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
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
posted by Dr. Licciardi at 6:57 AM
23 Comments:
I liked your blog. keep it up!
I'm a 34YO female with no known issues other than a small uterine polyp. My husband is a 34YO male with low motility but normal counts (motility varies, last sample was up to 31%).
He was originally diagnosed with a varicocele and was scheduled for surgery (original motility test showed 2.7%), but his latest counts were high enough that the doctor called it off. We've now done 4 IUIs, the first 2 with clomid, the last 2 with Femara and HCG trigger shot. Last IUI had a TMC of 10.5M and I had 3 follicles.
We can't get in to see our doctor for another consult for 2 months, how do we find out what our course of treatment should be? What do we do in the meantime--continue IUI for a few more months? Or do you suggest scheduling an IVF consult?
Not sure why I never posted before, but I wanted to say thank you. Last year, at age 28, I had two back to back early MCs (embryo never grew past 6 weeks). They were my first and second only pregnancies ever. I asked the doc to do the routine blood tests to see if we could find the cause of the MCs, but all came back normal. In the course of doing my own research, I came across a blog entry of yours describing uterine abnormalities (specifically the differences between unicornate, bicornate and septum uteruses and the like). I asked my doctor to check for this in me to see if this was a factor. She scheduled an HSG and lo and behold, they found I had a subseptate uterus which they believed was the cause of my early MCs. I had a surgery to remove the SU, and after the proscribed time to let the uterus heal, I was allowed to start TTC. I got pregnant for the 3rd time right away and am doing well at almost 18 weeks of pregnancy. Thanks for your very helpful and informative information!
After 6 years of trying, I have had 2 miscarriages in the last year, after my RE took me off all fertility drugs. We have timed my IUIs with LH kits. So far with this clinic, I have been pregnant twice out of the 4 IUIs I have done with them. Those are good odds, right?
Both pregnancies came back with low betas (highest being 44, 21 DPO). Both times my progesterone was very low with the last pregnancy peaking at 2.4. My RE will supplement my next IUI cycle, at my request.
My RE had blood work done on CD 21 the next cycle and my progesterone came back at 9.9. My HSG was normal, and my lupus anticoagulant was normal also.
What other tests can I request be done to figure out what is causing these miscarriages? So far, there has been no reason. I am so scared to try again because I don't think I can handle ANOTHER miscarriage.
I forgot to mention that my husband's analysis was normal, with the only "issue" being increased tapered heads.
Hi there
I would love to get your perspective on our situation.
I am 31 with no IF problems. Husband is 43 and had a vasectomy at the age of 31(!) Plan A: We tried 2 fresh IVF ICSI and one FET using TESA sperm. All went very well until the negative betas.
Plan B: A micro-surgical vasovasectomy done by a urolgist in South Africa. The sperm analysis 3 months post reversal was 18 million, 20% motility and 1% morpholgy.
Is the morph likely to improve over time? Should we try naturally, IUI or head straight back for another round of IVF/ICSI.
What would you guess our chances of success are with these options?
Donor sperm is off the table unfortunately.
Thanks so much!
Thank you very much for your blog. It is a tremendous source of assistance for those of us dealing with infertility—in my case unexplained.
My husband and I are 38. In 2006 I was pregnant (natural cycle) but miscarried at 7 weeks (d&c). A year later, I became pregnant again and miscarried at 6 weeks (doctor confirmed pregnancy via ultrasound). After numerous tests, the results were normal except for the MHTFR A1298C mutation with normal levels of homocystine. The doctor concluded that this was not the reason for my miscarriages. We had 3 failed IUI attempts, and then moved to IVF #1: (27 eggs retrieved, 22 mature, 16 fertilized, two good quality blastocysts transferred on day 5, none frozen), which resulted in a chemical pregnancy. Last month we began IVF #2. My FSH level was 5. The retrieval and transfer resulted in the following statistics (31 eggs retrieved, 17 mature, 10 fertilized, 3 grade A embryos (8-cell) transferred on day 3, and none frozen). Yesterday we learned that I am not pregnant.
Why none of our numerous good looking embryos (according to the embryologist) make it to freeze? They all stop on day 5 or 6. Also, are there any specific tests that I should get done besides the routine ones? Any suggestions for our next step would be much appreciated. Thank you again, Maria
After 7 FSH IUIs, I'm now pregnant after my first IVF with ICSI. Thank you very much for your advice in the past, and your wonderful blog. My question is this: when I left my IVF clinic, they recommended amnio (they do this for all ICSI pregnancies). I can't find great information on the increase in birth defects for ICSI babies. But after a normal quad screen, I am reluctant to do an amnio because of the risk to the baby. What birth defects increase with ICSI? Are they life threatening? Do you recommend amnio for your ICSI patients? Thank you!
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This post has been removed by a blog administrator.
This post has been removed by a blog administrator.
Have you ever had success with transfering an embryo frozen on day seven? I have had two failed IVFs. The first one was after transfering two three-day embryos. The second was after transferring two five-day embryos. Only one other embryo made it to freeze; however, that was on the seventh day. My RE doesn't have any experience w/ transferring an embryo frozen so late. Do you have any information on the success rates?
Also, is it OK to swim if one is using crinone gel?
Thank you.
First--thank you so much for the blog! I've learned so much from reading it.
I'm 34 with FSH levels that fluctuate between 11 and 15. I've had three failed IUIs and now we're talking IVF. While I'm willing to do whatever it takes, I'd much rather take oral progesterone vs the shots. What do you think about oral progesterone or progesterone through suppositories?
i also find it incredibly tacky that you deleted my earlier comment.
DX with MFI no known female(26yrs) factors after testing (8yrs ttc)
we have the option of 1 ivf or ivfx3 option but that one costs more per try because they dont include stuff....i want to go with the 1 but am scared it wont work and i wont have left over embryos... they said my chances the first try were 67%.and 97% after 3..are those good odds...can i feel comfortable with the 1 IVF????
I am 30 years old and have been trying to conceive for 8 months. We are currently seeing an RE. My day 3 bloodwork:
FSH: 6.4
E2: 23
LH: 5.2
I also believe I have ovulated every month. Two months ago (when I started seeing the RE), I had a progesterone test 5 days after my surge and it was 13. My doctor was happy with that. Last month, I had a 20 mm follicle and we did an iui - without drugs. My lining was only 5.3. It didn't work.
For this month, my doctor put my on estrogen (taken vaginally 2x a day) and 50 mg of clomid, days 3-7. I got a surge on day 11 and 12 and had an ultrasound... I had a 7.6 mm lining - but there were only small follicles. I continued to be monitored throughout the cycle and never produced a follicle - therefore I did not ovulate. This was all very frustrating because as I mentioned above, I ovulate on my own regularly (in months before seeing the RE, I would use opks, get a surge, feel crampy and get my period 14 days later so I am fairly certain... and then last month's progesterone level confirmed it).
So my question is, why would a normally ovulating person not ovulate on clomid? Is there anything medically to explain this?
I am now starting my second round of clomid - this time at 100 mg. My doctor wants to try one more month and then we'll move on.
Please let me know your thoughts and what may explain this. Thank you very much for your blog!
I appreciate the frankness of your blog. I hope you can give me some advice.
I'm 37YO. Husband is 48YO male. He had a vasectomy in 11 years ago. First reversal was in Jan 05 but unsuccessful. Second reversal was in Jan 07 and sperm returned.
In January 2008 we decided to do IVF w/ ICSI because of low count, 0 motility and 0 morphology.
We did 3 IVF w/ ICSI cycles. Each cycle had 6-8 mature eggs. Each cycle hads >5 fertilize. We transferred the following:
Cycle 1: 2-6cell, 1-8cell
Cycle 2: 1-6cell, 2-8cell
Cycle 3: 1-6cell, 3-8cell
All cycles have failed.
We did another SA and found that sperm count is now 27-35 mil, 6% motility, 2% morphology.
We are trying to figure out what to do next.
Do we have other options besides IVF w/ ICSI?
We are also considering changing from the local Michigan doctor to one in Colorado. The CO doctor has improved success rates. Do we risk loosing the "learnings" by switching doctors and reducing our odds?
I am 32YO female with PCOS and past endometriosis, dont not have a period, 7 failed rounds of clomid/femara and HCG, on 2000mg for almost a year metformin. My husband has been cleared and has great sperm counts. My RE doesnt want to do just FSH with IUI she is pushing IVF, she said that injectables with IUI is not done and to risky, although she said she would if we insisted which we did. Are we taking a huge risk by doing this is, should we move to IVF, or if I am monitored properly is it ok.
I have a question and would be so grateful to hear your opinion about it. I am 37 years old and I have a 9 month old child whom I conceived with IVF. It was an unplanned IVF -- I was doing my first cycle with injectable drugs (a very low dose because I have PCO) and I hyper-responded to them, made 26 eggs and had to be converted to IVF at the last minute. I suffered from bad OHSS during the beginning of the pregnancy -- had lots of pain and had to be "tapped," etc. I have 6 frozen blastocysts from that IVF. My RE (who works at a major fertility center in NYC) says that given the quality of the frozen embryos, I can count on getting "one or two" more children out of them. We would like to have two more children. My RE told us it would not be crazy for us to do a fresh cycle now while I am still relatively young, and then use the frozen embryos we have now (and/or any we get from the next fresh cycle) for the third child, just in case there are not two children to be had from among the frozen embryos we have now. I suppose this makes sense, but I am concerned about getting OHSS again -- is it potentially life-threatening? Could it have a bad effect on the child? Should I just try to get two more pregnancies out of the frozen embryos we have and do a fresh cycle only if we use up all the frozen embryos and still don't have two more kids (at that point I might be 40 rather than 37 doing a fresh IVF cycle). Please share your thoughts if you have time! Thank you very much.
Yours,
Mulling it over in Manhattan.
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I very much enjoy your blog. Lots of very interesting information. Thanks
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Truthfully, I was frustrated by your comments about the chances of a woman with an fsh of 16 having children with her own eggs. I had an fsh of 15 and recently completed my first ivf cycle, and I'm now 10 weeks pregnant with triplets. All the emphasis on fsh is puzzling to me.
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