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Infertility Questions and Answers: Almost Caught Up

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

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

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

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

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

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

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

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

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

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

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

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

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

I agree with Christine

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

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

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

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

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

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

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

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

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

Dr. Licciardi

Answers to Infertility Questions

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

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

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

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

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

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

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

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

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

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

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

Della hit the jackpot! Very nice.

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

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

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

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

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

Dr. Licciardi