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