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
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
posted by Dr. Licciardi at 8:25 AM
23 Comments:
I am a few days away from turning 40 and have had no issues when tested 2 years ago. Hubbyman has 145 million count but 45% low motility and we have never gotten pregnant after being married for almost 7 yrs. IVF/ICSI would help or no?
TIA!
Thank you for this blog, Dr. Licciardi. I am 40 and trying to conceive for the first time ever. I'm a nurse, so I have lots of questions and like the details. We just had our first visit to repro. endo. after trying for 6 mos, and I had some labs drawn. You have answered several of the questions I had about the results (which are normal, by the way), so if my hysterogram is also normal, I guess we'll just keep trying! Thanks again.
I find your blog very intresting---thanks for posting the things you do for women like myself.
www.thepiferfamily.blogspot.com
Im 24, TTC for 2yrs. Failed IUI, failed IVF (sept). FSH 12.6. What would you do next?
Dr. Licciardi, thank you for taking your time to educate us. I am 42, no apparent health problems, unexplained primary (most likely imminent ovarian failure as my FSH is about 12, and my AMH fluctuates and is about 0.6-0.8ng/ml - was 1.6 a year ago). I had two antagonist (!) protocols cancelled because of a premature LH surge. Both times it came with a drop in E2, so nothing could be done. The last time it came on day 8 of stims = cd9. Both protocols were "fixed" with 225 FSH started on cd2, 0.25 Cetrotide started on d5 of stims = cd6. Both times there was a leading follicle of 14-15mm on the day of first Cetrotide (the rest were lagging far behind). Judging from the literature (I spent a lot of time reading the academic papers on the subject), my monitoring was done up to the existing quality standards. Furthermore, in the couple fo last cycles, I used Ovulation Predictor kit (OPK) in the luteal phase, and had a few positive OPK in the luteal phase (around 4dpo amd 10 dpo - LH surge was confirmed by serum LH or by positive OPK, and ovulation confirmed by serum progesterone test). My cycles are on a shorter side (about 24-26 days). Could you please comment why I might have premature LH surges and high LH in luteal phase and suggest a possible alternative protocol or tests to be done? I spent long time trying to find explanations in the academic literature, but failed. I really hope you could help me. Many many thanks in advance, T.
I am 31 and had 3 failed IVf cycles.I have endo and have in the past had 6 months lupron therapy for the endo. This was before my first cycle. After 2 yrs the pain has come back so I chose to do lupron again this time 3 months(monthly shots). how soon do you advise I should start my next IVF? should i want for my period? or start right away 4 weeks from the last shot?
I was 40 when I had my first child and 44 with my second. I used Zestica Fertility which is a lubricant that supposed to help sperm. Not sure whether that was the reason I got pregnant second time around but would definitely recommend it as a great lube.
I love your blog! I just wanted to leave some encouragement for the ladies that had mentioned having several miscarriages and wondering whether to try again. My husband and I have a 4 year old and then lost 4 pregnancies in a row. When we considered throwing in the towel we realized that if we just gave up then all of our heartache would have been in vain. I am now 5 months pregnant with a healthy baby girl. Don't give up hope!!
If you are looking for a sperm donor or a co-parenting match: this website help to find your co-parenting partners (gay, straight, singles, couples...) www.co-parents.net
Two comments on your responses: (1) for the young woman with several miscarriages, although your clinic may not be doing it, a few clinics are doing very, very promising studies that permit an embryo to be tested for chromosomal abnormalities and are able to test all chromosomes. Success rates are very high and have especially helped women with multiple miscarriages and multiple failed IVFs; (2) in figuring out the SART statistics, I have been told to look at the clinic's donor egg statistics b/c donor cycles will be much more equal b/c the standards for donors are very similar clinic to clinic.
Thanks.
I have a question for you and I'm not sure where else to post general questions . . .. I'm wondering whether SART or other professional organizations for REs have set any standards or recommendations for discussing family planning with infertility patients over 35? For example, rather than jumping right into an IUI, if patient is AMA, it seems doing IVF and freezing embryos for future use would be a better approach for unexplained infertility that appears only to connect to AMA. In my case, I had one son through my first IUI when I was 38. Now, five years later, we are giving up being able to get pregnant again with my own eggs after 2 IUIs and 6 IVFs. I just think back to when I went to my first RE when I was 37-38 y.o. and we never discussed how many children we wanted and maybe it would have been better to do IVF and freeze some embryos if possible for a sibling down the road? As it was, I had to wean my son sooner than I (or he) wanted to in order to start my IUI/IVF cycles and now I'm just out of luck and it kills me. My OB/GYN is the only one who ever said--get in before you are 40 for another child. My first RE never said anything to me about this issue, it wasn't until I went back and started researching that I saw how screwed I was--a little late in the game. While maybe we wouldn't have ended up with any children at all and so I understand that the focus was always on the first one and forget about the rest . . . but even having the conversation and understanding the facts and what we would face would have helped me somewhat at this point. I'm interested in your input on this issue as a professional in the field.
Thank you.
I am 26 and have one child. I have had two miscarriages and one enacephalic baby. I am just beginning my infertility journey as I have have been TTC for 12 months, I can obviously conceive but no baby! I keep hearing I could be ovulating or it could be a follicle cyst, (I am going next Thurs. to find out by blood test) but my question is isn't that the same thing? Ovulation is a cyst bursting? And if ovulation is not the problem, what are your suggestions?
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thank you for this blog, Dr. Licciardi. during my workup for secondary infertility (i have a healthy 3 year old) my ob/gyn noted a Day 21 progesterone level of 4. she attributes it to anovulatory cycles but based on my charts, i see a thermal shift every month with a luteal phase of 12 days. do you think the low progesterone level is significant? am i not ovuating or is it a luteal phase defect? thank you so much for your time.
I am really grateful for this blog!! It has helped calm me. I have a question. I am 32 and have shorter but normal cycles. My husband, 32, has a varicocele, and normal counts and motility but 12% morphology. Is iui a successful option, or ivf with icsi? I would like to know if I am wasting my time. We have had 5 unsuccessful iui's. Would a medicated cycle help with iui? I have on clomid cycle and develped only my normal one follicle and a cyst on my other ovary.
I came across this site and thought it could be helpful. It is an infertility online course that helps women with infertility. I have suffered through it and now have a baby through IVF. Wishing everyone baby dust.
http://infertilityeclass.com/
Good one on "Frequent Fertility Questions".I'm using the methods from http://debtfreeliving.lose20.com to reduce weight and it really works.
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Hi Dr. Licciardi - I am 33 years old and have been undergoing fertility treatments for almost 2 years. I have 2 early miscarriages (one on femara + intercourse and one on follistim +iui).
I just failed my first ivf cycle with a day 5 blasctocyst transfer (1 3AA, 1 2BB and 1 4AC. I ended up having 4 more to freeze - all aa's, maybe 1 bb.) My lining was a 5. My lining never goes above a 6, despite oral estrogen, oral estrogen taken vaginally, vagifem, viagra suppositories and baby aspirin.
I live in the Albany, NY area and was wondering if you thought I should make an appointment to see you or if you had nothing else to suggest in terms of thickening my lining. (You don't take my insurance, so I would be paying for the consult out of pocket. IVF is also out of pocket for me.)
I realize that some women have thin linings resistant to everything and that I am probably one of those people, but before we move to a gestational carrier I just want to explore all my options since obviously I would love more than anything to carry my own child.
Thank you,
Jill
Thanks for the opportunity to ask questions! I am 28, had a abd myomectomy at age 20, which created Asherman's syndrome. Currently have an open uterus with significant adhesions at the top of the uterus, but have started back menstruating after my last mini-lap/lysis of adhesions (that was my 4th surgery for Asherman's). Currently having recurring endometriomas, last check 3 weeks ago showed right ovary with 6-8 cm endometrioma (aspirated twice, recurred both times), 6 cm on left ovary. Having significant pain, Lupron (2nd month) helping. RE now recommending hysterectomy for pain relief, but not convinced most of my pain is from uterus. Wondering if pain could be from endometriomas?? Getting 2nd opinion prior to hysterectomy - would welcome any suggestions, comments, guidance :) Thanks so much! Tara M.
I had a laporoscopy and severe endometriosis was removed. I recently went to a new RE for a second opinion and was told that my laporoscopy would most likely have to be redone because the first doctor only made 2 incisions (1 belly and 1 lower abdomen) and that 3 were necessary to do the job correctly (1 belly and 2 in lower abdomen)so that 2 separate tools could be used to remove the endo. I was wondering whether you typically make one or two incisions in the lower abdomen and if you thought my first doctor may have missed something by only making one incision?
Thank you for your column. It is very informative.
tHank you for this colomn. Pls I hv a question. I am 32 and ttc for 5yrs. Hubby has low count, my tubes are both damaged with hydrosalpinx on one. I had lap last week and was told the tube miraculously clipped the hydro in so nothing else was done. Hysteroscopy was clear aswell. I am about having nk cell test before I start a new cycle in noveber. Is there anything new I should do to increase my chances? I respond very well to the ivf drug and do produce upto 20 eggs. My ovaries are polycystic though and I had ovarian drill thus time aswell.
IVF at age forty is very risky due to the multiple birth issue. I would be concerned for your health as well as any future children since multiple birth will usually mean premature delivery.
I would strongly advise against IVF/ICSI.
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