It may just be that the doctor took much more time and found a little area that looks a little thicker and everyone leaves the scan feeling a little bit better.

Next time we will finish with other ways to make the lining thicker, and we will try to answer the question, what is the thickness target?
Thanks again, and please read disclaimer 5/17/06.
Dr. Licciardi

Some Additional Answers to Infertility Questions

Jill,
Eventually I will get to the blastocyst topic. For now suffice it to say that some programs are better than others at blastocyst, so it may not be your eggs. Don’t feel cheated because you never had a laparoscopy. A good doctor can usually determine which patients need a lap. Most of my patients do not need that surgery. Some patients request a laparoscopy, and that’s ok too.

Dear Matty,
Very sorry to hear your story. You doctor should not want you to do IVF with PGD, he should go over the options and let you decide. PGD may help, but it’s not all it’s cracked up to be. You are lucky to be making so many eggs at age 40. Your highest odds for pregnancy will come from IVF, but other methods can work. IVF usually has a 2-3 times higher pregnancy rate than FSH iui. If you want to do more natural iui, than that’s what you should do, at least for now.

Jamie,
12 mature eggs form 21 follicles is a little low, but this happens. If they were immature I would agree with going longer, but since they were mature, you did not receive hCG too early. Who knows, maybe you got it late. Ask you doctor what the pregnancy rates are with one frozen blast. It’s probably 10% or less.

Mrs. H,
You need to take the advice of your urologist, or get a second opinion form another urologist.

Danielle,
Most of us give steroids after retrieval to reduce the level of inflammation in the uterus. The practice goes back to very small study done more than 20 years ago. We are not really sure if it does anything. If they prescribed Medrol, that’s a corticosteroid.

Valerie,
The sperm seems fine. You need to check the stats for clamed iui, FSH iui, and IVF, then decide. I have a blog on those stats.

Dear Empty Baby Room,
You need another opinion. It sounds like there are too many unanswered questions about your diagnosis and treatment.

Ducks Mom,
Metformin may bring you to regular cycles. It doesn’t always, but in you case it sounds like you are improving. Infections: you really need to ask your doctor. If he feels there is not issue, that’s good enough for me. Sometimes a shifted uterus is indicative of scar tissue, but usually it means absolutely nothing.

Tabi,
Sorry about your ectopics. It really sounds like bad luck. Clearly you are at increased for another ectopic, unless your tubes have been removed. If not, you could consider tubal removal as an option. Odds are your next pregnancy will be in the uterus, even if you keep your tubes.

BVC,
Your problem is unique because you don’t have the option of trying on your own every month. Women, who say, fail IVF and want to try to get lucky on their own, sometimes get pregnant. You can not have the luxury of all those free tries, you are dependent on the office procedure Therefore if your odds are lower than other women’s, based on your FSH level, you still need to try inseminations. Not forever, but maybe more than you have so far. IVF and iui are a little different in that it’s hard to screw up an iui cycle, so you should be ok where you are.

Wanna,
We can’t promise you will get pregnant, but almost all women with your story have success. You have many factors in your favor. There are women reading this who wish they were in your shoes because of our age and response.

Caroline,
Sorry I don’t think there is anything to endometrial activation.

Sypergirl,
You need a second opinion. I find it unusual that you would have 8 fresh embryos for transfer and need to thaw the frozens in the same month. Unless you pushed them to do so. I see the results were somewhat helpful, it just seems like a lot of embryos to go through in one cycle.

LA Dude,
I do not think PGD is helping you, I think its hurting your chances. Now I need to say that I am not familiar with the proceedings of your specific clinic. Maybe they have great live birth rates with PGD, but they would be an exception. PGD is a profit center. If they can show you that even though PGD is more expensive, it’s worth it because it increases live birth rates, then I have no complaints.

Dear Eno-a-Go-Go,
Unfortunately your story is not uncommon. Your problems are being made worse by the doctor’s fighting. First the sperm is probably fine, and you will see this in the next semen analysis.
Now about you. I agree that is strange that your doctor put you on clomid with a 4 cm endometrioma. The problem is not that it made enod worse, it probably had no effect on your cyst at all. It’s more that if there is a big cyst, many times there is more endo elsewhere, and tubal scar tissue, therefore the clomid will not help you get pregnant. However, I saw someone last week who got pregnant on her own with a cyst just like yours.
If he did a hysterogram and the tubes were open, clomid is acceptable, but not the norm.
If most of the cyst is not removed, it has a higher chance of growing back. I remove the cysts completely. However, rarely, we come across a cyst that just does not want to come out, and we drain it. If you want to go straight to IVF, than that’s what you should do. It’s a very reasonable next step.

More next time,

Dr. Licciardi

Please read disclaimer 5/17/06

The Endometrium Part II

I’ve seen a lot of good questions come across the blog, and I will get to them in the near future.

What makes one woman’s lining thicker than another’s? Probably the only thing we know that makes a difference is uterine surgery. Now don’t everyone panic if you have had uterine surgery. Only very small percentage of women will have a problem, and if you need it, uterine surgery can be a good thing.

The surgery/thickness issue is related to scar tissue. Scarring in the uterus can make the lining thinner. Now there are 2 aspects of this. One is a local thinning. In this case, ultrasound can show a normal lining in part of the uterus, but a thin or absent lining in another area; where the scar is. Sometimes however, even when the scar is in one area, surrounding normal areas may look thin, and these thin areas thicken up after the scar is cut away. In this case it may be that the local scar keeps the 2 sides of the uterus tightly close to each other, and when the scar is cut, the front and back sides are not as close to each other and the lining can grow more thickly.

This last sentence requires a little basic explanation. You see, most people think of the uterus as a globe, round and hollow in the middle. While this is kind of true, the uterus is more like a peanut butter sandwich. The muscle is like the bread, and I call these the sides, or sometimes I say “front and back”, and the lining is like the peanut butter. So imagine areas where there is no peanut butter, the sides are touching in the middle. ( I must say I really hate food analogies, but I can’t think of a better way to say this.) So at hysteroscopy, we cut the scar, and the lining re-grows from the good areas. Of course, during pregnancy the uterus rounds out and becomes the globe.

The second aspect of thin lining and scar tissue is a little different. Here, even though the scar may be in one local area of the uterus, the entire lining gets affected. Last time we spoke about how the lining regenerates from the few glands beneath. Well for some reason, sometimes all of the cells that are supposed to make the new glands don’t work well. As an example, I once had a patient who came to see me because her uterus had been perforated during a hysteroscopy. Now usually such a perforation is localized. It’s a hole in just one spot in the uterus that usually heals well. In her case, yes the hole healed closed, but the lining throughout the entire uterus would not grow thick.

What this may be telling us is that when the uterus becomes damaged in one place, something is released to the surrounding areas of the uterus that permanently affects the ability of the lining to grow well. It may be a result of the injury, or maybe the injury allows for a small infection to start and cause damage. We really do not know how this all works, we just know that in some women, this is the story.

Should you have a hysteroscopy if your lining is really thin? Maybe. You should start with a hysterogram or sonohysterogram. I usually prefer the hysyerogram, but in some patients the sonohysterogram is ok. Some people need both. If these tests show scaring, then yes surgery may be indicated. If the cavities look completely normal, a hysteroscopy may not help because “looking in” without having anything to fix will not do anything to help.

I had one woman with a perfectly normal lining, got pregnant with IVF, and after a vaginal delivery, had a very very thin lining. Who knows, maybe a small infection, uterine tear or neither. A first trimester abortion, or d and c for miscarriage may cause this, but the odds are really low.

And there are some women who have never had surgery or a baby, who just have a thin lining.

Next tine I will discuss if a thin lining matters and ways we try to get the lining thicker.

Please read disclaimer 5/17/06, and thanks again,

Dr. Licciardi

The Endometrium

OK,here we go with another topic.

The uterus has 2 basic parts. One is the muscle, also called the myometrium. This gives the uterus its strength, even when stretched thin during pregnancy. Blood travels from the big arteries of the pelvis, through the smaller arteries of myometrium, and during pregnancy from the myometrium to the placenta. Fibroids start to grow from the myometrium.

The other part is the endometrium. This is the layer of glands that line the inside of the uterus. Almost all of the endometrium sheds during menstruation, and then the new glands arise from the small numbers of glands that were left behind. The glands support the pregnancy.

Because the myometrium and endometrium are different tissue types, and of different densities, the two can be seen distinctly via ultrasound.

The ultrasound view of the endometrium changes throughout the cycle. During the period, the endometrium can look very different from day to day and from person to person. By day 2, some women have bled a lot and have shed most of the glands, and therefore their linings look very thin on ultrasound. Some women have not bled much, so most of the lining has not yet shed, and their linings look thicker. This is why I never comment on the endometrium on a day 2 or day 3 scan. If it’s thick it will thin out, if it is thin, it will get thicker as days go by. This is why when some of you ask at the baseline scan, “how does the lining look”, I always say it doesn’t matter how it looks.

The glands then grow thicker day by day and this is the result of increasing exposure to estrogen, which is coming from the growing follicle. This growth phase is also very different from person to person. Some women need very little estrogen to get the lining thicker, and they do not need the estrogen levels to increase with time. All they need is a small amount of estrogen to get the lining to grow, and it will get thicker by itself. In other women, more estrogen is needed. For some women, the thickness can be related to the estrogen level, i.e. the lining can grow to a certain thickness, not more unless the estrogen levels get higher.

The lining stops getting thicker after ovulation, at the start of progesterone production from the follicle, now called the corpus luteum. Progesterone does not make the lining thicker. Progesterone changes the cells of the glands so that they can allow the embryo to grow. Usually the lining stays the same, or it may even get a little thinner after ovulation. Over the next 2 weeks, the lining is undergoing considerable change from day to day, but we can’t see any of these changes on ultrasound.

We can however see a basic change between the pre and post ovulation lining. Before ovulation, the glands look darker, and we can many times see the “triple” pattern, also called the ring. This is shown in the ultraound at the top of the page After ovulation, the emdometrium gets a little brighter, and there is no longer a ring, the pattern is more homogenous.

More to come,

Dr. Licciardi

Last Answer Session, For Now.

I have been collecting information on the thin endometrium and will write about it next time. So far, I have not come across anything earth-shattering, but I will let you know what I found and what I think.

Here we go with the list of questions.

Christine: It does not sound like progesterone was indicated for your natural pregnancy. In addition, many doctors do not think progesterone is necessary for a medicated iui cycle. It looks like your levels now are great.

Dear Helene, I cannot comment much more without seeing everything. Trying again is the key, and I hope you do better, you probably will.

Maggie, Unexplained infertility is confusing, so much so we doctors are confused about it.
Your doctor sounds right about your lining, it is thin, and he may not be able to do anything about it, and it may not matter much anyway. Your odds may still be very good.

Jenna, there is a lot of literature showing progesterone is not necessary for FSH/ LH iui. I may use progesterone if there is good indication, otherwise usually I do not. Usually, a bad pregnancy makes a low progesterone, not the other way around.

Lori, The infection rate after iui depends or the risk profile of the patients. In my practice, the rate is less than 1/1000. It also depends on what you mean by infection. True infections after iui are very severe and require IV antibiotics.
Your odds depend on your age. 20% is for women under 35, and it goes down to 5% for all women in their 40’s.

NYC, A low estrogen on day 2-3 is want you want. Levels through the rest of the cycle can really vary from person to person, so as long as there is some, you should be ok.

Hope, you need a Hysterogram (the x-ray), not a Sono Hsyterogram. A hysterogram is much better for diagnosing tubal problems.

13 million sperm? Use it, you never know. I don’t know why there is a difference. You should check the counts again, they will probably be higher.
Colchicine can lower sperm counts, but the change will vary from man to man. You need to ask a urologist.

Mrs H, Do not under any circumstances remove any testicles. I understand the frustration in not knowing why things don’t work out. Maybe you now have “unexplained infertility”. If you are not getting pregnant on Metformin, you need to talk to your doctor about other medications.

Underweight? Probably not a problem, as long as you are normally regularly ovulating,

43 yo, failed IVF with one embryo. It all depends on you. If you want to do another cycle with a 5% pregnancy rate, it’s your option. Most doctors would let you, but not encourage you.

Husband with cancer. If his sperm count is now zero, you really need to rethink this plan. First, you need to recheck your day 3 bloods, I bet they are more normal than your last set. You have 2 vials. Why waste ½ of the sperm on iui? Your odds with the iui (if your bloods are more normal) will be 20-30%. You need to consider IVF. With IVF, less than a vial can be used. The embryologist can chip away at the ice crystal removing some sperm , but leaving most of the vial intact. Therefore you can get many IVF tries from 1 vial. Now, if you don’t want IVF, or can’t do IVF, they you are left with iui. If your husband is producing some sperm now, then iui does make more sense.

Bad donor eggs. Hard to say. Maybe the eggs were good but just didn’t fertilize, and you were left with one that squeaked by. It’s also possible you had a donor who made poor eggs, however is more commonly seen when fertilization takes place and the embryo development is poor. Whatever the cause here, your uterus probably had nothing to do with the bad outcome.

Implantation hormones? There are no reliable tests for this yet, that I am aware of.

Blue: Blastocyst transfer: another blog. We like to see embryos at least 5 cells, 6 is better, on day 3. 8 cells are probably a little better however if the grading is good, 6-7 cell embryos should be good enough. Sometimes it depends on the time of day. If the transfer is early or late, the cell number can be different.

Adenomyosis: I’ll put it on the list.

Napro: no comment.

Della. Most of us go through 3 FSH iuis before IVF. But everyone has different circumstances, so you will have to decide. I don’t think a couple of extra iui cycles will hurt anything. I have had women get pregnant on their 4th try.

Mwiegers: of course you should try again. There are a ton of positives here. You make eggs, and will fertilize more, and make it to blast, and get frozens. It’s almost all good. The next protocol probably does not matter much. If you had hyperstimulation issues, your doctor needs to lower your dose.

Gestational Surrogacy: OK with me.

Shelli: yes bad luck with age mixed in. If you get pregnant again, odds are you will have the baby. You may not, but the stats are in your favor.

Pegs. It’s hard for me to comment on a cyst I have not seen. 4 cm is on the bigger side, sorry I can’t tell you more.

Desperate: I am very sorry to hear about your loss. I am sure it’s hard not to feel guilty. Bad things just happen. Don’t be afraid, you have to stay strong. Go when the time is right. None of the odds change. You didn’t hurt or help you chances going ahead.

Pam, Forgetting about the morphology, it seems like you have done everything short of IVF and need to consider IVF as your next step.

Iron and miscarriage: usually not.

Clomid day 14. It depends. If you don’t ovulate then you can take clomid day 5, 15, 25 or any other day, provided you didn’t start your cycle yet. Some doctors want you to get your period, or bring on a period before clomid. This may depend on how long it has been since your last period.

Infection and Infertility: I really want to comment, but I can’t. Therefore: no comment. If you see me in my office I will have a lot to say about this.

Anna: Yes your story is strange, but I have seen this. There is no explanation. Hopefully this is your last strange cycle.

Thanks again, and read disclaimer 5/17/06.

Dr. Licciardi

Infertility Questions and Answers

Eggs fragmented as they were undergoing ICSI: same response. This is a very unusual thing to happen. In 13 years of ICSI I have not heard of this. Maybe you are a really rare case, or maybe you need to find another clinic. There is no way to know till you try again.

Too soon for IVF? It’s up to you. I agree that is very reasonable to try more FSH iui before IVF. Some women would prefer IVF now. You got pregnant 1/3 of your cycles of FSH iui. Not bad.

ICSI. Yes I have written a bit about this. You describe 2 completely separate things. ICSI for low morphology and ICSI for low sperm counts. ICSI for low morphology is not performed in all IVF centers. ICSI for very low counts is mandatory. Is ICSI safe? We think so, but we will need a few more decades to know for sure. There is a slightly higher risk of n abnormality after ICSI. We think this is because men with low sperm counts are more likely to carry and pass on abnormalities. If ICSI is not necessary don’t do it.

Improving sperm counts: Yes, you are on a good track, as long as your hysterogram is normal. If natural doesn’t work, you need to decide on the next step, using the pregnancy rates of your clinic. The FSH level is probably OK, your response to the injections will tell you more, if you need them.

Elle in Wyoming: You need to check your tubes with a hysterogram and go from there. If at least one tube is normal, you will eventually need more aggressive therapy in the form of fertility drugs and insemination or IVF. If both tubes are bad, its IVF, surgery or both .

Mama in Michigan; You will have to ask your doctor about the best weight loss plan for you. Mid-cycle is probably not the best time to start. Good luck with the cycle.

Lazarus: I say don’t lose the month, unless your doctor really insists.

Density gradient. Basically that’s how most iui’s are done. There are a few other methods. These procedures do not make the sperm any better; they just concentrate it so that at iui, more sperm get to the eggs than would during intercourse. So the density gradient is a procedure that usually goes along with other treatments, like fertility drugs. You can also do a “natural cycle” iui. It all depends on the sperm counts.

Miscarriage with progesterone. Unfortunately this happens all the time. While the progesterone may assist you in carrying the pregnancy, it does not save a bad pregnancy. Most pregnancy losses are chromosomal and progesterone cannot save a chromosomally abnormal pregnancy. There are other much rarer causes of miscarriage, and most of these are not aided by progesterone.

Filling defect. I do use a balloon for about a week in some cases, depending on how big the scar was. You will need a hysterogram. The results vary. The bigger the initial scar, the lower the chance of success. For most people, the scar is not huge and things go well.

80% pregnancy rate per try in a frozen cycle. I am tempted to say that this just cannot be possible. Even the top clinics are 30-40%. But, since I don’t know where you are going, it’s not fair for me to be suspicious. However, if they are at 80%, it should have made the New England Journal of Medicine, which I read, and I have not seen it there. Please ask them to be more specific with their stats. Out of the last 20 frozen cycles, how many got pregnant and made it past 8 weeks? Many of us do vitrification, and no one has shown that vitrification has higher pregnancy rates than slow freeze. People like vitrificaiton because it’s much easier. Get another opinion to see if you may have bailed early.

Thanks again and see disclaimer 5/17/06.
Dr. Licciardi

Lots of Good Questions

Severe Infection after Delivery. There are some women who have a normal hysterogram but still have some scar tissue around the tubes. The HSG can not find all scar tissue. The tubes may be open, but if they cannot move due to scar tissue, it’s harder to get pregnant. Ask your doctor about this.

Sperm Penetration tests. The only real sperm penetration test is human IVF; that’s it. If you do IVF again, ask your doctor about doing ICSI on some eggs and no ICSI on some eggs. This may give you all your answers.

Varicocele and PCO and 3 surgeries for endometriosis. All roads point to IVF. He can have the surgery, but odds are it will not help, and it sounds like even with normal sperm, IVF is a reasonable option due to your history.

Varicocele at Cornell. Can’t comment.

IVF and Religion. I have had some patients with similar concerns. Options are 1) speak directly with your minister and confirm that IVF is not allowed; you may be surprised. 2) do IVF and decide ahead of time how many eggs you are willing to fertilize.

Jill. Clomid and PCO can be a process. Not every cycle is good. If your cycle length is greater than 32 days, it is reasonable to do clomid 3-6 times. Many women do not do the 6 tries because they get frustrated and move on. 14 mm does sound small, but you never know.

Natural pregnancy after IVF. It definitely happens, but not that frequently. It’s ok to try, but don’t wait too long.

Does a large egg number effect egg and embryo quality? In general no, however, if you get your hcg early to prevent hyperstimulation, you will have many immature eggs. The other mature eggs are probably just fine. It’s hard to comment on the specifics of your IVF cycle without seeing the details. I don’t know why you did PGD. You should definitely use less drug next time, and get to the best IVF center you can.

Coasting. In my experience, 1-2 days of coasting seems ok, but I have seen poor embryo quality after “prolonged coasting”.

I too am baffled.

Laura, It depends on the amount of sperm in the urine. It’s hard to recover enough for IUI but we can in some cases. And of course it also depends on the status of your tubes.

I do not believe in the natural killer cell theories. Nor do most OBGYNs and REs.

Estrogen falling in an FSH iui cycle. This occasionally happens. Sometimes it is explained by lowering the dose of medication. Now, lowering the dose is frequently done and is a smart thing to do, but some cycles just don’t tolerate the decrease. The only thing your doctor can do is learn from your specific case and do things a little bit differently next time.

Thyroid and IVF. Anytime your estrogen goes up (from oral contraceptives or fertility treatments) your TSH will go up. Therefore, it’s hard to know what your thyroid status is during an IVF cycle. What you want to do is make sure your thyroid is ok before the start of the cycle. I do not measure the TSH once the cycle starts. If you are pregnant, make more adjustments if necessary. Early pregnancy is another difficult time to get the thyroid perfect.

Kaleigh: It depends. If you had done many natural iuis before FSH iui, then it’s almost time. If you only did 3 attempts, you could wait longer.

Helene: your story is unique. It is very very rare that an egg would be fragmented before the ICSI. Something is not right and I am not sure where the problem lies. It could be your eggs, but I am not so sure about that.

I don’t think low morphology is an issue.

Clomid: if you are ovulating on the lower dose there is no need to increase the dose, unless your doctor has another reason for doing so. If you look up treatments for luteal phase defect (which I don’t think exists, except for rare cases) one is clomid. A trigger shot may help.

Sarah. Your case is like many others. IVF will give you your best odds of having a baby. IUI may also work, but pure stats favor IVF. Yes, your odds are lower than other women your age. The miscarriages and infertility are all related. Of course to be successful with IVF you need to have close to normal FSH and make eggs. Ask your doctor about skipping the PGD, you may be damaging your 1 good embryo.

5 fresh IVF cycles. It depends on your age and the number of eggs you make. Get to the best IVF program available.

It may be better to dilate before the iui. Dilating may disrupt the lining and cause bleeding. aLso, your doctor may not be avavilable to dilate you on insemination day.

Follicles in the luteal phase? Some women do, but this is a very bad sign. Most women with follicles and periods that are off schedule have high FSH levels.

If you have never tried and have regular cycles, I prefer natural over clomid. If natural does not work, it’s time for clomid. Yes, clomid can have some negative effects, but statisticallty, clomid is better than natural, once natural fails.

Kirsten, The sperm is a little off, but probably fertile. I would repeat his test. Make sure it’s done at a fertility center.

Sperm motility of 1%. It’s all IVF.

Ovualtion stopped. Try office monitoring. If no ovulation, clomid may be necessary. Of course your doctor needs to look for causes of your ovulation changes.

Dr. Kleinman. He has been working on this for years. No proof yet. Very nice guy. If you think the test will change you plans, have it done.

Thanks again, and please read disclaimer 5/17/06.

Dr. Licciardi

Back to Infertility Questions:

DHEA: After getting to know me and my blog style, you can probably predict my response: show me the data. To be fair, the DHEA people seem to be doing a good randomized study, so let’s wait and see. I do not see that DHEA will hurt, but you will need to get specifics from the doctor.

Improving Sperm Morphology: Sperm morphology may not need improving. Your problem may lie elsewhere. It’s ok to explore the issue if you wish, but don’t let months pass dealing just with this. Do some sort of infertility treatment at the same time.

IUI success rates: we don’t keep track of this, probably because it’s a little more complicated and less controlled. For the best rates, you need to be able to get services 7 days a week. Many offices say they can give you this, but find reasons to do your IUI early or late depending on their schedule. It’s a little harder to mess up an iui than it is for IVF.

Laura: low sperm/IVF vs iui. His counts and motility are really in the IVF range. It doesn’t mean you can’t get lucky with an IUI, but your odds are low. It depends on how quickly you want to get pregnant. If you don’t mind waiting to get lucky, do IUI, if you want to give yourself the best odds sooner, do IVF.

If you can’t tolerate Clomid, don’t use it. There are other options that work very well. FSH is a very good option, provided the dose is correct. Femera may work; I don’t use it because I am paranoid about someone using it while pregnant. It sounds remote, but people take clomid while pregnant all the time.

Thin lining. Very tough. I will do a blog about this.

Helen: Sorry to hear about your complicated history. I assume you have had every test under the sun. My addition would be to be sure that your RE has looked at your hsg film.

Two Clomids and one Follistim. It’s up to you. Many women would do 1-2 more FSH iuis, and then IVF. But you have the option of going straight to IVF. I do not think the morphology is the issue.

Minerva: You just need a plan. You need to time your intercourse. Getting on clomid to give you more regular predictable cycles may help you get pregnant more quickly.

Elisa. The good news is that you respond very well to the meds, which should mean that you have plenty of good eggs. This does happen, especially in the first try. Next time use a much lower dose and you should be fine.

I am not sure why you are on Lupron for 3 months. This sounds very extreme to me, and of course is delaying your treatment for 3 months, while making you miserable. I am not sure about this beta test, it is more likely you just didn’t get pregnant.

What is the rationale behind the wide variety of post transfer guidelines? What a great question. There is not much rationale. After transfer, you could probably go the gym, swim a mile and do whatever else you wish, with no effect on outcome (this is not a quote from our discharge instructions). If jumping up and down were a contraceptive, we would have figured it out by now. Yes IVF is a little different, but not much. In natural pregnancy, embryos pop down the tube, in ivf they come up the cervix, and the rest is the same. So the party line is “take it easy”.

Balancing the finances for iui vs IVF. You can lower the cost of an iui cycle. If you have regular cycles it’s easier to use the kits for timing. You can use clomid and the kits together. This avoids monitoring and your only cost will be for the iui. Office monitoring is more precise, but if costs are a factor, home monitoring can work as well in most but not all cases. If the kits don’t work well with you, then you may need monitoring. If you are doing FSH injections, you need monitoring.

FSH levels have little to do with fragmentation. Usually they are separate issues.

Clubbed tubes. Clubbed could mean 2 things. It could mean the ends are scarred but open, or it could mean they are scarred and closed. Closed is what we call a hydrosalpinx , and you can read about this in a previous blog. In any event, odds and embryo number are based on the clinics rates for your age. Optimism is my emotion of choice.
See you soon, and read disclaimer 5/17/06.
Dr. Licciardi

Varicocele

Hello Again!
This is a subject that I have been avoiding for years. I am not a urologist, but in 40% of the couples I treat, male factor fertility is at least part of the problem.

While I have my opinion, established through 18 years in the business, this morning I went through much of the research on varicocele repair and reconfirmed that this topic is as controversial as it gets. Most urologists say varicocele repair is a must-do, and others say it’s a procedure that will not help.

A varicocele is a dilated vein, or a whole collection of dilated veins in the testicle. No different than varicose veins in a leg. The problem? The theoretical problems are:
1) The temperature of the testicle needs to be lower than normal body temperature to function properly, and some say the big veins keep the temperature too high.
2) Veins take blood away from organs. Some feel that if the veins are enlarged and congested, they cannot properly take the blood away from the testicle, and this leads to a buildup of waste products and toxins that impair proper sperm development.


Just a few thoughts of my own:

In my experience, I have not had men improve their sperm counts after varicocele repair. To be fair, I do not have a log tracking the counts of these men. In addition, maybe some of them become fertile and leave my practice pregnant without telling me. I don’t know about this one. My patients are very good about communicating with me, and while I should at have heard of at least a few of such cases, I have heard of only one. I see tons of men who show me their sperm reports pre and post varicocele repair with no change in the counts, motility or morphology.

So what do care if mister has a varicocele repair? Well, why have a procedure that may not be necessary? A bigger issue for me is the waiting. Urologists who perform the surgery tell you you need to wait 6-12 months to see a change in the count, sometimes even longer. Hello? Are any of these wives approaching 40? Waiting 6-12 months can do in whatever chances you currently have with iui or IVF, even if the sperm gets better.

I also see some men who know that the procedure may not do much, but volunteer for the knife in order to show support and help contribute to a problem that effects the partnership as a whole. This is to be commended, but not always necessary. Surgery is not to be taken lightly, as there is a complication rate associated with any surgical procedure. And if the count is less than 5 million to start, I recommend freezing sperm. There are cases of sperm counts becoming lower, even going to zero, after the surgery.

What if the doctor does not feel a varicocele, but sees a small one on ultrasound? This to me is really pushing it. If he can’t see it, something only visible via ultrasound can’t be making much of a difference.

Another question is, what constitutes an improvement in sperm quality? Is a count that goes from 2 million to 4 million a success?

A good rule of thumb in medicine is that if something is controversial, it means it does not help most people.

Now there are urologists out there who swear but the varicocele, and say it’s not controversial. They should at least present to you the counter argument so you can make an informed decision.

Hearing an opinion form a gyn/infertility specialist is not as powerful as hearing an opinion from a urologist. Therefore I can summarize the philosophy of a famous urologist who used to work with me. He had 2 main points. One, evidence for improved fertility after varicocele repair is lacking. A little study here and there showing improvement does not make up for the larger studies showing no benefit. Two, men’s sperm counts change without varicocele repair. This is especially true with very low counts because just playing the law of averages; a low count may be higher when tested in 6-12 months later, even without surgery.

Thanks again and please read disclaimer 5/17/06.

Dr. Licciardi

More Answers to Infertility Questions

Hello Again,

Let’s get to more questions.
.
IUI with 17 million, 28-58% motility and 8% morphology. I like your odds. IUI using sperm with normal counts and motility is very commonly done and can lead to success. I have been impressed with iui when the sperm is not exactly great, a little low in some respects, as long as the post wash is over 10 million motile sperm. Here, since 1% of the sperm make it through the cervix during intercourse, a low count or motility will reduce chances naturally. But iui will get more sperm to the eggs, so that if the only problem in the sperm, iui can overcome the problem, provided post wash is not too low.
I do not care if my patients do back to back cycles. However, sometimes there are follicles left over from the stimulation that are still present on day 2 or 3, and starting needs to wait a month. Starting with a few smaller follicles is ok, but sometimes they are quite large.

Change your IVF protocol? If you are not pregnant after 2 cycles on one protocol, change to another. It may not make a difference, but it’s worth trying. This is unless your doctor is very pleased with the eggs and embryos and feels changing may not be the best thing. I usually switch but not always. If there were problems with the first cycle, change right away.

Jill: You stimulated well, it may be hard to improve on your cycle. If you doctor feels embryo morphology was an issue, consider changing something. I used to work with a doctor who gave the same stim every time, no matter what. I was commonly surprised about how we would see the same patient have very different results from time to time. At NYU we prefer progesterone in oil.

Dear Mary, you are 39, you have been trying for 18 months, and you are only up to iui with no drugs? Yes that may work, but the odds are against you, and I hear 40 coming. As with all patients you need to proceed at a rate that works for you, but most women in your shoes would be much more aggressive. At 39, natural cycle iui is 3-5%, clomid is 5-8%, FSH iui is about 10%, and IVF is higher (numbers are estimates).

I don’t have much faith in varicocele repair for improving sperm counts. Sounds like another blog.

45 day cycles and ovulation on day 14 does not make sense. Talk to your doctor about medications.

BFN. If your doctor has an overall positive feeling about your stim, it is ok to stick with the same.
Qualifications of the lab workers will vary. They can be PhDs or biologists in training. There is no “embryology license” and the training is in house. The andrologists (sperm iui lab people) in New York are state licensed.

Morphology of 0-1%. Yes natural preganny is possible. Without looking at the sperm I can’t give you much more information.

Chromosome Translocation: another blog

Switching doctors happens all day, every day. I don’t know if your doctor is good or bad, if you want to switch you should. Don’t be shy about it. Or, at least get another opinion. It doesn’t hurt to let your first doctor know. If he is human he will be grateful for the relationship and thankful for you honest communication. If he is upset or defensive, that’s the way it goes.

Miscarriage and infertility after a baby. Difficult. Naturally your age and FSH are important factors. Sperm count issues are best handled by a urologist. That being said, in most cases, not all, there is not much the urologist can do. So then you may be back to dealing with the up and down counts. If the counts are mostly on the low side, going back to IVF may be your best option.

4 miscarraiges and a baby: You and your husband at least need karyotype testing. After that, all testing and theory becomes less science and more art.

First cycle: be positive, it really could work. If you have issues that you are not sure about, do not be afraid to call your doctor. He/She will not mind.

Heathero. You do have a tough problem. 14 days is a long time to be on meds without much of a response. If you are paying for the drugs and monitoring, take some time off and get another opinion.

I have never heard of a doctor refusing simple tests. Furthermore, these tests are clearly indicated. Consider another opinion.

Extensive endometriosis. Your case is quite extreme, but it sounds like your doctor is really helping you. It’s not common to be pain free for so long. I have not heard of this treatment, but that doesn’t mean it is a bad idea.

Next time I will go back to a topic,

Please read disclaimer 5/17/06.

Dr. Licciardi

More Answers to Fertility Questions

Hello Again,

I am continuing to get great questions, so I will answer some more of them today.

Should a regularly ovulating woman trying donor sperm insemination use clomid? I don’t think there is an advantage. If natural cycle iui is not working, then going foreword with fertility medication may be necessary.

Can woman with 40 day cycles enhance her odds by using progesterone cream? This really depends on your general feelings about medication. Many women get pregnant with 40 day cycles and many do not. The reason some do not is that when the cycles are spread out, it is more difficult to be sure about the day ovulation. The other reason is women with 28 day cycles have 13 chances per year, whereas women with 40 day cycles only get 9 chances per year. So if taking fertility pills goes against your life philosophy, don’t take them. If you find such treatment acceptable, get on clomid because you will be more sure about your ovulation time and get more chances per year. I do not think the cream alone is the answer.

FSH and Estradiol: it’s just as you say. Estrogen (estradiol) pushes down your FSH because your body figures it doesn’t need to make FSH if estrogen is already floating around. Your doctor probably ordered a Fragile X test.

Sorry if I am a little late with this one. If you failed fertilization you should do icsi. Of course it’s your choice, and odds are that some fertilization will occur without icsi, but I think it’s too risky.

Starting Clomid day 3 or 5? It does not matter. I started using clomid day 5. Then I read a few things about starting earlier, the theory being more eggs will come along if the drug is started earlier. By day 5, the dominant follicle may already be selected, whereas on day 3, there may not yet be a dominant follicle, so more than one may develop. So I tried day 3, and there was no difference in the egg number or pregnancy rates. I did not do a formal study, but I didn’t notice and differences. So I went back to day 5 just to make it consistent with most other doctors.

CGH vs. PGD? CCH may someday be the answer, but it’s way too early to tell. There is one doctor in particular who pushes CGH, but he has pushed a lot of other things in the past, none of which were any good. I am not saying he is wrong about this, I just need to see data reputable data from him or others.

Most women with PCOS are very fertile, providing they get help ovulating. The odds of ectopic are higher after one ectopic. But iui is allowed and commonly performed after one ectopic. Ectopics can occur with IVF too.

One natural child and then 4 failed IVF cycles. This is a tough one. You say there is severe male factor. If the counts and motility are really low, and you were told IVF is your only realistic option, you are stuck with more IVF. This is of course providing your emotions and finances want to try again. If you do try again, get to the best program available.

IUD and a thin lining? I don’t know where this is coming from, I have never heard of this. Many women get pregnant with a 6.5 mm lining.

37 yo with FSH of 18 and 22. As optimistic as I try to be, these numbers are high, and you options are very limited. I would have to know more about you before recommending laparoscopy, but it is an option.

Baby Aspirin in general will have no effect. If you have a minor thrombophelia it will not hurt.

Yes, there is a dark tunnel, you need to bring a light. 5 years is a long time, but 2 cycles of clomid is too early to get discouraged. You can proceed at a pace that works for you. If you want to get more aggressive now, go right ahead.

An unusually low egg number. This does happen and we try to explain it, but in reality, we really have no clue as to why it happens. Something about this cycle was different than your past cycles and it probably will not happen again. Maybe there were more immature eggs, and these are a little harder to remove. But usually this happens when the hcg is given earlier, or with smaller follicles. Yes, the main reason to check e2 levels is to avoid hyperstimulation.

Embryos that are very asymmetric have lower implantation rates. We do not know anything about the factors related to embryo shape and fragmentation. In your case, the embryos, even though they may look of lower quality, have good quality as proven by your pregnancy. So I wouldn’t worry much about it.

If you have many autoimmune issues, you probably have a rheumatologist. He/she should be able to look at the blood test results that you ahve alrealy had, and tell you if there may be a problem. In general, with few exceptions, autoimmune issues do not impact infertility or miscarriage.

Thanks for the questions and please see disclaimer 5/17/06.

Dr. Licciardi

Fertility Preservation

The topic of this blog is Fertility Preservation and it was contributed by my partner, Dr. Nicole Noyes, who helped bring successful egg freezing to NYU.

Fertility preservation is a hot topic today. The most common and successful means to preserve fertility is through egg freezing (also known as oocyte cryopreservation). More than 500 babies have been born from this technique worldwide. Egg freezing is a process whereby eggs are stimulated in the woman’s ovaries and then harvested and stored for use at a later date. This can be done in the setting of a medical emergency, such as a newly-diagnosed cancer, or for personal reasons e.g. a woman who is not in a life situation currently conducive to childbearing.

It is important to understand that egg quality is best when a woman is in her reproductive prime, meaning between the ages of 16 and 28. Most women today are not looking to mother a child in their teens and quite frankly, our society has stigmatized childbearing at the age when women are most fertile. This leaves many young people looking for ways to protect themselves against pregnancy in their early prime years and then facing the choice of when childbearing is optimum. In some instances, this decision is easy – when life events are streaming parallel with having children. In other circumstances, the decision appears arbitrary or worse, can be in direct conflict with concurrent life choices such as career and/or personal advancement and fulfillment. Many women in their 30s are struggling with the latter situation.

A women’s eggs are usually still of good quality in the mid-reproductive years (meaning between the ages 29 and 38) and may remain usable (but definitely with diminished chance for producing pregnancy) in the late-reproductive period (age 39 to 44 years). If necessary or desired, it is best to have eggs that are frozen when they are of the best quality possible. For instance, eggs frozen at the age of 35 are more usable than fresh oocytes produced at 43 years of age.

An oocyte cryopreservation treatment cycles starts the same way as a regular IVF treatment cycle and involves stimulating the woman’s ovaries with a fertility medication called FSH (follicle stimulating hormone). Normally, during the reproductive years, a woman’s body releases one egg from the ovary in the middle of each menstrual cycle. The fertility medication tries to cause maturation of more than the usual one egg so that multiple oocytes can be obtained from one treatment cycle. Follicle Stimulating Hormone is self-administered as a daily subcutaneous injection for about one week, during which time monitoring of the ovarian response is necessary through frequent doctor visits. The ovarian monitoring usually includes five to seven visits in the course of two weeks where blood tests and ultrasound examinations are carried out. During this time, the patient may experience some abdominal discomfort, weight gain and irritability.

Once the eggs are deemed “ready” by the doctors, a late-night shot is necessary, followed 1 ½ days later by the oocyte harvest procedure, commonly known as the “egg retrieval”. The harvest is performed under mild sedation and takes about 15 minutes to complete. The number of oocytes retrieved varies from woman to woman and may be anywhere from 0 to 45, depending on a woman’s age and how the individual woman’s body responds to the fertility medications. The average number of eggs retrieved from women freezing for the purpose of deferring reproduction at our clinic is 14, the range being 2 to 42. It’s important to appreciate that not all oocytes are suitable for freezing. Of the average 14 aspirated eggs, usually only two-thirds are mature and only mature eggs are currently frozen for later use. A special microscopic exam of the eggs can be performed before eggs are frozen if the lab is equipped that evaluates the spindle, the part of the woman’s egg that later serves as a platform for chromosomes to align after thawing and fertilization by a male sperm. On average, women at our program have about eight eggs retrieved that exhibit a spindle. It is important to point out that not all eggs are meant to be babies and not even all spindle-positive eggs can be guaranteed to create pregnancy. From prior data in our lab, we estimate that approximately one-quarter of mature eggs exhibiting a spindle will result in embryos suitable for transfer back to the uterus.

After the egg harvest or retrieval, a short recovery room stay is necessary. It is important to have an escort take you home after the procedure because of the anesthesia. Once removed from the body, the eggs are brought to the clinical laboratory where they are initially evaluated for health and then frozen.

Over the week following the egg retrieval, some additional abdominal bloating is experienced by most women. During this time, we advise you to refrain from high-impact exercise or long-distance travel. This discomfort usually peaks approximately one week after the procedure and then subsides completely over the following few days. This feeling is the result of the natural ovulation process; it is just more intense after treatment because multiple eggs have been extracted from the ovaries as opposed to the one usually released during natural ovulation.

At present, oocyte cryopreservation is still considered “experimental” by the American Society of Reproductive Medicine. This is in part due to the fact that many centers around the country currently offering egg freezing have never had or have a very low success rate regarding pregnancy. In addition, there have been many fewer babies born from egg freezing and thawing than from embryo freezing and thawing, or from regular fresh IVF treatment cycles. It is important to do your homework when pursuing egg freezing; you need to check out the success rates of the clinics you are considering.

Dr. Nicole Noyes

Thanks to Dr. Noyes for taking the time to write this entry. I will give a few comments on egg freezing next time.
Dr. Licciardi

More Infertility Questions

Hello Everyone,

Let’s keep going with the questions. I want to get to as many as I can over the next few weeks.

69 XXY embryos: These are not age related, so they are probably not due to a bad egg, or at least an egg that is older. It’s probably a rare mishap of 2 sperm getting in at the same time, but it could be due to an egg that divides abnormally.

Pregnancy complications after septum resection do rarely occur. If miscarriage led to repair of the septum, miscarriage may still occur. Septums do increase the odds of miscarriage, but removing them do not make the new miscarriage rate zero. Some woman have 2 or more reasons for miscarriage. I have read of rare cases of uterine rupture during labor. For most women with septum repairs an automatic c section to prevent rupture is not indicated.

The chances of having a baby from a frozen embryo donor cycle is about 30%-40%, but ask your doctor about his/her rates. The fact that you failed a number of times using your own eggs does not lower your rates with DE.

Chemo and Fertility: Go to Fertilehope.org. This is a wonderful organization that disseminates critical information to men and women with cancer who are concerned with preserving their fertility.

It is not normal to have bleeding on and off every day after ovulation. You need to be evaluated more thoroughly. Get another opinion.

Mary, Your doctor should be more confident about saving your ovary. Almost all 5 cm dermoids can be removed without removing much of the normal ovarian tissue. If he is not absolutely committed to do whatever is humanly possible to remove just the cyst, see someone else.

Prolactin levels in the US are measured as ng/ml, in Europe they are measured as mU/l. So an 18 in the US equals 360 in Europe. Find out what your units are. Regardless of the units used , 1500-2000 is too high and you will need further testing, probably an MRI of the pituitary to start.

I have a blog covering FSH vs FSH/LH.

Endometriomas of the Ovary: As long as I know the cysts are endometriosis, I do not touch them unless they are very big. I agree that removal does lead to follicle loss. It’s hard to give you a size cutoff, but let’s say 2 cm is small and 8 cm is big.

Poor embryo quality: Try IVF again with a completely different protocol, and make sure you are at the best clinic available to you. Embryo quality is usually a function of the egg, not the sperm, although there are a few exceptions.

In Vitro Maturation. I don’t know the reason you need IVM. In general, IVM has a really low pregnancy rate. If you have the option, do regular IVF.

Exercise , BMI and pregnancy. I agree with you. If you are having regular cycles and your hormone levels are fine, weight is probably not the issue.

Scar tissue treated at laparoscopy: Your odds of pregnancy depend on how much of the scar tissue affected your tubes, and luck. If you uterus was covered by omentum, but your tubes looked normal, your chances are much better than if there was also scar tissue involving your tubes and ovaries. Tubal scar tissue, even when treated by the best surgeon, can come back giving you continued infertility. Time will tell.

ICSI or not: This is very program specific. Ask your doctor what the odds of fertilization failure if the sperm is normal using non-icsi, in his clinic. If the odds are low, you should be comfortable skipping the icsi. Of course , this also depends on the sperm counts and motility.

Depending on the cause of infertility, many women do get pregnant on their own after an IVF baby. Try for as long as your nerves will let you.

Clomid on day 6 will still work.

The need for ICSI has nothing to do with a woman’s age. The “shell” of the egg does not harden with age.

More to come, and please read disclaimer 5/17/06.

Dr. Licciardi

Fertility Questions: SCSA

I am going to continue with the response to questions for a bit more. This time I will start with the most recent and work backwards. Here I will address the SCSA question. I will continue to get to the other questions as the blogs roll out.

The SCSA: I do not order this test. Maybe someday I will, but I need more science. When a new test comes out (I know it’s been out for years, but it’s relatively new and not universally performed), there are a few reasons that it becomes popular.

One is that it is a great test and can really distinguish between who is fertile and who is not. Another reason is that some company is making tons of dough and can afford to spend a lot of money convincing your doctor this is a must do test. Another is that some doctors do some quick and dirty research, making a case for the test thus boosting their careers. Another is that some famous doctors are on the boards of these companies, and they use their international reputations to convince other doctors it’s a good test. Another reason is that in order to keep up with the competition, you doctor needs to order the test, even if he does not believe in it, so that you will not leave him and go to the doctor who orders the test. Another reason is that when anything new comes out there is a quick flurry of studies showing its good, but it takes years for studies to come out against. When something is new, a lower quality of research suffices for publication, whereas the standards of publication go up over time. There are probably others.

Now I never said the first reason did not apply to the SCSA, but as you can see other reasons need to at least be considered.

I can say one of the tests sales people came to my office last week and started to tell me about the test. He said the test has clearly been shown to distinguish between the fertile and infertile. I said show me the data and he said it’s not published yet. I thought how strange, you have been selling this test for years, and you are telling me it’s a must do, and yet you can’t show me any data?

I do see that a woman wrote in saying the test helped her. I am very happy about this. The universal question is, if she did not have the test, would her course of therapy have changed?

Why does this matter to me? So what if you get one extra test? Because what if the sperm is actually good, and someone tells you the SCSA says the sperm is bad? What if you don't need IVF, or you don't need ICSI, or you don't need to adopt? That's the issue: giving people erroneous bad news. At NYU, like most good centers, we have been doing just fine without the test. Men with low counts have lower natural pregnancy rates, and may need IVF with ICSI, or even biopsies. But almost every fertility doctor has pregnanies from men with alomst no count, almost no motility and hideous morphology. Can we really tell anyone to give up based on this test, or any test? This test better be perfect, and few things are perfect.

I am going to sign off now. After I get to some more of the questions I will get back to you about this.
I will contact the company again and search the medical data base for some hard published data.

Dr. Licciardi

More Fertility Questions Answered

I have not answered questions since October, so here we go.

Because it’s been a while, sorry if my answers are a little late for those asking, but I hope other readers will have the same questions and learn from the dialogue.

A woman wrote in frantically about her new experiences using Clomid. In fact she was so distraught, she was really concerned about getting pregnant with her second child even though she was not yet pregnant with her first. Yes Clomid can make you extremely emotional, but no one should really be over the edge. If you feel like this woman, get counseling (which more people really should do) or get off Clomid, or both.

Antral follicle counts are only a guide. If you have a total of 11, you don’t really know how the cycle will work out. 11 is a very adequate number; you will probably have a nice enough response for pregnancy.

Cost efficiency of IUI vs. IVF. If you have PCOS, your injection iui cycles may be more expensive than other women’s cycles because you need to be watched more closely. But, you are more fertile that the average woman. Go over the costs of each with you doctor in the beginning. And of course you need a little luck. If you get pregnant quickly with iui, you look like a genius.

Zero Sperm Morphology. I don’t think sperm morphology is much of an issue unless it’s zero, but usually that translates to a fertilization problem. If miscarriage is the problem we don’t know. The dilemma is no one can tell you will never become pregnant with his sperm.

From to Clomid to IVF with PCOS. Women with PCO can safely be given injectables. The key is starting on a very low dose. It is sometimes a pain because the cycle becomes long, but if you don’t want to go to IVF right away, ask your doctor about a low dose protocol.

MTHFR: I like your doctor’s response. No one has shown that blood thinners are appropriate or even help. Be sure your homocystine levels are normal.

Hypothalamic Amenorrhea. Most women with this do not bleed after Provera or other progesterones, and most do not respond to Clomid. Usually the injections are necessary.

What are normal progesterone levels? We don’t know. All doctors have their own ideas. I don’t think they need to be very high.

BMI cutoffs for IVF. This depends on a few things. Can you be safely administered anesthesia? Are you at risk for having a very complicated pregnancy? Can the doctor find the cervix? Large BMI may have a negative effect on stimulation and pregnancy rates, but not to a great degree.

How many follicles are too many for IUI? IT depends on your age. Once I see more than 5-6 I talk more seriously about the odds of multiples and talk about cancellation. If there are more, I may just cancel the cycle. It’s hard to give you an exact cut-off number; it depends on age and other fertility factors. Making extra eggs is the goal of the injection cycle because extra eggs increase your odds of becoming pregnant.

AMH is a new tool. We have done some research, and are planning more. I’ll write about it in a separate blog.

Poor egg quality. I hate this term because more often than not the doctor throws it out there with little evidence, other than his own frustration. Embryo quality means 2 different things: it’s about how the embryos looks (morphology) and the embryo’s chromosomes (genetics). If you have done IVF, and your embryos barely develop or are very fragmented, you have poor egg quality. This is a morphology issue. If you have done IVF a few times and your embryos look OK, yes you may have poor embryo genetic quality. But it is also possible that you just have not yet become pregnant and your time will come. My problem is with the doctor who tells a 39 year old with 11 eggs and 6 decent looking embryos, 3 to put back, that she did not become pregnant because she had poor embryo quality.

Pumps for Hypothalamic Amenorrhea: Sure. Sounds a bit cumbersome to me, but if you want to give it a go, especially if nothing else is working, go ahead.

More answers next time. Please read disclaimer 5/17/06.

Dr. Licciardi

If You Live in the State of New York, the Government May Help Pay for Your IVF.

I am sorry that this blog only applies to a small percentage of you: residents of the State of New York, but the message is so important I feel I need to spread the word.

New York State gives money to those who need it for IVF. The program is called the New York State Infertility Grant Program, or “The Grant” for short. To be eligible you must be 21-44 years of age, a New York State resident and have a combined household income of less than 200,000. You must show your most recent federal and NYS tax returns. If your income is 100,000, the state will pay for approximately ½ your cycle. If you make less they pay for more; if you make more they pay for less. This is approximately how it works. Our billing managers can tell you more about the details and any other costs.

Also, you must have commercial health insurance. Any one will do except Medicare, Medicaid, and HealthPlus; these are not commercial carriers.

You need to have had 4 cycles of ovulation induction (OI), unless you are not a candidate for OI due to tubal disease or severe male factor infertility.

There are a few other rules. Start by going to nyufertilitycenter.org and click under financial information. On the left you will see NYS Infertility Project. On that page you will find everything you need to get started. You can also click a link to the New York Department of Health.

It’s easy to fill out the application and it does not take very long for the application to get reviewed.

Some patients have come to our office knowing about the grant; in fact the grant is what brought them to see us. In other cases, patients are very happily surprised when I tell them such a grant exists. I am even more surprised that they had not heard of this great opportunity.

Only certain IVF centers are approved by NYS to be grant sites, and those centers are listed on the New York State Department of Health website. You can hit the link from the NYU site. I want to also say that I am not the only doctor in our office that can work with you as a patient on the grant. Drs Noyes and Berkeley would be happy to see you too.

So if you need IVF, live in New York, and have commercial health insurance, IVF may have just become less expensive for you.

I’ll try to get another blog out within the week.

Dr. Licciardi

Minimal Stimulation

Does taking a lower dose of fertility drugs improve your chances of becoming pregnant with IVF? I think not, but I can tell you of some exceptions. Mostly I have had some very good experiences with patients confirming that lower is not better.

How do I know?

Well, as it turns out over the past few years I have been seeing more patients from Europe. There are a few things that have contributed to this. One is the blog. It’s been fun getting e-mails and seeing patients from around the world. The second is the exchange rate: for some, New York is now a “reproductive tourism” destination. The third has to do with laws in Italy, Germany and other countries that restrict IVF and donor egg.

Anyway, the European doctors give their patients a much lower dose of drug that we do in the US. Part of this is due to the fact that they may not be allowed to fertilize more than a few eggs, so they don’t bother trying to get more. Another reason may just be due to a general philosophy that less drug is better.

So the typical European woman that sees me has done IVF many times, usually making just a few eggs on a lower dose of drug. Unless she has had a fantastic response, I increase the dose for her IVF cycle with me. In most cases, the egg yield is much higher (still in a safe range) and the pregnancy rate in these women is very high. So the point is that in these women, a higher dose is better because it increases the number of eggs, and therefore there are more embryos available for selection.

Do some women make more eggs with a lower dose? I have seen a few cases of this. This is typically the woman who was given a lower dose for IUI and develops more follicles than she did with her higher dose IVF cycle. Should we go back to the lower dose for the next IVF cycle? It’s a gamble and it takes a little courage. It is really hard emotionally to go into an “experimental” IVF cycle.

Many patients considering this have had many attempts and may not be ready to give up a couple months for a “let’s see” cycle. If you and your doctor can stomach it, you can give it a try. I can tell you I have one woman, who had been through many cycles, who wanted to give it a go, and she did better with less. Was that her month to make more, regardless of drug dose? Who knows, but let’s give her the credit.

But I do think starting on a minimal dose, just because your doctor thinks it’s more homeopathic and will result in better quality embryos, is not correct. To return to our common theme, if one of the self proclaimed experts in minimal stimulation wants to take 100 women and give them minimal stimulation, and take another 100 and give them regular stimulation, and then show us that minimal is better, great. But until this happens we have to say that it’s not better, and may be worse for most people. I know some of you can tell me that you did minimal and got pregnant. I just feel that my experience has shown that overall, regular may be better.

Please read disclaimer 5/17/06, and thanks again, Dr. Licciardi

More About Fibroid Surgery

So why not just remove all fibroids to treat infertility and to prevent pregnancy complications? Because the operation is not without discomfort and risk. Overall, myomectomy is a safe procedure, however complications are possible.

One complication is bleeding. If the surgeon is meticulous, the odds are bleeding are lower, however you doctor can’t control everything. Even in the best of hands, transfusion may be necessary. The odds are related the to number of fibroids being removed. Most people with a few fibroids do not need transfusions. If there are more than 10-20 fibroids, your odds will be much higher.

Transfusion risk can be lowered using a machine called the “cell saver”. This machine takes blood you lose during an operation and recycles it back into your veins.

Can a myomectomy make infertility worse? In some cases yes. There is about a 30% chance that a myomectomy will cause scar tissue to form around the tubes, ovaries or uterus. During the fibroid surgery incisions are not made in the ovaries or tubes. However, as the uterus heals, scar tissue can form throughout the pelvis that can envelop the ovaries and tubes. This scar tissue, also called adhesions, can make it more difficult for an egg to get from the ovary to the tube.

This can be dealt with in different ways. A few months after the myomectomy, a hysterogram can be performed to look for tubal blockage. If blockage were present, you would have the option of a laparoscopy to evaluate and possibly treat the adhesions. Or, you could bypass the laparoscopy and go straight to IVF.

What about pregnancy? There are cases where the fibroid is clearly the cause of premature delivery, but these cases are not that common. Here the fibroids grow considerably during pregnancy. Most do not, and even those that do grow are usually not a problem. But again, its impossible to predict which ones will be problematic.

Another problem is degeneration. If the fibroid grows quickly during pregnancy, it can outgrow its blood supply. This causes the center of the fibroid to die, and this can cause considerable pain. As a result, inflammatory substances are produced, and these can trigger premature delivery.

Throughout this post I have been somewhat fibroid sympathetic, but I need to be clear. Yes I believe that some myomectomies may be unnecessary. However, any fibroid needs to be taken seriously. I perform myomectomies. There is an important place for fibroid surgery.

Pros of myomectomy are that the surgery is rather routine. The procedure is not much different than a c-section. If there was any problem with pregnancy related to fibroids, the patient would have wished she had the myomectomy before getting pregnant. Therefore some would recommend having the surgery from the get go.

As usual, the main point here is do your homework, and get second opinions.
Please see disclaimer 5/17/06.

Dr. Licciardi

Your Fibroid: Should it Stay or Should it Go?

Happy New Year. I hope this year is your year.

I received many good comments after the last few posts and I want to get to most of them. But I never finished the fibroid discussion, so I’ll do that now.

There is no final word when it comes to fibroids. You may find that we doctors are not on the same page when it comes to recommendations for myomectomy. In addition, we sometimes ask similar patients to do different things based on just how we feel about each situation.

In general, many physicians will recommend myomectomy for fibroids over about 5-6 cms. Why? There is no good literature to support this. There are a few recent and older papers evaluating fibroids as a cause of infertility and miscarriage, but none are close to definitive.

Why would a myomectomy be recommended? If you go back to my first blog on fibroids read about location. In some cases there really is no choice, but these are the minority. In most cases the choice is not clear. A typical example would be a 7 cm fibroid that is in the wall of the uterus, not growing into the cavity and not distorting the uterus. Here the doctor may be worried that this is preventing pregnancy or will cause miscarriage or premature delivery. However, it is almost impossible to know which fibroids are problems and which are not.

Most fibroids of most sizes do not cause a problem. Pregnancy occurs easily and delivery occurs at term. I’ve seen women who are 15 weeks pregnant who look like they are 9 months. Their response to my puzzled look, “I’ve got big fibroids”. So in these cases, big fibroids were not a problem.

I had a patient with 6 cm fibroids who was told by another other doctor (actually one of my partners) that she needed to have a myomectomy. The month she was told that, she became pregnant and had the baby at term with no complications.

On the other hand, the picture is not always so good. I have had a couple of patients with 6 cm intramural fibroids not distorting the cavity, who became pregnant but unfortunately had very premature deliveries. Did the fibroids cause the early delivery? No one knows for sure. There is a chance that the fibroids at least contributed to the early labor.

One more about fibroids and surgery next time.

If you have any stories about fibriods, good or bad, please write a comment.

And as usual, see the disclaimer and talk to your doctor.

Dr. Licciardi

Exercise

Please exercise.

In the preceding centuries, tremendous physical activity was required for human survival, and yet, reproduction carried on. Imagine the exhaustion and stress if we had to spend one week hunting or farming with few tools or resources. Yet probably, under these conditions, most women would be able to get pregnant.

Excessive extreme exercise causing weight loss will cause ovulation to stop because the body figures that there are not enough nutrients stored for both the woman and a fetus. If she can just barely feed herself, she can’t feed the growing baby. The same is true for an anorectic. But here we are talking about extreme extreme. Moderate exercise is fine.

Surprising to me, I did come across a paper from Harvard showing that women who underwent moderate levels of exercise had lower pregnancy rates that those who did not. Like we always say, it’s just one paper. I do not really believe it. The Harvard doctors that I know do not restrict moderate exercise.

Exercise is bad if you are taking fertility drugs because the medications make the ovaries grow. Normally the ovaries are about the size of a walnut, and the drugs increase the number of follicles, therefore the ovarian size increases. Sometimes the ovaries can get to the size of plums or even oranges. They hang inside the pelvis. As they become heavier, they become more likely to twist, and this is called torsion. Here the twisting cuts off the blood supply and causes the ovary to choke. This really hurts, and is treated by laparoscopy. Exercise will increase the odds of this twisting. So in this case, exercise is not good.

Exercise increases blood flow to all areas of the body. The uterus and ovaries are organs that would love to get as much blood flow as they could.

Exercise clears you head. Yes, endorphins are released with strenuous activity, and these can help us fell better, but I think it’s more than that. My theory is that it’s not just about increasing the good chemicals; it’s about getting rid of the bad. Increased blood flow flushes away the old stale thought chemicals that are just hanging around causing trouble. Get rid of them.

Even better, do exercise that requires tremendous concentration. This really clears you head. Any sport will do: sailing, golf, soccer, basketball, biking, you name it. Some are more strenuous than others, but they all work. Same thing; flood your brain with fresh blood and new thoughts, lose the waste products.

Exercise builds muscle mass. This is also good. It just makes you feel better if you have a little tone. Even if you think you are fat, the tone goes a long way. It’s healthier to have some tone and muscle. It helps with balance and lowers you chances of getting injured during an accident (falling, for example). And people with a little tone just age better.

Not to mention all of the obvious benefits of upping your cardio-vascular reserve.

I am not an expert in Yoga, although I have happily done it a few times. It's very good alternative.

So you don’t have time for exercise? Yes you do, make time. If you are tired, go to gym tired, it works just as well. You will sleep better.

If you do decide to take my advice (and the advice of others), go all out. A little exercise once a week is better than nothing, but more is better. You need at least 2 sessions per week of vigorous activity to really make a difference. Don’t start on any aggressive workout without checking with our doctor first, and consider a trainer at least initially.

See disclaimer 5/17/06 and Happy Workout,

Dr. Licciardi

Fertility and Diet

As I walked from the elevator at my usual 7:00 am, I glanced through the waiting room and something caught my eye: a pregnant woman on the cover of Newsweek captioned by “Fertility and Diet.” “ Oh no,” I said to myself. “Here come about at million questions!” So I figured I would read the article and take the time here to go through some things; beat you to the punch.

According to the article, diet the recommendations are aimed at preventing and reversing “ovulatory infertility.” This goes back to my blogs on PCOS. Therefore if you already ovulate regularly, the diet issue does not apply to you.

It appears that women with better diets had more regular ovulation. Brilliant. Lets start with carbs. The article shows that carbs are fine, but women who ate more “healthy carbs”, such as brown rice, pasta and dark bread, whole grains, beans and vegetables, and whole fruit, ovulated more than those who loaded up on white rice and potatoes. Sounds familiar. For any medical well-being issue, the message is the same.

Trans fats can make you fat. Brilliant. A diet higher in trans fats usually means the diet is lower in the good things mentioned above. This concept can also be applied when examining that plant protein may be better that animal protein.

The milk and cream issue requires a little more analysis. There are 2 types of women who do not ovulate: those that are starving themselves, and those who are eating a bit more that they should. The article does not always make the distinction clear. The point is that if a woman in not eating, milk and ice cream will help her ovulate. Increasing caloric intake, through whatever means necessary, can jump start ovulation. However, if someone is overeating to start with, milk and ice cream may not make a difference, unless she starts to substitute some of the bad food with yogurt and cottage cheese, which will lead to weight loss.

Exercise is good. Brilliant.

To be perfectly clear, I agree with everything they say. Proper diet is a good thing. Potential pitfalls here are that women may feel that by taking an extra hit of salmon per week will feel they can lick their fertility problems, and not get the help they need until they are older. If you are not getting pregnant, eat well and see the fertility doctor. If you are 32, overweight and don’t ovulate much, it’s ok to get on a program, lose weight over 6 months, start to ovulate, and avoid Mr. M.D. If you are 38, ovulate regularly and decide to modify your diet for 6 moths before seeing the doctor, I think you may lose too much valuable time. Do both.

In addition there are reasons for non-ovulation (we call it anovulation) other than those related to weight and diet. Problems with the thyroid, pituitary and adrenal glands can also contribute. Therefore, if you are not ovulating, you are better served by a basic simple workup. If everything is ok, at least you know, and then you can make a decision on how to proceed.

Admittedly, I am jealous that some researchers reported on things we already knew, published a book, and got on the cover of Newsweek. Brilliant! But I am happy that by reinforcing some basic principals people can be healthier, and some more women will get pregnant. We all have experienced that some people process a message better when it comes from the press as opposed to from their doctor, spouse, mother ect.

As usual, see the disclaimer blog.

Thank you,

Dr. Licciardi

Myomectomy

Surgery to remove fibroids is called a myomectomy (fibroids are also called myomas). There are a few different procedures depending on the size and location of the fibroid. Most are removed via laparotomy. This means through an incision in the abdomen that resembles the incision of a cesarean section. This is an incision that goes from left to right, and is sometimes referred to as a bikini incision. If the fibroids are extremely large, a larger incision is required that is made vertically. This gives the surgeon more room to operate inside the abdomen.

Some fibroids can be removed through the laparoscope. Here a small incision (less than an inch) made through the navel and 2-3 other smaller incisions (½ an inch) are made in other parts of the abdomen.

Some can be removed through the hysteroscope. This is the scope that is placed through the cervix up into the uterus. Here fibroids can be visualized and removed by shaving the fibroid piece by piece. It’s an elaborate d and c.

So who gets what?

Almost all myomectomies are performed via the cesarean section style route. Usually this gives the surgeon enough room, and the fibroids can be removed without difficulty. If the fibroids are just too big to be removed this way, the other, larger incision may be necessary. The negative to this is that the scar is bigger and visible to anyone who sees your abdomen.

A very small percentage of fibroids are removed through the laparoscope.
The best candidates for this procedure are the fibroids that are mostly on the outside of the uterus (subserosal). Clearly the advantage of this procedure is much smaller incision size, which translates into less time in the hospital, less post op pain and much less downtime after the surgery. Unfortunately, most myomectomies are not done this way. The reason is that it is a very difficult procedure to do quickly and with minimal blood loss.

I need to say that there may be a rare surgeon out there who can remove a higher percentage of fibroids in this way, but most can not, at least not safely. I have performed this procedure, but pick patients who I know who have fibroids on the outside, almost hanging off the uterus, so that I do not need to make a big cut into the uterus. It is this cutting into the uterus, which is usually necessary, that makes the laparoscopic approach less desirable.

I recently spoke to a renowned surgeon who spends his week traveling throughout Europe performing very advanced laparoscopic surgery. I asked him why he does not perform laparoscopic myomectomy and he told me it’s safer to just make the incision. Laparoscopic surgery to remove an intramural myoma (in the wall of the uterus) can add hours on to the surgery time and has a much greater chance of blood loss requiring transfusion. In addition properly sewing up the uterus after the fibroid has been removed must be done neatly and precisely. This is a difficult, sometimes impossible task through the laparoscope.

Some doctors are getting more experience using computer assisted surgery (sometimes called robotic surgery) and this does make sewing and knot tying much easier. But so far, in most cases, it remains easier to perform a safer procedure through the standard incision.

A little more about fibroids next time, and please read disclaimer 5/17/06.

Dr. Licciardi

What’s a Fibroid?

A fibroid is an abnormal growth in the uterus. We also call them myomas. I say abnormal because a fibroid shouldn't be there, however so many women have fibroids we consider them common. How common are they? At least 30% of women have fibroids. I have recently heard that some say that up to 60-70% of women have fibroids, although that sounds a little high to me.

How do they get there? We don’t know how they start. We do know that they grow in response to estrogen. They are not seen prior to puberty and get smaller after menopause. It seems that each fibroid starts as one fibroid cell, and this cell keeps dividing resulting in a large fibroid. Even though they come from the cells of the uterus, they do look different than the normal uterine muscle. They are whitter because they have few blood vessels, and they are firmer, about the consistency of a potato. We don’t know why some women have only one; some have 40.

Fibroid size and a word about centimeters. Most medical things are measured in centimeters (cms). One inch equals 2.54 cms. So a 5 cm fibroid is about 2 inches. A tennis ball is about 6.5 cms. How does this compare to the size of the uterus? The uterus, not including the cervix, is about 5 cms tall, 2.5 cms thick and about 5 cms wide. So a 5-6 cm fibroid is about the size of the uterus. A bigger fibroid would be bigger than the uterus. A 10 cm fibroid is a lot bigger. I commonly find fibroids on ultrasound and as I point them out to my patients they say ”wow, that’s big”. But something that looks big on ultrasound may be really a more medium sized and not a problem. Every doctor has a different view on the minimum fibroid size they consider tolerable. It’s usually around 5-6 cms, but it also depends greatly on the location.

Location. It’s either subserosal, intramural or submucus. Patients ask all the time, “is it growing in the wall?” They all are growing in the wall to some degree. The wall means the muscle of the uterus and that’s where fibroids mostly come from. It’s just a matter of how they grow after they start in the wall.

Some are loosely anchored in wall, more towards the outside, but have most of their growth on the outside of the uterus. These are called subserosal (the subserosa is the thin outside layer of the uterus). Some of these become pedunculated, which means they hang like a ball on a short thick string.

Some are mostly intramural, but the wall of the uterus is only about 1 cm thick. So as the fibroid grows bigger than 1 cm, it will bulge either inward or outward (becoming more submucusal or subserosal)

Some grow from the uterine wall but mostly bulge into the inside of the uterine cavity. Now the inside of the uterus is lined with the glandular cells called the endometrium. These are the cells that shed with menstruation. These are the cells that provide a nice place for an embryo to get started. This is the same endometrium that is measured during induction of ovulation and IVF. A fibroid will disrupt the endometrium. It will stretch the lining and cause gaps in the lining, and this leads to abnormal bleeding. More on fibroids to come,

Dr. Licciardi

Are You Sure You Need Donor Eggs?

This is going to be a tough blog to write. Many have asked, when should I say goodbye to using my eggs and switch to a donor’s eggs? This of course assumes that you would consider using a donor’s eggs. Donor egg: It’s not for everyone. But for those who are interested it can be a very real way to become pregnant and have a child.

Every woman and man has a different threshold for getting to donor egg (DE). If you are in menopause and would consider donor egg, your decision is made for you. For everyone else, choices need to be made. For some people, decision-making in general is very easy, for others it is almost impossible, and most fall in between.

No one else knows what’s best for you. No doctor, lawyer, friend can tell you which direction to turn. A little advice from any available source you feel comfortable tapping into may not be a bad idea. But no one really knows how you feel; no one has had your unique life experiences that you go back to as you make your choices.

Before you even face the decision, you need to feel good that you are at the crossroads. You need to understand the advice of your doctor and you need to feel that you have received correct the information about your ability to produce eggs of reasonable quality.

Stories of the average woman going to donor egg did not inspire me to write this blog. Rather, it was the stories of a smaller group of women who were told they needed to go to donor egg, maybe a little prematurely. Over the years I have seen a few too many women who were told they needed donor egg when in fact they would have been better served using their own eggs.

To be clear, I am not talking about most of the women going to DE, including women who we would say have a “very reduced” chance of becoming pregnant with their own eggs. All of these cases can be debated, but in the end DE may be the better option mostof the time.

What I am talking about here is the woman who is 39, makes 11 eggs, gets 2 fair embryos back, no frozens, and at her post cycle visit the doctor brings up donor egg. The doctor may talk about doing another IVF cycle, but for some reason he/she has a real need to start planting the seeds of egg donation. This happens way too often, and I don’t really know why.

One failed cycle of IVF is not completely predictive of future cycles. Yes many women are consistent in their response to meds and embryo quality, and not every woman at 39 will become pregnant with IVF even with multiple attempts. However, women get pregnant with marginal quality embryos every day. Women get pregnant on their 2nd or 3rd IVF cycle every day, and 39 year olds get pregnant every day.

I said this would be a hard blog to write. The reason is that I am trying to avoid upsetting any of you (especially my own patients). Every case is different so it is impossible for me to say who needs what. I do want to state for the record, however, that there are too many women with reasonable chances at getting pregnant using their own eggs being offered donor egg.

So if you cant really understand why your doctor is bringing up donor egg after one failed IVF cycle, you need to entertain the option of getting another opinion. Who knows, maybe your doctor is absolutely correct. Or maybe you would much rather go with 50% using donor vs. 25% with your eggs. If that’s ok with you, it’s ok with me.

What I don’t like is when the doctor almost shames you into donor egg by stabbing you with the bad embryo quality speech. Embryo quality cannot be accurately assessed after 1 IVF cycle. If you have done more than one cycle and you are being told your embryos grow poorly, show the pictures to someone else. If you are of a reasonable age and you make nice looking embryos, but are told they are not good, get another opinion.

Donor egg is a great way to get a family started, or expand the family you may already have. Just be as sure as you can that DE is really the next step for you.
Thank you and please read disclaimer 5/17/06.

Dr. Licciardi

Some More Quick Answers

The questions was: is it necessary to take progesterone if you are doing clomid or FSH injections with iui? The answer is that you may not need progesterone for these cycles because the ovary can do a great job of producing high levels of progesterone. The corpus luteum is not disturbed by an IVF needle. Also, we usually do not give lupron or antagon or cetritide for an IUI cycle. Personally, I usually do not give progesterone for IUI, but I will in some select cases. Some doctors give progesterone because of the high estrogen levels produced by the fertility drugs. They feel that if the estrogen is high, the progesterone needs to be high too. This is a theoretical concept and has not been shown to be valid for women on fertility drugs. Certainly if the period is coming early after the iui, progesterone should be considered.

HA stands for Hypothalamic Amenorrhea, which is when there are no periods due to extreme exercise, stress, etc, despite a good number of resting follicles and a low FSH. It’s the hypothalamus that sends signals to the pituitary to make FSH and LH. If the hypothalamus doesn’t send the signal (GnRH), the pituitary does not make the FSH and LH. It’s the brain’s way of preventing pregnancy if the body is too stressed.

Moving from Clomid Straight to IVF for PCOS. FSH iui in women with PCO can be done safely, without the production of too many follicles, providing the starting dose of the FSH is low enough. Even in such cases careful frequent monitoring and occasional cancellation, is necessary. Talk to your doctor about this. Again, the starting dose needs to be very low. In general, 3 cycles of Clomid are attempted before going to the next steps, however there is an exception in women with PCOS. If you are not getting regular cycles off Clomid, and Clomid straightens things out, more attempts, around 6, may be ok.

Abnormal Sperm Morphology Causing Miscarriages: I have not seen this connection, and I have seen tons of men with low morphology. Now maybe you are one of the couples where there is a connection, but you will need to discus this more with your doctor or a second opinion.

An 8 mm uterine lining is not thin, it’s fine.

An antral follicle count of 11 is fine, you don’t need more. “Normal” FSH can mean many things. In other words there is a big difference between 6.8 and 11.2, and both are in the normal range. If it’s on the lower end, you will be ok. If you are on the higher end, you may also be ok. You may produce fewer follicles that another woman with more resting follicles, but it sounds like there are enough.

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

Catching Up with Your Questions

Spotting before the period could be from a few things. A luteal phase defect is a possibility, but more investigation is necessary. Uterine polyps could be the problem (another blog to come). Another problem could be adenomyosis (another bog to come). There are some cases when we check and look and don’t find the problem. If no problem is identified after careful searching, most patients do not have reduced fertility using any of the various treatments.

Talking Finances with your Doctor. Why not? How you choose the path of your fertility treatment depends on many factors, and money is a very important issue. You do need to talk to your doctor about this. As you know, some insurance plans pay for nothing, iui only, medications only, IVF once, etc. So for example if you are 42, made 2 eggs at your last ivf cycle and have no coverage, so you want to spend cash on another IVF or save for a DE cycle or adoption? IF you are 32 and have a total of $10,000 to spend form your insurance company, do you want to chip away at it using iui or go straight to IVF? Your doctor’s input here may be very important.


LPD is probably not related to the length of the follicular phase or embryo quality.

Clomid and FSH are recognized treatments for LPD. We don’t know exactly how they help; it may just be that more eggs means more CLs and higher progesterone levels.

Skipping the injectables and going straight to IVF. I just returned form the annual meeting of the American Society of Reproductive Medicine. There was an excellent presentation from a Boston group examining this issue. All patients in the study did 3 cycles of clomid iui. Those that did not get pregnant either did 3 cycles of FSH iui and then IVF, or no FSH iui and IVF directly. When all (I mean everything) of the expenses were compared, patients who skipped the FSH iui got pregnant faster and spent less money.
Now everyone is different and your situation needs to be individualized, but this study may help some people make a decision.

One woman had a day 3 FSH of 44 and an Estradiol of 26, another month FSH 7, Estradiol 73. This is a massive shift and not explainable. A third test will help.

HA is really not that rare; another blog.

For HA women who makes no LH, how can you hyperstimulate? This is a good question. The low dose of hCG you took to ovulate lasts about a week in your system, more than enough to get hyperstimulation rolling along. HA women make a very low amount of LH, but it’s usually not zero, so there is probably enough to give a little push to the CLs.

What about low hCG levels and low progesterone levels in a bad pregnany? hCG stimulates the CL to make progesterone. If the hcg is low, the progesterone will be low. It also may be true that hCG is not the only important hormone made by the early pregnancy. There are probably other substances made by the pregnancy that we have not discovered yet, which stimulate progesterone production.

That’s it for now, please read disclaimer 5/17/06. Dr. Licciardi

Why is Progesterone Used for IVF?

Why is Progesterone Used for IVF?

Thank you Kami for the question.

In a natural cycle, progesterone is made by the corpus luteum(CL)(see blog from August 17, 2007). In most cases it’s just one, and for many millions of women around the world, this one little CL puts out enough progesterone get the job done. During IVF, there are usually many more than one CL, and therefore one might expect that there should be plenty of extra progesterone produced and available for the pregnancy. So why give more? There are 2 reasons.

The first is that the natural CL and the extra CLs that are produced during ovulation induction with insemination are different than the CL of IVF. The CLs of IVF were all disturbed by the IVF needle. The CLs from IVF all started as follicles containing eggs. At the retrieval, the needle is placed into the follicle, the egg is removed, and other cells can also be removed. The follicle is mostly fluid, but it also contains tons of cells that make up the follicle and surround the egg. These are called the granuslosa cells, and these are the cells that convert to progesterone CL cells after ovulation. So if the needle removes some of these cells, as is usually the case, the CL may not work as well and less progesterone would be produced.

The second has to do with the IVF medications. The CL makes the hormone progesterone, but the CL needs a hormone to help it perform this function. Leutinizing Hormone(LH) is the one. Yes the famous LH, of the LH surge. LH comes from the pituitary gland, and it is produce in high amounts just before ovulation to get ovulation to occur. (for IVF we use the LH substitute hCG, just to help with the timing). After ovulation, LH comes from the pituitary gland, in smaller amounts, to “leutinize” the follicle, or to get it to make the progesterone. LH is secreted throughout the luteal phase to keep the CL making progesterone. If a pregnancy occurs, the hCG from the pregnancy takes over to stimulate the CL progesterone system. If there is a problem with LH production in the luteal phase, there will be a problem with progesterone production and there will be a problem with the pregnancy.

Almost all women who undergo IVF are given a medication that causes a problem for LH production. Whether it’s Lupron or Antagon, LH production stops. Sounds bad? No it’s good, at least initially. Stopping LH means preventing a premature LH surge, which can ruin 10% of IVF cycles. In a natural pregnancy, or when doing iui, surges are fine, they cause ovulation. In IVF, we need to time the retrieval to the hour, so that a surge at the wrong time ruins everything. Therefore, we give medications to stop LH, but what they do is stop LH for a while, and this compromises the ability of the to make progesterone.

So there you have it. Progesterone may be lower than normal during IVF for 2 reasons. The second is probably more important than the first. That is, if we didn’t use the Lupron or Antagon, progesterone production would be fine for most women doing IVF. There are so many CL during IVF, a little needle disruption may not be a big deal.
Dr. Licciardi

More About Pregnancy Rates

The pregnancy rates issue raised a few important questions. I agree, there are some programs who try to stack their numbers by rejecting patients who are very difficult. I do think this happens less often than you might think. Can you figure out who these clinics are? The rumor mill helps but it’s not the best system. The program's numbers may give you hints.

Look at the pregnancy rates for the women under 35. Yes, there are some women in this age group who have high FSH and/or are poor responders but the vast majority of women in the age group are ok. So if a program takes hard patients in this age group, there should be enough easier patients to still give the group as a whole a high pregnancy rate. If a center has high rates in the younger patients but lower for the older patients, they are probably not selecting.

Even better, go to the donor egg stats. There is no selection when it comes to donors. If the program has low pregnancy rates in the donor egg patients, they probably will not have high rates in any group, and it has nothing to do with selection. Another thing to watch for is cycles cancelled. As you know, some patients get cancelled after they start their medications because not enough eggs develop. If a program reports 0 cancellations, be suspicious. It is impossible that every patient made it to retrieval. 0 cancellations means the program is not accurately reporting their stats.

I think there is less selection out there these days. All of the programs are facing more competition as new clinics pop up every day. Rejecting a viable but difficult candidate means losing that woman to another clinic; not an easy thing to let hapen.

The fact is, some programs are better at getting women pregnant than others. Just because the doctors are nice guys and gals, and come from prestigious medical institutions, it doesn’t mean they provide a top notch product. There are hundreds of steps that occur in the IVF process, and a little extra attention to each of those steps will help you in the end. All architects are not equally skilled, the same for mechanics, lawyers, hair dressers, etc. I am not saying it’s critical to find a program that is 2 percentage points higher than the other. But, if there are real differences in the numbers, use the information to your advantage.

The SART stats are not perfect but they can be used as a guide. This system was developed to protect the consumer. Compiling and reporting the numbers from each clinic is a tremendous task that is very time consuming and expensive. You get to see the results for free. They are a good place to start.

Dr. Licciardi

Four Simple Clicks Will Help You Have a Baby

This article was written by one of my patients, Debbie Denenberg, a Choice Mom of 4 year old twins. Excerpts will appear in Choice Mom Guide to Fertility by Mikki Morrissette, available for purchase in November 2007 on www.ChoiceMoms.org. My patient is right on about using the SART statistics to help chose a doctor and she shows you how. Here it is:

I was a lucky one. Because I found Dr. Frederick Licciardi at NYU Fertility Center, I gave birth at age 42 to boy/girl twins. My experience taught me one of the most important first steps in seeking infertility treatment: all doctors are NOT created equal, and with a few easy clicks you can find the best doctor in your area.

Infertility is one of the ONLY fields of medicine where the lay person can actually compare medical results, because success rates of infertility clinics nationwide are reported and accessible. This fact is exquisitely, crucially helpful to the woman seeking to become pregnant.

Here’s how easy it is. Go to www.sart.org and click on the big yellow button: IVF Success Rate Reports. Then click on a state or type in your zip code. Now you see a list of clinics to compare. Click on one to see Clinic Contact Information. The last line is a link: ART Data Report click here. When you open that link, you can review the results by age. The best comparison is “percentage of retrievals resulting in live births”. And if a doctor doesn’t report results for any reason, run! All the excellent clinics report results.

A quick example. The NYU Fertility Center performed 356 IVF cycles on women under 35, and the “percentage of retrievals resulting in live births” was 52%. Another clinic in walking distance to NYU (we’ll call it Clinic X) reports 131 IVF cycles performed, with 22% resulting in live births. Think of what that means:
52% vs. 22%! Based on these track records, if 100 women do IVF at each clinic, 52 will have a baby at NYU Fertility Center, and only 22 will have a baby at Clinic X.
That means 30 (a huge number) failed as a result of choosing the wrong doctor. And failure is not to be taken lightly. Some of the failures may be a woman's last chance; some women may go into debt just to try.

Still not convinced? Another clinic in Manhattan performed only 25 ivf cycles in a year’s time, and reported only ONE live birth. Would you walk into that clinic? Perhaps these doctors have a lovely office or great bedside manner. Perhaps they went to school or play golf with a GYN who, not having checked their numbers, refers to them. (YOU have much more at stake than your referring physician. It is up to YOU to protect yourself). It took me only four clicks to uncover these dreadful results.

Be careful of clinics that tell you about a high pregnancy rate, but publish a low rate. Many programs with low numbers use the excuse that they do the harder cases. The opposite is usually true. After women have failed one or more cycles, they usually seek out the programs with the best reputations.

Size may matter. There can be small practices with good results, but these tend to be exceptions, so check them out carefully.

Dr. Licciardi points out, “Your infertility doctor does not work alone. He depends on embryologists, laboratories, nurses and many others. If any link in this chain is weak, your chances for success are compromised. So my recommendation always is to go to a program with published, excellent results. Your homework here could be well rewarded.”

And it only takes four clicks!

Luteal Phase Defect 3

So we thought we had it all figured out. There were many studies establishing what “the ideal” biopsy should look like for each day. But then science started changing for the better and some important issues were raised.

First, the original studies of luteal phase defect were done using the day of temperature rise as the day of ovulation (LH kits and fancy automated blood test machines were not yet invented). It is true that in many women the temp rise signifies ovulation and there are plenty of web sites dedicated to the temperature rise. However, the temperature rise is not completely accurate and could be off by a day or 2. So if luteal phase defect is all about timing (the day in the cycle after ovulation) the original studies were flawed because they used a less reliable method for timing the day of ovulation.

Second, even highly trained reproductive endocrinologists differ on their opinion on what the biopsies for each day should look like (even using the book) . If you give the same biopsy slide to 2 different qualified doctors, they could differ form one another by a day or 2. Well that’s just not good enough. Even when you give the same biopsy slide to the same doctor on 2 separate occasions, the opinion may be different. Not good if we are saying everyone with more than a 2 day discrepancy ahs a luteal phase defect.
Third, no one has ever shown that untreated women with abnormal biopsies are less fertile than the general population.

In general, most reproductive endocrinologists do not believe in the luteal phase defect and do not test for it. In the old days, doctors would use progesterone clomid or FSH to treat the supposed defect, and today women are getting on those meds more quickly than before. And it takes time; months and months can go by while you’re waiting to see if the progesterone is working. In most cases you don’t have the time to waste.

I realize there are some of you who were diagnosed with luteal phase defect and were given progesterone with great success. I am very happy for you, but your success is the exception, not the rule.

What about the obvious case: a woman who knows she gets her period day 11 after ovulation (normal is 12-14). Here I think most doctors would agree that this indeed may be a luteal phase defect and there is no harm in treating accordingly.

What about progesterone levels, what are the right numbers? We have no idea. There is no good study showing some levels are better than others. And if you were pregnant, had low progesterone and had a miscarriage, it’s usually a bad pregnancy casing a low progesterone level, not a low progesterone causing a miscarriage.

So if you are in a doctor’s waiting room and the other women with you are trading stories about how you all have luteal phase defect, that’s too many. Your doctor is probably over diagnosing LPD. If you are the only one or one of the few with LPD, then the physician is probably more reasonable and is close to getting it right, and treatment may be the right thing for you.
Don't forget to read the dislaimer 5/17/06.
Dr. Licciardi

Luteal Phase Defect

As the cycle progresses there are changes that we can see in the endometrium. To see these changes, an office biopsy must be performed and the tissue needs to be examined under the microscope. This is the “endometrial biopsy”. Through the follicular phase, the only change is that the tissue gets a bit thicker, so we don’t biopsy here, we wait till after ovulation (the luteal phase). In the luteal phase the changes are very real. From day to day (or every couple of days) we can see changes in the cells. On day 16 the cells of the endometrium look different than they will on day 19, 22, 24 etc. In references books there are pictures of what the cells should look like on certain days, and your infertility doctor may have been trained (I was) to look at the cells and figure out what day in the cycle the cells were taken. How are we counting the days? Day 14 is the day of ovulation. It does not matter if ovulation occurred 9, 11, 14, 18 days from your last period, ovulation day we artificially call day 14 (many times ovulation is really day 14, but if it’s day 12, we change the 12 to 14.) and the next day is 15 etc.
The length of the follicular phase is usually not important when talking about luteal phase defects. (To answer a question this is the phase that gets shorter with age and increasing FSH levels. What probably happens is that the FSH rises, so the ovaries get stimulated earlier in the cycle and the follicular phase gets shorter. This has nothing to do with Luteal Phase Defect so I don't want to confuse the issues). The length of the luteal phase is important. It should be around 14 days, and as short as 12 may be OK, longer is not an issue.
It’s the progesterone that makes these changes. Ovulation is around the start of progesterone production, and as the days of progesterone go on, the cells of the uterus make progressive changes.
So let’s say you are scheduled for a biopsy, and it’s day 25. You know it’s day 25 because you timed your ovulation using a kit or took your temperature or took hCG. You have your biopsy and the results come back saying your cells look like day 22 cells. There you have it, a luteal phase defect, because the development of your cells is more than 2 days behind. Next time we will go over why it’s not that simple and why biopsies are not done much anymore.
Dr. Licciardi

The Follicular Phase and the Luteal Phase

So you’ve been to the doctor and you were told you have some sort of defect, and you feel so happy that despite all you have been through some joker is now saying you’re defective: super.
Are you defective? Possibly, but probably not. Luteal Phase Defect, what does it mean? It has to do with the functioning of the menstrual cycle, so let’s go over that first.
The typical menstrual cycle, from the first day of bleeding to the next first day of bleeding, is divided into 2 parts. The first is from day 1 till ovulation. It’s called the follicular phase, because the most important thing is the growing follicle (the fluid filled cyst that holds the egg). If you are taking fertility drugs it’s the same, except that there may be more than one follicle developing at the same time. Here the main and most important hormone is estrogen, which comes from ovarian cells that surround the egg in the follicle (these are called granulosa cells). So estrogen does not come from the egg itself. The ovarian cells make more and more estrogen as the ovulation approaches. The most important job of the estrogen is to make the lining of the uterus thicker. Estrogen probably has little effect on the egg or embryo. That pretty much sums up the follicular phase. In a 28 day cycle it’s about 14 days, shorter in a shorter cycle, longer in a longer cycle. You will probably read about other hormones that may be involved in important ways during the follicular phase, but the estrogen is the key.
The second phase is the luteal phase. Here the key hormone is progesterone. Around the time of ovulation, the granulose cells that were making estrogen change and start making progesterone. The cyst that was the follicle stays a cyst but becomes the corpus luteum, the progesterone making machine. It’s called that because it luteum is Latin for yellow, and the cyst can be yellow in color. The most important role of progesterone is to cause changes in the endometrium so that the uterus can accept the embryo. Progesterone does not make the lining thicker, it just changes it. Without progesterone pregnancy can not occur. We know this because if the corpus luteum is removed in early pregnancy, the pregnancy will fail. Also, the abortion drug RU486 blocks progesterone and stops implantation.
Next time we will talk about more specifics of the luteal phase and “luteal phase defect”.
Dr. Licciardi

Let’s Go Over Some Questions

Some of you have asked about DHEA, Sperm Fragmentation, and Varicocele. Eventually I will get to these, but don’t hold your breath waiting. The problem is I will not give high marks to any of these. If I write about each one in succession, I am afraid that all of you will say, “That Dr. Licciardi, he doesn’t believe in anything!” I do believe in time tested things that have been shown to work, of which there are many, although I realize you are reading this because nothing has worked well so far.

Cathi had a killer response to my 7/22/07 blog. I am sorry that you had to hear all of those remarks.

Luteal Phase Defects, I’ll get to this. If you had 11 miscarriages, why not take progesterone?

Side effects of ICSI: We are not sure. We know that there are many children alive today that would not be here if it were not for ICSI. So clearly there is an indication for ICSI. Is it more risky? We don’t know (which is likely to mean no). We do know that children born from ICSI may have a higher rate of chromosomal abnormalities. We also know that men who need sperm ICSI have a higher rate of chromosomal abnormalities (the rate is still low; it’s just a little higher than of the general population).

Metformin may be used with Clomid, if Clomid is not causing ovulation. Alternatively, some women will stop with the pills all together and move on to injections with either IUI or IVF.

Progesterone Again. There does not appear to be a downside. I don’t like it for everyone, but if you are at the end of the rope, it probably will not hurt. There are some older papers saying progesterone can increase genital defects in males and females. But almost every women undergoing IVF is using progesterone, over 100,000 cases a year in the US. I say that if you and your doctor agree, and there is a specific reason for taking it, it can be a reasonable option.

A transient mildly elevated Lupus Anticoagulant is not enough to make a diagnosis of auto immune disease. You need more clinical or laboratory evidence.

Unexplained infertility: over 20% of our patients. It’s a hard group to be in because it would be nice to find a problem and fix it. Patients with unexplained infertility in the end do as well as, and sometimes better than, patients with other types of infertility.

Can embryos fall out of the uterus through the cervix? Maybe they can. They do get up into the tubes. Pregnancies in the cervix are extremely rare, so I would think that the number of embryos traveling down the cervix would be pretty low. On the other hand, maybe the cervix is such a bad place for an embryo, it doest grow well there. Does this mean that some women have a leaky cervix explaining their repeated lack of pregnancy? It may. My feeling is that the cervix is made to block out bad things and keep in good things. The theory has been proposed before, it's just such a tough thing to prove.

A writer was told her embryos were bad because they were only 6 cells on day 3. 6 cells on day 3 are not so bad. If the quality is poor, that’s another thing, but if it’s just the rate of development, 6 are OK.
Please see disclaimer 5/17/06. Thanks, Dr. Licciardi

A Bit More on Seeing Your New Doctor

Thanks for the great comments. I will just finish up where I left off and conclude this topic.

2) Foolish. This one she made me understand. It’s like driving around with a broken car for 6-12 months and the mechanic telling you that you really messed things up by not coming in sooner. Or like being afraid the stockbroker will tell you that if you had come sooner, you would have made a lot more money (or lost less as the case may be). So I kind of get it. But if you get to a good doctor, mechanic or broker, you will not be treated as any thing other than someone who deserves time and explanation.

3) Guilt. You are on your own here. We all feel guilty for the past “the right decision at the time”, and some of us feel guilty for…, well you name it. Throw it out the window and move forward. I know, easier said than done, but do the best you can.

In summary, hopefully your doctor will gladly anticipate your arrival. He/she will make you feel empowered by educating you and helping to make you feel at ease. So get on in there, better late than never. Think about all of the other women not taking the first step and you will feel better about what you are doing. And don't get discouraged if the doctor is not for you. There are plenty of other doctors who can't wait to see you.

Dr. Licciardi

Meeting Your Doctor: What are You Thinking, What is the Doctor Thinking?

This topic was suggested by a woman who had been my patient years ago. We continue to communicate regularly and she recently told me of the thoughts and feelings that she brought into my office at the first visit. She told me that she had a number of beliefs that made her at first very uncomfortable. They had nothing to do with me as she had them before we met.
I was surprised by what she now said, and I explained that her assumptions were really off the mark, but she insisted that she was not alone in her thoughts. So let’s see what you think.

She thought:
1) She felt that she was going to be a burden on me. She figured I was really busy doing important things, and seeing her was just an interruption to my demanding day.
2) She was worried I was going to make her feel foolish.
3) And of course, if she were to foolish, she would by default go on to feel guilty for being a fool.

I thought:
1) I probably checked my schedule a week in advance to see who was coming to see me. I really like when my day is full. I don’t like packed, but I can control that. I leave a full hour for my new patients because I don’t want to rush. I need to enjoy what I am doing and I can’t do that overbooking my day. The truth is that even though I had never met her, I couldn’t wait to see her. I think seeing a new patient is the best part of my job. Everyone and has a story (at least one) and everyone is a puzzle. I just like meeting new people. My first priority is doing what I can do to help them. My secondary objective is getting to know them as well as possible. I like hearing where people grew up, where they went to school, what they do now, etc. My father has been selling real estate for most of his life, and he would typically come home from work and tell us enjoyable stories about the new people he met that day. I like doing the same thing.
It’s also about the connection. I have 1 hour to connect, and really I better connect a lot sooner than that. It reminds me a little of the job of a journalist. Of course a journalist needs to be smart, write well, get the story straight. But the best ones connect immediately with their interviewees because this way they will get more from them. It’s the same for me. If I can connect I get to be closer to some nice people, but also the communication will be better and that is a positive for patient care. That is the way I want to practice medicine.
As far as the medical side goes, when I am asking patients questions I feel like Sherlock Holmes. Solving the puzzle is important, challenging and fun. Yes sometimes the history is rather straight forward, but most of the time’s it is not. Almost all of my patients have seen another doctor before me and some have been to many fertility specialists. I really want to fish through the history to see what is missing, what has been overlooked. Sometimes it’s nothing, sometime it’s more a matter of opinion sometimes its something very obvious.
So I was not too busy for her, I wanted to be busy seeing her.
We’ll talk about some of the other things next time.
Dr. Licciardi

Miscarriage, Infertility, Antibodies and the Immune System

We are entering the world of unknowns. You will see me contradict myself a bit, but I will try to explain why.
I will start by saying that no one has ever shown well that any of this matters at all. There have been no good studies showing that antibodies of any type have an effect on the ability of someone to get pregnant or keep the pregnancy (outside of the women with Anti-phospholipid Syndrome mentioned last time). Now I know there are small studies out there proving x, y, and z, and some of you have been treated with success, but as far as large well designed studies showing antibodies matter, they don’t exist. The same is true for levels or activity of natural killer cells, platelet activation, factor 5, protein c and s, and the list goes on and on. In fact, the American Society of Reproductive Medicine has put out a statement saying treating abnormalities of anti-cardiolipin antibodies is not recommended.
So if having the antibodies or clotting issues may not matter, how will treatment help? Good question. Many of you know that blood-thinning drugs, like heparin, fragmin, Lovenox, are given to tons of women. Also IVIG, which is supposed to lower the immune response, is given out rather frequently. But again, no one has ever shown well that these drugs are doing anything. This is hard for me to deal with because it would be very easy to the right study. Just give 100 women Lovenox and 100 none, and look for a difference. The same for IVIG. I am sure that the practices that use this stuff like water could easily do a study.
And these drugs are not risk free. You can bleed from blood thinners and there may be unknown risks of IVIG, which is made by pooling human serum.
So here is the contradiction. I do have a very small group of patients who are getting these treatments from other doctors. Why, because they are in the hole of last resort. They have tried for a long time without success. They feel good that a doctor has found a possible problem and feel good that something is being done. I am sure many of you are in the same hole. And guess what, some of them get pregnant and have a baby. If they didn’t get the treatment, would they have had the baby? Probably, but we will never really know.
I know there will be many detailed questions on this topic but this is about as far as I can go. There are too many unknowns, and not enough proof.
If you are considering these treatments, be sure your talk to your doctor about possible risks, and remember to see disclaimer 5/17/06. Dr. Licciardi

Miscarriage and the Immune System (antibodies)

As many of you have noticed, I have been avoiding this one. It’s just too controversial. Actually, there are many known facts but very little data.
Let’s start with what we know. We know that there are people out there who have high levels of antibodies who have miscarriages. Who are these people? They have the “anti-phospholipid syndrome”. Which is? A condition whereby the body makes antibodies against its own cells. We all have antibodies that help us fight disease and none of us would be here if it were not for antibodies. Some, probably many of us, have extra antibodies that don’t fight disease, but rather fight ourselves. These are auto-antibodies. Probably the most common are the thyroid antibodies; antibodies that the body makes that attack the thyroid gland. Up to 10% of women have thyroid disease, and the vast majority is due to antibodies against the thyroid that slowly destroy the gland making it under-active (Hashimoto’s Thyroiditis). Grave’s Disease is thyroid antibody condition that makes the thyroid overactive. There are many other autoimmune diseases, such as Rheumatoid Arthritis, that occurs when the body makes antibodies against the cells of our joints.
Phospholipids are large molecules that are on the surface of most of our cells, so as you could imagine, antibodies that help destroy phospholpids can’t be a good thing. In patients with the Antiphospholipid Syndrome (APS), these antibodies somehow affect the blood clotting system (we don’t exactly know how). These people are very prone to large blood clots in their arteries and veins. And it’s not just the vessels of the legs and pelvis, but the arms, neck and brain can also get dangerous clots. Now the placenta also has large blood vessels and vascular spaces. In patients with true APS, clots can form between the uterus and the placenta, reducing or stopping blood flow, and this causes miscarriage. This is what we know, and this is about all we know. As you will see next time, we know very little about clotting and miscarriage in women who do not have APS.
So where does Lupus come in? Well now we are getting into some overlap and probably a little confusion. Patients with lupus can have antiphospholipids, but not necessarily the full APS. Patients with Lupus usually have other autoantibodies that attack DNA, again not a good thing. Here almost all types of the body’s cells (brain cells, joint cells, kidney cells, joint cells, to name a few) can be affected. One of the blood tests for APS is called the Lupus Anticoagulant test. So some women have both, some have one or the other, and some can have a mix. And in case you were wondering, cardiolpins are a type of phospholipid, so anticardiolipins are another type of antiphospholipid antibodies.
Next time we will tighten this up and talk about what this all means to some one with miscarriages and abnormal clotting tests.

More Questions about Ectopic Pregnancies

Thanks for all of the comments and questions. As the weeks and months go by I will get to as much as I can. I would like to finish up a few more about ectopics. I realize this topic only applies to a few of you, but everyone having fertility treatment should know more about ectopics.

What are the Treatments for Ectopic Pregnancy? It’s surgery (almost always laparoscopy) , Methotrexate or observation. Observation is ok if the levels are falling and you feel well and you are highly supervised. Before we started using Methotrexate (about 20 years ago), everyone had surgery.
If I have surgery, does my tube need to be removed? Not always. Sometimes, if there is no rupture, the tube can be opened and the pregnancy removed. If however, the tube is removed, it’s usually for a few good reasons. Studies have shown that the natural fertility is the same after a tube is either fixed or removed for ectopic. The reasons for this may be that the tube was damaged anyway (leading to the ectopic), therefore its usefulness was low. It’s also possible that the ectopic occurred in a normal tube, but the ectopic damaged the tube. Also, having an ectopic increase the chances of another, so removing the tube will prevent that. Also, many patients who have ectopics are undergoing IVF, so if IVF is happening, removing the tube is less of a concern. Problems associated with leaving the tube in are an increased risk of re-operation bleeding from that tube. Another is that the hCG levels sometimes do not completely fall after leaving the tube in. If this is the case, methotrexate or additional surgery may be necessary.

What is Methotrexate? Methotrexate (MTX) is a medication that can treat most ectopics. It interferes with folic acid metabolism. DNA, RNA and proteins cannot be made or maintained without folic acid, therefore MTX causes cell death. The reason the other cells of the body are not harmed is because the pregnancy cells are dividing much more rapidly and need more folic acid. If the dose was higher, and the treatment longer, the other cells would have trouble surviving. MTX was developed and is still used as chemotherapy for certain cancers (other rapidly dividing cells). The dose of MTX for ectopic pregnancies is lower than for cancer chemotherapy, so the side effects are minimal. The package insert says MTX can cause hair loss, nausea and vomiting, low blood counts and other complications. The reality is that because the dose is relatively low, these side effects are very rare. I have never seen them, maybe some of you have. The dose is calculated based on a person’s height and weight.
One dose of MTX successfully treats an ectopic pregnancy 80-90% of the time. Sometimes a second injection is necessary if the first is not effective. We measure the effectiveness buy the level of the hCG. If the hCG numbers don’t fall after 1 week, a second injection may be necessary. And rarely, even after methotrexate, tubal bleeding can occur making surgery necessary.
That will do for now. Haven’t decided on the next topic yet. Please read disclaimer 5/17/06. Dr. Licciardi

Ectopic Pregnancy FAQ

How does an embryo get into the tube? After the egg leaves the ovary, it gets picked up by the tube, and after intercourse or insemination, fertilization takes place midway down the tube. The new embryo then needs to get through the rest of the tube into the uterus. If it stays in the tube, there’s your ectopic. Compared to the uterus, the tube is probably a sub-standard implantation zone. It is probable that there are many embryos that get stuck in the tube but don’t divide further, so they may be ectopic, but they dissolve away and no one knows they even existed.

Aren’t some women prone to ectopics? Yes they are, and these are women who have some sort of tubal scarring. The tube is a muscular tube about the length and diameter of a pen that has one end attached to the uterus and the open end hanging around near the ovary. This open end needs to be free: it shouldn’t be attached to anything, this way it can move to pick up the egg. Now we don’t know if it moves towards the egg and actively picks it up, but we know that tubal freedom is a plus. If there is some scar tissue on the outside of the tube, holding the tube down, it can’t move well. This may prevent the tube from getting the egg, but if not, it may cause the embryo to get stuck inside the tube. There is a second type of tubal scarring, and this involves the cells on the inside of the tube. These cells are large and lush and have microscopic hairs (cilia) that help sweep the egg and embryo towards the uterus. These cells may become damaged, usually from infection or endometriosis. If the sweeping can’t occur, ectopics can.

I had an ectopic, but my tubes are normal? Yes, even though some women are at higher risk, most ectopics occur in women with normal tubes. It’s just a numbers game: the vast majority of women trying to conceive have normal tubes, so even though their rate of ectopic is low, they have the majority of ectopics.

I had one ectopic, will I get another? You might. In medicine, the biggest risk factor for getting something bad is having it once before. If you get pregnant without IVF, odds are it’s in the uterus, but you really need to be watched for an ectopic.

How do ectopics occur with IVF, I though IVF bypasses the tubes? Embryos that are placed in the uterus can somehow move into the tubes. It may happen all the time, but the embryos flow back to the uterus. If they get up into a damaged tube, they will have more trouble getting back down. A few more next time, and please read disclaimer 5/07/06.

Ectopic Pregnancy

Hello again.
I want to start with the real story and discuss the details next time. Many of you will relate to this because it covers many aspects of ectopic pregnancy.
The patient is a very nice married woman, young and healthy. She had been trying for about a year and her basic problem was lack of ovulation. She did a couple of Clomid cycles before meeting me, and since all of her testing was negative we felt that a few more Clomid IUI cycles would be best for her. The subsequent cycles looked good on paper, but no pregnancy resulted, therefore she wished to proceed to IVF.
Being young with many resting follicles, we started on a relatively low dose of FSH, 150 units, which worked out well. She made many eggs and had 2 above average embryos transferred, with no luck. Actually, her first beta was positive, but over the next 2 weeks it rose and quickly fell. For her second IVF we modified the protocol a little, she again made many eggs, and had embryos that looked a little better. 2 were frozen.
Her first beta was 10, a low number. 6 days later it went to 198, and 5 days after that it fell to 141. So we were not sure where the pregnancy was, uterus or tube, and as hard as it is not to have a normal pregnancy, when things don’t look good, a falling beta can be a relief. But, she came back a week later and the beta was up to 1108: bummer. Usually, once it starts to fall it continues to do so, a rise like this is unusual, and can’t be good.
Ultrasound showed a small ectopic without a fetal pole or heartbeat and there was no internal bleeding. After reviewing the options, she received methotrexate, which I told her had a 90% cure rate with one injection. All looked ok, however her next hCG level was even higher. Her ultrasound remained unchanged and she was not bleeding, so the decision was made to give another methotrexate injection, which I told her takes care of the problem most of the time. Her next beta was slightly lower, but the others following showed a nice decrease. We were on our way to resolution.
Unfortunately she had a trip planned out of the country to see her relatives and I had to tell her she could not travel. So this poor woman started her IVF cycle mid March, and two months later was still getting treatment for a pregnancy that was doing nothing but delaying any other treatments and worrying her with the low possibility of rupture despite treatment and falling betas.
And then what happened? Despite her beta falling to ¼ of the previous levels, she ruptured the tube, developed internal bleeding and needed emergency laparoscopy to remove her tube.
What a pile up of bad circumstances. Any of her events taken alone (the low beta at her first pregnancy test, multiple methotrexate treatments, the long uncertain waiting time, the cancelled trip, the surgery, the loss of a tube) are tough on anyone. But to get all of this happening to the same person over a relatively short period of time is excessive.
She will take a break and then continue on, she has some nice frozen embryos and things still look good. She is young, makes plenty of eggs, has nice embryos and we remain very hopeful for success.
We will go through some details about ectopics next time. I would like to thank this woman for giving the ok to tell her story. I think many other women will be able to relate to and learn from her ordeal.
Dr. Licciardi

More About PGD

So should you have PGD? Well, this is between you and your doctor. Hopefully this blog will help you in your discussion with him/her. Let me start by saying that there is a place for PGD. There are some patients that are clearly candidates, and many children have been born as a result. I am very happy for those of you who have had PGD successfully. The problem is in saying that if it’s good for some, it’s good for all.
We already said that PGD is not all it’s cracked up to be. How could that be? Isn’t IVF science cutting edge? Yes it is, but it’s not perfected and here are some of the pitfalls.

Mosaicism. In basic biology it is taught that the cells of the early embryo are identical. Since it all starts from the DNA of the fertilized egg, as the cells divide they all have the same DNA. Well, this is usually the case, but often enough, there is mosaicism, meaning that some cells have one type of DNA and other cells have different DNA. For example, in an 8 cell embryo, it’s possible to have some cells that cause Down’s Syndrome (this is an extra chromosome 21) and some cells can be normal. Just to back up, almost all of us have 23 pairs of chromosomes, for a total of 46. If an embryo is missing at least one, or had an extra 1, we generally call this aneuploidy. Aueuploidy is the genetic problem related to aging. Down’s is an extra chromosome 21, but any of the chromosomes affected in the same way, either an extra or missing. Getting back to PGD, if the embryo has 2 normal cells, and 6 abnormal cells, and the biopsy plucks off a normal cell, this mostly abnormal embryo will be transferred, probably producing no pregnancy. If the embryo is mostly normal and an abnormal cell is tested, that embryo will not get transferred, yet it may have produced a normal child.

Embryo Damage. This is very hard to quantitate, but embryo biopsy is a rather invasive procedure. So it may be that removing 1/8 of the embryo reduces its viability.

Testing Error. Even when done correctly in experienced hands, error happens. Meaning the lab says the cell is normal when it is abnormal, and visa versa. The error rate is low, but if many embryos are tested the chance of an error per case increases.

These pitfalls get magnified when a woman produces few eggs. The biggest risk here is that the one good embryo gets damaged or is misdiagnosed as abnormal.
So the most important question you have to ask is, “will PGD increase my chances of having a baby?” If your doctor says, “Yes, absolutely”, or “most of our patients are getting PGD”, get another opinion.
The bottom line is that the medical community is not so sure yet if PGD increases pregnancy rates. Theoretically it should, but in practice nothing has been proven yet. It is possible that PGD will reduce the chance of miscarriage, and there are some studies to show this is the case, but there is other research showing it may not.
And what about the cost? My partner Dr. Berkeley brought up a great point. For the extra cost of 2 PGDs, you can pay for another IVF cycle.
Just to repeat, I have patients who do PGD, but they make the choice after getting whatever information I can give them.
Please read disclaimer 5/17/06.
Dr. Licciardi

p.s. I have recently heard of programs that freeze the embryos of poor responding patients over a few cycles to get a batch big enough to biopsy all at once. It sounds a little extreme to me, but I can't really comment until I see the results published. Just remember, a frozen embryo is not a good as a fresh.

3 Good Stories About 2 Opinions

So how was your week? Mine was fine thank you. I was very busy, saw many patients, but I want to tell you about 3 who I hope are better off after the second opinion.

The first was a young woman who gets her period very infrequently. She had a HSG that showed bilateral proximal occlusion. She was told she needed to go directly to either laparoscopy/hysteroscopy to fix her tubes, or to IVF to bypass her non-functioning tubes. If you need a little background on this subject please check my blog archives. In fact, she read the blog and wanted my opinion. I told her the same thing I discussed in my blog, namely, she needed to have another HSG at a place where back-up tubal cannulation could be performed if necessary. Sure enough, the repeat HSG showed non-blocked tubes, no further procedures were necessary. We started Clomid to increase the frequency of ovulation and I am happy to report her last cycle was successful. She didn’t need surgery or IVF.

The second was a woman with multiple miscarriages and an abnormal uterine ultrasound. She was told by one doctor she had a bicornuate uterus. Another said it was a little arcuate but not a problem, essentially normal. If you need more background there are a few past blogs on this subject. I examined her, performed my own ultrasound, and ordered the MRI. My feelings were she had a septum. The ultrasounds and MRI did not make the diagnosis perfectly clear, so I recommended a laparoscopy and hysteroscopy. Sure enough, she had a very large septum, which I recently corrected. She asked me how there could be such difference of opinion.

The third was a woman who was trying for about 7 months and went to see a fertility doctor. The HSG report said there was tubal blockage. Not looking at the film, the doctor told her the tubes were not repairable and she needed to go directly to IVF. After some failed cycles she understandably decided to revisit the tubal issue. I looked at her film and felt one tube was perfectly fine and the other had possible proximal tubal occlusion. Because of a history of mild endometriosis, we decided upon a laparoscopy. Sure enough the tubes were perfectly normal. She asked me why the other doctor said her tubes were no good.

So want do these stories have in common? Even in the world of well trained reproductive endocrinologists, in the world’s most sophisticated cities, opinions can vary considerably and even be diametrically opposed. This puts a big burden on the patient. It is a burden to get a second opinion but it’s even a bigger challenge to decide which diagnosis or plan is correct. When I tell patients that I disagree with their other opinion they are really stuck. I say use the second opinion to your advantage, and get a third if necessary. I’ll get into trying to pick the right doctor in another blog. I still owe your more on PGD.

The PGD Paradox

The next couple of blogs will be about the downside of PGD.

PGD: Pre-Implantation Genetic Diagnosis, otherwise known as Embryo Biopsy.

A day 3 embryo is ideally 8 cells. One of the cells can be removed and the DNA in the cell can be analyzed. If the cell is normal, we can transfer the embryo into the woman’s uterus. If it is abnormal it will not get transferred. Now it can be a little more complicated. Some centers are biopsying polar bodies, and some talk of testing blastocysts; but the great majority of the biopsies are done on day 3.
PGD is mostly performed for 2 indications. One is to look for genetic diseases. Here, one or both parents carry genes that will lead to illness in the child, so they undergo PGD to identify the embryos without the abnormal gene or genes.
The second is to look for aneuploidy, which means an abnormal number of chromosomes. This is the problem that occurs with age related infertility and miscarriage. You’ve heard of Down’s syndrome, which is when the child has an extra chromosome 21. But we have 23 pairs of chromosomes, so if an embryo gets one too few or one to many of any of the chromosomes, the embryo may be abnormal. In these cases, the embryo may just not implant, or it could grow early on and miscarry, or in rare cases it could turn into an abnormal baby.
Aneuploidy testing is the most common indication for PGD, and for good reason. Women who want to increase their chances of becoming pregnant, or want to reduce their chance of miscarrying an abnormal fetus, can do in vitro fertilization, get their embryos tested using PGD, and transfer the good embryos.
The problem is that PGD for aneuploidy has not been as helpful in improving pregnancy rates and reducing miscarriage as we had hoped, thus the paradox. If you were a patient undergoing IVF, had a good stimulation, normal uterus, nice embryos and no pregnancy, what explanation would you get from your doctor? He or she would probably tell you that although they looked good, your embryos were probably genetically abnormal. This tells me that if you were to do PGD, and had only the normal embryos transferred, you should expect a very very high pregnancy rate. Unfortunately, this is not the case. I’ll talk about possible reasons why next time. As usual, please read disclaimer 5/17/06.
Dr. Licciardi

The Last Word on PCO, For Now.

Wow, this turned out to be a great topic, thanks for all the comments. I want to just finalize a few things. I received a lot of great questions. Rather than answering them all here I will get to them eventually as part of other answers or new blogs.
I just want to go back to the first blog. I basically said if you have PCO get on Clomid, and most of your problems will be solved. Why didn’t I get right into the big metabolic issues? Because in my practice there are not many patients with metabolic issues. Most of my patients see a doctor regularly and know if they have diabetes. I may check a few, but always come up empty-handed. Most are not obese and have normal thyroid, prolactin and 17-hydroxy progesterone levels. The long term endocrine issues are not critical because I have a fertility practice, and getting my patients pregnant is the primary issue. So for the woman reading this who does not have access to the most advanced medical and fertility care, it’s a few tests and then Clomid all the way. Most women will have early success. If they don’t then it’s time to get more serious.
As far as the HSG and sperm tests are concerned, I do think they are important. Please remember the information here is for the average patient, and the average patient does not have multiple issues. If pregnancy is not occurring despite a few months of ovulation from Clomid, the other tests become mandatory. Of course, the patient has the option of getting all of the tests before going on Clomid.
I just can’t use Femara. I think it’s a really good drug, especially in women who don’t respond to Clomid. Because of the warning however, I don’t use it. The drug is very bad for an early pregnancy, even in low doses.
LH. We have no idea why the LH is high in many (not all) women with PCO. Yes, there are tons of theories, but no one really knows. It is this high LH that interferes with the ovulation predictor kit. Some women with PCO can not use the kits because the baseline LH is very high and there is always a color change even when not ovulating.
The bottom line is that if you have PCO, you are probably very fertile. You may need a little of the doctor's help, but in the end, most patients do very well.
I am sure more PCO topics will sneak into other blogs. Please see disclaimer 5/17/06. Dr. Licciardi

Even More about Polycystic Ovaries

Should every PCO patient be on a drug like Metformin? This is up to you and your doctor. If you are diabetic or borderline diabetic, Metformin may be just what you need. What if you are a little overweight and have high cholesterol? This is more debatable.
What if you are trying to get pregnant? Say you are normal weight or above weight, no diabetes, don’t ovulate and were told you have PCO. Here, the early studies said yes; as very high rates of ovulation and pregnancy were reported. In fact, some studies showed pregnancy rates from Metformin were higher than Clomid. Many doctors went with this information and gave their patients Metformin rather than Clomid feeling that lowering the insulin levels was the key to natural ovulation.
And then as more studies were published, the results looked less favorable. Metformin did not allow for normal ovulation as often as advertised. I realize there are some of you who took Metformin, ovulated, got pregnant and swear by that system. I am very happy for you, but most people did not have your experience. Most ovulated rarely or never. I noticed this in my practice and found I was just extending the infertile time for my patients.
The New England Journal of Medicine recently published an excellent paper on PCO, written by members of the Cooperative Multicenter Reproductive Medicine Network. The title is “Clomiphine, Metformin or Both for Infertility in the Polycystic Ovary Syndrome”, published February 8, 2007. I hate to get too scientific, but I want to say a few words about this because the findings surprised even some of the authors. Most studies that are published are not of high enough quality to make doctors change they way they practice medicine. There are many reasons for the low quality including a low number patients studied, non-randomization, flaws in the statistics, and the list goes on and on. This paper is of very high quality. In summary, while 24.9% of the patients taking Clomid never ovulated; the rate was 44.7% in women taking Metformin. There was a 22.5% live birth rate in women taking Clomid, a 7.2% live birth rate in the Metformin group. Rates with Clomid were not increased by adding Metformin. So Clomid was clearly better for becoming pregnant than Meformin.
Now this is just one study and treatment needs to be individualized. I just wanted to present the case that as of 2/08/07, Metformin is being questioned as a reliable primary method of conceiving. I’ll finish up with PCO next time, and remember speak to your doctor and read the disclaimer 5/17/06.

Polycystic Ovaries and Insulin Resistance

Thanks for all the comments. I would like to address the very important comment about insulin resistance and PCO. I need to start by saying that, as with many things in medicine, we though we had this figured out but in the end, we may be a little off the mark.
What is the definition of PCO? 2/3 of the following:
1) no or infrequent ovulation
2) physical signs of excess androgens, or high levels of androgens in the blood.
3) polycystic ovaries on ultrasound (12 or more little follicles on each ovary)

The physical signs of PCO vary considerably. Some women are thin and just don’t ovulate, and have polycystic ovaries on ultrasound. The opposite is women who are heavy, abnormally hairy, have high levels of androgens; testosterone and the other male hormones. Even normal women have these hormones, but not in excess.
So your PCO may be completely different that your friend’s PCO. And the treatment of your PCO may also be different.
Now let’s get to PCO and insulin resistance.
Insulin is the hormone made by the pancreas that allows us to use sugar. Sugar (glucose) needs to get from our food, into the circulation and then into our cells. Cells can not function without glucose. It’s the insulin that allows us to properly use the glucose. No insulin, no proper glucose utilization, no life.
Diabetes is a condition where there is a problem with insulin. Without insulin, blood levels of glucose rise to dangerous levels. Type 1 diabetics don’t have insulin, and need to take insulin by injection.
Type II diabetics make some insulin. Some Type II diabetics make a small amount and need a little help with medications to improve the action of insulin. However, most Type II diabetics make more that enough insulin, but for some reason the insulin doesn’t work well and glucose levels rise. So they have high levels of insulin and glucose. These patients are “insulin resistant”. They also take medications to improve the actions of insulin.
Some women with Type II diabetes have PCO, some women with PCO have Type II diabetes. A number of decades ago, researchers noticed this relationship and started asking if PCO was related to diabetes and some progress was made in the area of insulin resistance. That is to say, it was determined that some women with PCO also have insulin resistance.
When all this came about, researchers were quick to say that all women with PCO have some degree of insulin resistance. They may not be diabetic, but their insulin levels are high. By the way, insulin resistance is not in the definition of PCO.
Here comes the most important point of this blog. Because insulin also acts a growth hormone, it can make people bigger and fatter. People who are insulin resistant, have higher levels of insulin and may be bigger. (Now I know that some of you are type II diabetics and have normal weight, but most type IIs are at least a bit overweight.) The idea was if we lower the insulin (with medications that help insulin work more efficiently) patients will lose weight, and ovulation will occur normally. And it’s not just about the weight, there may be other benefits of lowering the insulin levels that help women with PCO. Lowering insulin levels also may lower the androgen levels. Metformin, aka Glucophage, is the most commonly used drug for this purpose. We will get into this next time.

More on Polycystic Ovaries

Please start off by going back to the archived blogs from 7/06/06 and 7/22/06. These will update you with the basics of cysts and polycystic ovaries.
So let’s say you were told you have PCO, or Polycystic Ovaries, and you want to get pregnant. What are your next steps?
The first steps have to do with further diagnostics. You don’t ovulate and getting you to ovulate is probably all you need to get pregnant. Clomid may be all you need. Do you need to do any other tests before you start the Clomid? Probably not but you may. It is common for women to have more than one fertility problem. Some women with PCO also have blocked tubes (totally unrelated to having PCO) or a low sperm count. And some have other hormonal issues.
The basic things to check are your prolactin, thyroid and 17 hydroxyprogesterone. The last is a test for congenital adrenal hyperplasia, a rare disorder that can create a picture like PCO. If the blood tests are all ok, then you can consider the hysterogram and semen analysis. It is OK to start Clomid without these 2 tests, may patients do. Just understand that these tests need to be performed eventually. It’s really bad if you get a Clomid prescription for 6-12 months. A few months are fine and if you’re not pregnant, then check the tubes and sperm.
How do you know if the Clomid is working? If the time in between cycle is greater than 35 days and Clomid gives you cycle that are around 28 days, it’s working. If you still rarely get a period, it is not working. There are more accurate ways to check. If you take your temperature (temperature charting is too much work, but I know some of you are regular temperature takers) there is usually no clear rise mid cycle, but there is when Clomid is working. Progesterone causes the rise and progesterone is only present after ovulation. No ovulation, no progesterone, no temperature rise. The ovulation predictor kits are another option. These are hard for women who get cycles far apart because it’s difficult to know when to start testing, and testing can go on for weeks if ovulation is not happening. But if you were getting 50 day cycles and now they are 29 days, you are ovulating. It becomes easier to use the kits and time intercourse if your cycles become more regular. The best way to prove that you have ovulated is a blood test for progesterone. The problem with this is people get hung up about the level. This is not important. If your level is 6, 9 or 21 it does not matter. Progesterone levels vary throughout the day anyway. As long as it is elevated above baseline (2-3 depending on the lab) you are OK. More next time and please read the disclaimer 5/17/96.
Dr. Licciardi

A Little More about IUI

Should you have one or two at each ovulation? We don’t think there is an advantage if 2. Since the egg is good for 1 day and the sperm 2, one well timed iui should cover it. However, I have many patients that would just feel better having 2 iuis. I have no problem with this. Sometimes it’s hard to figure out when to do the first. If you are getting an hCG shot and want 2, probably the first iui should be the day after the hCG. If you are using a kit, it’s a little harder because the actual time of ovulation is less. So the day of the first iui is really up in the air. If you are using you partners sperm, and the counts are low, you really want to make the first iui the day of ovulation because sometimes (not always) the counts are lower the second day in a row.
For donor sperm, should you use 1 vial or 2 at each insemination? It depends on the recommendations of your lab and the counts from each vial. You would like to get around 10 million motile sperm for each iui. If you are a little under that’s ok. So if one vial is giving you 13 million, that’s enough. If you are getting 6.5 million, maybe 2 would be better. You may need to do your first iui, see what you get, and change plans for next time.
Can your doctor provide iui on the weekends? Many can not. Most patients don’t realize that the timing of their iui may be based on the doctor’s schedule. If you think you should be inseminated on a Saturday or Sunday, and the doctor finds an excuse for you to wait till Monday, head for he hills (or at least to another doctor who can get you services when you need them).
Can a nurse do the iui? Yes, an experienced nurse is an expert at iui.
How long do I need to stay on the table after the iui? It does not matter. Getting up immediately will not change your outcome.
Should I have a cap or sponge in my vagina to hold the sperm in? No, most of the sperm is above the cervix, in the uterus.
Dr. Licciardi

When and How to time the IUI

Thanks for asking me to write about this. I have requests for other topics too. I’ll get another blog out about PCO as soon as I can.
Let’s start with iui in a natural cycle: how should it be timed? It’s nice if iui can be performed on the day of ovulation. The egg is good for about a day after is released. The sperm can stay in the tubes (where fertilization takes place) about 2 days. Sperm may stick around even longer than that as there are reports of pregnancy up to 6 days after ovulation. {I know some of you are thinking “I should be so lucky”.} Six days is really a stretch, so let’s stay with 2. So if the egg is good for a day, and the sperm is good for 2, maybe precise timing isn’t so important after all. Probably correct, but we do try to get is as close as we can. The point is the sperm and egg don’t have to collide in the tunnel. The sperm can be hanging around waiting for the egg and the egg can be moving through the tube waiting to be chased by sperm.
“Natural” testing using mucus, temperature and the calendar can work ok, but that’s because we just said getting the timing perfect may not matter much. I mean to say it’s not accurate.
Then there are the kits and the monitor. I find the kits easier that the monitor. Just because the monitor is more expensive does not mean it’s better. The ovulation predictor kits do just that: they predict ovulation. One day there is a color change and the next day is ovulation. The kits measure the hormone LH. This “spikes” about 36-24 hours before ovulation. Because you are not testing every 10 minutes, you don’t really know when the spike occurred. We just know it has occurred since we last tested and ovulation will take place at the most 36 hours later, but probably in the next 24 hours. So the best day for iui is the day after the color change. Some kits say the best time to try for pregnancy is the day of the color change. The day of the color change may be a good day, but the next day is better.
What if your doctor gives you an hCG shot? This is a chemical that is almost like LH and it also causes ovulation when given once when the egg is ready. hCG just helps with the timing. If you have an ultrasound and the follicle looks ready, we give hCG. You will probably ovulate without the hCG, but getting it avoids you needing more days of blood tests and ultrasounds, plus you avoid missing your natural ovulation. Even with careful monitoring, occasionally the ovulation is missed, which is understandably upsetting for patients, but it does happen. A little more next time, and please see disclaimer. Dr. Licciardi

Last One About Septums

Thanks for hanging in there. This subject applies to very few of you, but the information is important to those who may be affected.
The reason it is vital to know your diagnosis has to do with treatment. If you have a septum, most (not all) doctors would recommend treatment. This is because an experienced reproductive surgeon can fix a septum relatively easily. It’s done through the vagina using a hysteroscope. The doctor looks in, then slides a tiny scissors through the scope and makes small cuts at the septum until it is gone, making the uterus normally shaped. Some doctors will recommend a laparoscopy at the same time to guide themselves through the surgery. Others will perform the surgery using the hysteroscope and an intra-operative ultrasound to guide them, avoiding the laparoscopy portion. In either case, patients go home the same day.
A bicornuate uterus is a whole different story. To fix this a doctor needs to perform a laparotomy (an incision into your abdomen), then slice the uterus wide open, then sew it up in such a way that the 2 sides come together to make one round uterus. As you can imagine, this has a much higher complication rate, and has a higher rate of infertility due to post-op scar tissue. Hospitalization can be 2-3 days. Full recovery is 6 weeks. Because this procedure is more difficult and has a higher complication rate, it is rarely performed.
This gets us back to the very beginning. If you have a septum, but your doctor calls it a bicornuate, you probably will not be offered treatment and be faced with continued increased odds of infertility and miscarriage. If the correct diagnosis of a septum is made originally, you could have a more simple procedure that may increase your odds of reaching your goal.
Many patients have come to me with a diagnosis of a bicornuate uterus. Told surgery was not a good option, they ask me what else can be done to help them get pregnant or reduce their odds of miscarriage. Some actually have a bicornuate uterus. Some are very surprised when I tell them they really have a septum and should revisit the surgical option.
I need to point out that septum repair does not guarantee fertility or a delivery, but for some patients it may be very helpful. As usual, please see disclaimer 5/17/06.

It’s Been a Year

This blog started a year ago. I was talking to a friend of mine about ways I could “get the message out”. She asked me if I had a blog, I asked her “What’s a blog?” The same week I spoke to a patient who told me about her blog, so I got started.
This has been a very good year for me. I really like doing the blog. I get very excited