Questions About Infertility Issues

Ovulation Timing Questions
If your cycles are 55 days, are you ovulating? Most likely, probably around day 41. However, it is possible that you are not, so you must confirm through your doctor.

What if your cycles are 28-31 days but a progesterone test proves ovulation day 11? Very unusual, but it does not mean you are infertile. Check for ovulation a little earlier using the LH kit to see when it starts and to see if this is a consitant issue.

Is there a problem with 70 day cycles? Yes. You can try to track ovulation but when do you start to do so? If your cycles are always 70, check a progesterone day 60. If it shows ovulation at least you have that. It’s just harder to time things with such a long cycle, and you really don’t have many ovulations per year. If you want to get pregnant, get some help.

Miscarriage Questions
If you are having miscarriages on clomid, will IVF up your odds of going to term? Different doctors will give you different opinions. The IVF option will sit differently with different patients. We aren’t sure if IVF will reduce your miscarriage risk. So the answer is probably no, your odds will be the same with or without clomid. However there may me a play to try IVF with PGD. This option you really need to talk about with your doctor.

Does having an early miscarriage predict further pregnancy loss? Usually not. The odds are still excellent for having a baby in the next pregnancy if you had had only 1 miscarriage, or even 2-3 for that matter.

Will you ever conceive again after trying 3 iuis that resulted in one ectopic and 2 miscarriages? And suppose one of the tubes was removed? If the remaining tube is open, your odds would be excellent of conceiving again. But don't wait too long before getting help.

Is there a relationship between a long follicular phase and miscarriages? Most likely no.


IVF Questions
Is it better to transfer a fair quality embryo on day 2 or let it grow to day 3 or day 5? Does the uterus provide an advantage over the Petri dish? Unless the lab is really bad (these days there are few really bad labs), then it does not matter. Now that’s’ if there are only 1-2 embryos. If there are more, going to day 3 will help you select the better embryos for transfer. Lab differences are more of a factor when going from day 3 to day 5.

What if the sperm is normal and you are not fertilizing? Should you try donor egg? If you wish, but the problem is more likely related to the sperm. Of course, unless you try donor sperm or donor egg you would not know, but if you look at a 100 patients who are having your problem, almost always the sperm is the issue.

If you are a poor responder, will adding clomid to an IVF cycle give you more eggs? It is one of the options. I make it may last, I put Estrogen prime of microdose first, then maybe clomid. Clomid sometimes makes the uterine lining thinner.

Is there a weight limit for IVF? It depends on the program. The fact is, people are getting bigger and doctors are getting more used to dealing with the big problem. However, it may be important to meet with the anesthesiologist who would be taking care of you during your retrieval. More important than your weight is the configuration of your neck and throat. They want to be sure that if you have trouble breathing, they can get a tube down without a problem. And let’s not forget that your doctor may be less worried about the retrieval and more worried about you and your baby during and after the pregnancy. It has been clearly shown that obesity is bad for pregnant women and bad for babies to be in the short and long term.

If you’re a poor responder, will dexamethasone produce more eggs? This has not been shown to be the case.

Do frozen embryos make healthier babies than fresh? There was one article that somehow came to this conclusion. We do not think there is a difference.

What if a “dominant follicle” seems to be the problem? Dominant follicles come in a variety of forms. Some women are very poor responders and only make one follicle. I have heard this referred to as a dominant follicle. More commonly, a dominant follicle means that you have the potential to make many follicles, but for some reason, only one is big and the others remain small. There are strategies to try to reduce this phenomenon but they may or may not work. We believe that in a natural cycle, the dominant follicle may be selected before the period even comes, so by day 2 the body has already laid out its plan for that month, and stimulating the ovary with drugs may not be able to alter that plan, leaving you with a low number, or just one dominant follicle. So by using oral contraceptives or lupron to turn off the ovary system for a little while, we may be able to stop the dominant follicle pre-selection and give more than one follicle a chance at becoming dominant. However, most of the time, the difference is not extreme

25 years old and not pregnant after an IVF cycle with nice embryos? In the end you will probably be fine. As I have said many times, get to the best program possible. Even at the best programs, these things happen.


What if you have a low AMH level (a sign of poor ovarian reserve) but have many resting antral follicles as seen by ultrasound and make many eggs during stimulation. In your case, the AMH is just dead wrong. As far as we know the AMH is not predictive poor egg/embryo quality, just egg numbers. AMH is promising as a way to measure reserve, but there are a few problems, most of us are not comfortable yet using if for a definitive diagnostic tool. In many cases it does give us correct information, but we need to fine tune the testing and result interpretation.

Interesting question. If a clinic is more aggressive in bring patients to IVF early without much other treatment, will their IVF success rates be higher than clinics that get some people pregnant first with clomid or FSH? Will doing IVF on fertile people make a clinic look better? I would say in a few case yes, this makes sense. In fact overall, since IVF seems to work well enough for most people, more people are doing IVF after shorter intervals of clomid or FSH. However it depends on the IVF success rate differences between the 2 clinics. If there is a small difference, I would point to the selection. If there is a big difference, IVF quality is a big part of the discrepancy.

How do you know if the clinic does a good job with blastocyst culture? Try asking what percentage of transfers are blastocyst for your age group, then ask the delivery rates for blast vs. day 3. Of course check their SART statistics. If they have very good pregnancy rates but do much blast, that may be fine. However also check on the number of embryos they put back. If they have good rates with a higher number of embryos returned and a higher number of triplets, that’s not so good. One of the goals of blastocyst culture is to take advantage of the natural selection process so that by day 5 the best embryos will stand out. If we can see which ones are better, we can put fewer in and reduce the odds of multiples, while maintaining higher pregnancy rates.

IUI Questions
When should you do the iui after the trigger shot? Ovulation will take place 36-38 hours after the shot. There is not a specific time that has been shown to be better. The sperm may be available to fertilize for at least 2 days. The egg is good for about 1 day. So it is reasonable to have the iui performed 24 hours after the trigger.

What if it seems on FSH you are ready too early? Even though you may be ready on the early side, the egg or eggs are probably not affected. However, if it is early there is less harm in waiting an extra day or 2 to give the hcg. I have not heard this to be more effective than just giving the hcg at the usual follicle size, independent of the cycle day.

Should you see an RE or should you let your general OBGYN handle the clomid? It depends on your threshold. If it’s really that more convenient and less expensive, and you are not in a super rush, a few months with your generalist is fine. Otherwise, get to the RE.


Donor Egg Questions
One of my most difficult questions. What if you are doing donor egg with a proven donor and your embryo quality is not great, even when splitting the eggs ½ donor sperm, ½ partner sperm? Clearly all avenues have been explored. If you have not already, and wish to continue, consider another opinion. Now I have seen proven donors give disappointing results in subsequent cycles. It is true that a young donor is more likely to make a baby with embryos that don’t look as good, so maybe the proven donor made fair embryos last time and made a baby. We have been surprised when there are pregnancies from poorly looking donor embryos, but thankfully we see it now and then.


Tubal/Uterine Questions

What about a second surgery for a septum, may it be necessary? Occasionally, more likely with a larger septum. Sometimes at surgery the cavity looks fully repaired but an HSG 2 months later shows there is still a good piece remaining. In this case maybe the upper septum scars together making it appear it was never cut. Or maybe it was never cut, which could be for 2 reasons. Maybe the doctor cut and cut and cut and was really pleased and observed there was a little piece left but felt almost it was gone, and that it was ok to leave a little. He may have wanted to avoid cutting too much, which would increase his chances of perforation. And many women do just fine with a small piece left, as long as it is not too big. But leaving a small percentage may still be leaving a substantial amount. To cut more and reduce the odds of perforation, the doctor can use an ultrasound during the surgery to watch the uterus and the septum, to help cut most of the septum but not perforate.
Another reason for finding some septum after the surgery is that there may be times when the pressure of the fluid used to distend the uterus during hysteroscopy pushes the and remaining septum up towards the muscle layer, making the inside of the cavity look smooth and normal. Yet, once the pressure is relieved by removing the fluid, a bit of the septum bulges back down into the cavity of the uterus. This is theoretical on my part, but I am guessing it does happen this way.

If you have proximal occlusion and your tube is opened, will it stay open? If it was really blocked and you have a procedure to have it opened the odds are about 70% that it will stay open.

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

Dr. Licciardi

Egg Freezing and IVF: How Many Eggs Do You Need?

Again, this entry has many elements that apply to standard fresh IVF cycles.

Here we’re trying to close in on the real question, “If you do egg freezing, will it help you have a baby?”

Well, it will really does help if you can make some eggs. Sorry if that sounds too obvious, but the more you make the better your odds of this whole thing working years down the line. Just as with any IV F cycle, egg production is based on the number of eggs that are still in your ovaries, and how they respond to the medications.

Much of this is loosely related to a woman’s age but there are a number of other factors involved. The dose of drug can have an effect on the number of eggs produced; the more drug the more eggs, but only to a point. In other words, if your ovaries are full of eggs, a dose of 450 units per day may be way too high and lead to danger, but a dose of 225 might get you 15-20 without much of a risk. However, if your egg reserve is marginal, 225 may make 6 eggs, 450 may make 8, but going over 450-600 probably will not get you any more.

There are papers and book chapters written about how to stimulate ovaries to get the maximum response in women with limited ovarian reserve. For today let’s just say that one of the hardest things we do is try to get the ovaries to produce more eggs than they want to. There are numerous stimulation protocols that we try, and sometimes we get more eggs than expected, but sometimes we get fewer. In very many cases, it may be that it wasn’t the doctor’s choice of medications; it was just the woman’s body being more or less cooperative during that cycle.

Testing for ovarian reserve is one way to get a general guess about your response, but it’s not always helpful. A bad ovarian reserve test is not good news; a favorable result does not guarantee results. There are many of you reading this who despise ovarian reserve testing and some of you who have proved doctors wrong, having babies after being rejected for bad day 3 blood tests. I understand this. I think the testing is should at least be performed to give you a general idea about your prognosis so that the expectations can be based on all available information. Included in this is an ultrasound examining the antral follicle count. Again, not a perfect test, but it will help you get closer to answering the question, “Will this help me?”

You will not know about your egg production until after you start your cycle. Let’s say you have had your consultation and testing and things look reasonably positive, so you decide to give it a go. Fine, but you need to know a few more things. Especially if you have never been on the fertility injections before, the number of follicles that you develop will be a mystery until you are on the drugs for 5-8 days. By then your follicles will have begun to grow and your doctor can count them up and let you know how you are doing. Unfortunately, some women will be producing a low number of eggs.

Follicle number does not equal egg number. We see follicles on ultrasound; we get eggs from the follicles. We never really know how many eggs you will get until we try to take them out on the day of retrieval, but we have certain expectations. If we see 10 good sized follicles, we expect to get 8-10 eggs. There are endless examples of variations. For instance, let’s say you are ½ way through the stimulation and it looks like there are 5 follicles. But there may be others that look very small, maybe too small, but over next few days the small ones may catch up, giving you say 9-10 decent follicles on the day of retrieval. Another possibility is that you have 5 good ones and 4 tiny ones at retrieval, and even the tiny ones that never caught up in size, still give up good eggs (this is not typical).

The opposite could also happen. Your doctor may see 10 follicles and only retrieve 5 eggs. How is this possible? It’s not uncommon to have fewer eggs than follicles. Some doctors feel that there are some follicles that do not have eggs in them. I think this is possible but not very common. It may also be that the egg is in the follicle but it just does not come out through the needle. This I think is more common. Generally the egg is very loosely attached to the inside of the follicle, but if it’s stuck to the inside, it may evade the needle.

So how many eggs do you need to have a successful egg freeze (or fresh ivf cycle for that matter)? Again the too obvious answer is the more the better. However 10-15 is a good yield. More than that is a bonus. It is true 30 may be better than 15, but most women do not make 30 so that should not be your goal. Estimates in the 10-15 range usually do not prompt much patient/doctor discussion, however when the estimate is lower, the talks become more frequent and important.

Usually your doctor is close enough with the pre-retrieval estimate, so assume it will be close. If a low number is estimated you will need to make a decision, with the help of your doctor, about having the retrieval or not. Yellow flags should rise if you are told there are less than 10 follicles, and red flags should rise if you are told there are 5 or less.

Overall there is just no absolute egg number cut-off for cancellation. Some programs may have strict guidelines, but most do not. We all understand the dilemma. If there are few, your odds of success are lower, however if there are few, it means your fertility may be passing. Getting, say, 4 eggs now may be better than nothing, because as months pass, you may make fewer in the future. Stopping without the retrieval, and restarting in a short amount of time, using a different protocol, would probably be the best choice. However, even with making changes you may have the same or even fewer next time. Now I picked 4 follicles as just one example, but the discussion needs to be tailored for 3,5,6,7 etc. Your age, previous response and your desires all need to be taken into account each time.

Your doctor needs to take the information above and formulate your chances of not just getting eggs, but of getting a baby from your egg freeze cycle. This applies to all cases, good egg production or not.

You will get the most accurate information if you are using an egg freezing practice that has results, not just freezing experience. Experience and results with the thaw and transfer is very important; you need a program with a track record. You need to know their experience in going from eggs to babies. Many busy egg freezing programs have no results because they have not thawed any of their eggs yet. Others have done less than a handful of cases.

I do want to refer you to the NYU Fertility Center web site section on egg freezing.
http://www.nyufertilitycenter.org/egg_freezing.
Spend some time going through all of the pages, the information is very helpful.

Thanks to the fantastic research and efforts of the doctors listed there, NYU is known for its egg freezing practices and results. I could summarize the site here, but in the interest of accuracy, go directly there to get it from the horse’s mouth. The results are frequently updated.
The breakthrough, as mentioned on the site, is that we believe that our egg freezing success rates will remain similar to our fresh IVF success rates. Therefore, it will help if you have your eggs frozen at a program with excellent fresh IVF pregnancy rates. If their fresh IVF rates are low, their egg freezing rates will probably be low too.

Not all egg freezing programs can show good data to support good results (2 out of 4 pregnant is not enough.) There are a few who can, so if you are interested in egg freezing, you need to seek out the good ones. Details are sparse, so I really only know about NYU. Odds are there is not a quality program near where you live, so if you can swing it, it may be worth traveling.

Even the NYU rates need to be clarified. Most of the studies at NYU and elsewhere on egg freezing have been performed with good prognosis, younger women. We are not positive that older women’s eggs will freeze and thaw well. They probably will, but there is no data yet to prove the case. We don’t know how long eggs will last in the freezer. We do know there have been children born from sperm and embryos frozen for over a decade, so eggs should be able to last at least as long, but again there is no proof yet. Egg freezing is very new and still considered experimental you do need to freeze your eggs at the right place.

We and other doctors can not completely predict the landscape 5-10 years down the road. We are optimistic that our pregnancy rate estimates are correct. However there is a chance that due to unforeseen circumstances, the rates will be lower. You just need to know this going in. It may also be possible that the outcomes will be better than we had hoped.

Next time we will cover what you should know about what happens after the eggs are retrieved and how the cost structure works.

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

Dr. Licciardi