Infertility is full of questions, and often it feels like the questions go unanswered.  One of the most anxiety-producing experiences along the long and winding road of infertility is meeting with a specialist for the first time.  It’s difficult to know what to ask when you’re not even sure what the future might hold.  It can also be hard to share every intimate detail of your lives with a complete stranger, who might or might not even be the right specialist for you.

When Laura, one of our Facebook members, asked the group what questions she should ask, I immediately checked in with Dr. Marc.  Who better to ask than a specialist?  Dr. Marc has counseled countless couples down this road, and his bedside manner truly makes him one of the best specialists out there (biased, but true).

I hope Dr. Marc’s list helps you along the way.  But remember, it’s never too late to start asking questions.  So even if you’ve been in it a while, print this out and ask or ask again.  You can never ask too many questions when you’re trying to get pregnant!

Hi Laura,

The first interaction with an infertility specialist can be quite overwhelming.  Sharing the most intimate details of your life as well as your hopes, aspirations and fears with a perfect stranger is daunting.  Additionally, any strain which infertility has placed on a marriage is often magnified in the setting of a doctor’s office.

With this in mind, it is a good idea to prepare some questions for your doctor before going into the consultation.  The questions will serve you well not only through their answers, but if the doctor anticipates them and provides answers before you ask, that is a good sign!

Obviously, each patient and situation will have its own unique set of questions.  The following list is general questions and should apply to most people speaking to a fertility doctor for the first time.

1.     What is my diagnosis?

-While this sounds like an obvious question, it is hardly ever asked and even less frequently answered.  I like to think that a diagnosis provides patients with a “target.”  Once they can identify what the problem is, it is easier to overcome.   While your doctor may, or may not be able to provide this to you on your first consultation, you should at least receive some possibilities.  Even if your doctor says you have “unexplained” infertility, at least you will be able to label the cause and move on from there.

2.     What is my chance for success?

This is useful for planning, and setting appropriate expectations.  In some situations the doctor can be very specific.  For example, most IVF clinics publish yearly success rates broken down by age.  Your doctor should be able to provide these to you.  If you are not doing IVF, the doctor should still be able to give you some general guidelines as to the chance of conceiving as well as the chance of delivering a healthy baby.

3.     What is my chance if I keep trying naturally?

This may not apply to single patients, same sex couples or those with blocked tubes or no sperm; however for patients with “sub-fertility” they still have a chance for natural conception each month.  It is important to consider this chance in comparison to the success rates your doctor provides you.

4.     Are there other treatment options available to me?

Some doctors will tell you what to do without offering alternatives. This is not necessary a bad thing, it is good to have a doctor who is decisive and confident.  However, fertility treatment is highly personal and most patients are well informed.  I feel it is better to provide several appropriate treatment options, recommend the best one and then allow for a joint decision between all parties.

5.     What are the risks to me?

As with any medical treatment, there are risks to fertility therapy.  In general, the likelihood of complications is low and most complications are minor, but I feel that one of the best ways to avoid complications is by acknowledging their existence.  Further, patients who are aware of potential complications are less likely to encounter them.

6.     What are the risks to my offspring?

There has been significant research looking for an effect of fertility treatment on offspring.  The truth is that there may be up to a twofold increased risk for fetal abnormalities (from 2% in the general population to 4% to those conceived with fertility treatment) in babies conceived through fertility treatment.  What is unknown is if that increased risk is due to the fertility treatment or simply a reflection of a greater risk of fetal abnormality in people who require fertility treatment.  Regardless of the cause the overall risk is low, but important for patients to discuss with their doctor.

7.      What would you do if you were in my situation?

This question is tricky and may not be appropriate for all doctors, but I think patients can get a good feel for their doctor’s personality through this question.   If your doctor is not comfortable sharing their personal views, that is fine, but what better way to get to their strongest recommendation than to find out what they would do for themselves.

So Laura, this is really only a partial list, but having a game plan and some prepared questions before your consultation will help ensure that you get the most out of your time with the doctor.

Good luck!

Dr. Marc

p.s.  As for question #7, I have personally used that one on Dr. Marc more than once, and his answers have helped me through some very difficult scenarios.  Don’t be afraid to ask!

A couple of weeks ago, my lovely friend Diane Mizota invited me to a lunch with an amazing group of writers and bloggers.  We sat on her back patio on a picturesque Los Angeles afternoon and chatted about all things writing, blogging, family, and ice cream.  Because, seriously?  Diane brought in the owner of Nitropod - he makes organic flash frozen ice cream.  It’s insane.  In a good way.  You’ll just have to trust me on this one.

Anyway, the real reason Diane brought us all together was to screen the trailer for an amazing kickstarter campaign called, “Pushing Motherhood”.

“Pushing Motherhood” is the story of two best friends who have quite literally been through absolutely everything together (careers, love, marriage, divorce, love again), including infertility.  The film follows Sybil, 38, and Linda, 45, as they attempt to embark on motherhood.  And while Sybil was lucky enough to bring a healthy baby boy into the world and is now trying for a second, Linda has not been so lucky.

If you’ve spent any time here, you know that I’ve struggled.  You also know that even though I’m 99% sure that my family is complete, that 1% still wakes me from a deep sleep, causing tears to pour down my cheeks as I will myself to feel grateful for what I have:  My children and my life.

You also know that there isn’t anything easy about infertility, and that blame is a useless strategy.

Listening to Linda talk about her struggle as she fought back tears brought so many emotions about my own struggle.  I am one of the lucky ones.  This is what I repeat every time that 1% percent creeps in.  I am one of the lucky ones.  But I remember the pain.  I remember the longing.  I remember the appointments, the losses, and the anxiety.  I remember every single second of what began to feel like lost years.

Here’s something you don’t know about me:  I promised myself that when I got to the other side, I would find a way to help alleviate the isolation that STILL surrounds infertility.  And so I started to write.  I filled page after page after page with every little thing…all of the things that are left unsaid.  I signed with a literary agent.  I revised and revised and revised until my eyes nearly popped out.  And then my proposal was out of my hands.  Editor after editor came back with the same reply:  Incredible story.  Not big enough of a topic. We don’t think we can sell enough copies.

I was heartbroken.  Not because I needed to sell just any book, but because I wanted to do this for all of you.  For those of you struggling now, and for those of you yet to find your way here.

Not big enough.  It’s hard to believe, isn’t it?

So as I sat and watched this trailer, tears streaming down my face, I was struck by a renewed energy.  The book didn’t sell, but this documentary needs to get made.  We need to shout from the rooftops to get more support, more coverage for treatment, and more people talking.  We need to break down these walls right now!

And you can help…

Sybil and Linda started a Kickstarter campaign to raise the necessary funds to cover the cost of post production, music, and various other things that documentaries need.  Watch the trailer.  Pledge whatever you can.  They have seven days left – this documentary has the potential to make a huge difference for everyone struggling with infertility.  And please, pretty please, share this information.  Let’s kickstart this!

Thank you so much for watching…

Mother’s Day is supposed to be a day to celebrate mothers.  It might involve things like flowers, breakfast in bed, cards, and endless hugs.  Sometimes large, unexpected gifts arrive.

It’s supposed to be a time to reflect on the greatness that is mom.

For the most part, it is.

But for some, Mother’s Day is not so simple.

Some of you have convinced yourselves to simply celebrate your mom.  To put all of your focus on her for the day.  To stay focused on the original intention of the day.  You’ve practiced your best smile, bought the perfect gift (large or small), and written the perfect note inside the perfect card.  You’ve poured your energy into your mom.

Been there, done that.

Some of you are planning to hide out.  You’ve stocked your kitchen with comfort foods, wine, and chocolate.  You’ve taped a Lifetime movie marathon and you’re ready to close the blinds and disappear for the day.  The phone?  Silenced.

Been there, done that.

Some of you aren’t sure what to do.  You’ve tried thinking only of your mom, but infertile thoughts kept creeping in.  You’ve tried blocking it out, but infertile thoughts kept creeping in.  You’ve tried doing a little bit of both, but those pesky infertile thoughts just kept creeping in…

Been there, done that.

Mother’s Day, as it turns out, is not so simple.

The truth is that there isn’t a simple solution to a day that brings so much joy and so much sorrow at the same time.

Yes, you should celebrate the mother in your life.  Now more than ever, you know that motherhood isn’t a given.  Now more than ever you know that motherhood is hard and challenging and completely worth fighting for.  You might not have your baby yet, but you understand the challenge just the same.

This Mother’s Day, you should also celebrate the mother within.  Each and every one of you fights this fight every single day because that huge mommy heart is already in place – it’s just waiting for the baby to arrive.  No matter where you are in your infertility story, you are fighting, working, begging, and maybe even praying to hold that little baby that your mother within is so very ready to nurture.

And that…is exhausting.  It’s sad, it’s frustrating, it’s gut wrenching, and it’s anxiety producing, but, above all, it’s completely exhausting.

So instead of focusing on others or hiding out, take a chance on you this Mother’s Day.  Head out to the spa, or don’t.  Enjoy a mimosa on the beach, or don’t.  Have brunch, lunch, or coffee with your partner, or don’t.  Whatever you do this Mother’s Day, remember to nurture your mother within.  Give her a break.  Send her some flowers.  Buy her that purse that she really loves.  That big mommy heart, that mother within, has been working hard to get to the end of the story.  And she needs a break.

Give her the rest and relaxation that she needs.

And remember this:  Your baby will find you.  One way or another, your baby will find you.  And when that happens, your new story will begin.

My name is Kristin, I am 31 and my husband Aaron is 39 (he has a 16 year old daughter from a previous marriage). I am currently seeing a fertility specialist and recently had cycle day three testing, ultrasound and an HSG. Upon completion it was determined that I have Diminished Ovarian Reserve and a Unicornuate Uterus on my left side (one Fallopian tube that is completely healthy on my left side as well as a good looking uterus on my left side, both ovaries, although, are small). My husband had a sperm analysis done as well and his Count/Motility/Volume were more than double the normal range. So we now know that the infertility issues are due to my body alone. We have discussed our options with our Dr and have decided to go ahead with medicated IUI cycles starting in May 2013 although our Dr thinks IVF is a better option. We cannot afford to do IVF at this time, IUI is far more cost effective for us. My question is how likely am I to conceive from IUI. My Dr only gave me a 2% chance of conceiving naturally, 5% with medicated IUI and 30% with IVF each cycle. Is that accurate? Or is it possible my chances may be higher given that my husband has exceptional sperm and even though I do have DOR I am still fairly young?

I appreciate your taking the time to answer my question. Thank you in advance.

Sincerely,

Kristin

Hi Kristin,

As I see it, there are a few issues to discuss.

First, I think it is important to recognize that infertility is NEVER due to one partner alone. Remember that making a baby is a team effort.  Just because one partner’s tests are normal and the others are not, does not necessarily mean that one person is at fault or responsible.  Further, remember that women have many more variables at play in this situation.  Men only have to have a few normal sperm; women need normal tubes, ovaries and uterus not to mention the hormonal environment for the 9 months of pregnancy!  It really is a lot, so don’t get down on yourself!

Second, the unicornuate uterus represents abnormal embryonic development.  The prognosis of a unicornuate uterus can range from poor to good, but it depends on how small the uterus is.  From your letter, it sounds like your uterus is of decent size so as not to be too much of a problem.  One thing I would recommend however, is that your doctor evaluate your kidneys.  The kidneys and uterus form at near the same time and is not uncommon for women with a uterine abnormality to also have a renal (kidney) abnormality.

Third, the diminished ovarian reserve (DOR) is a bigger deal.  I am not sure what your doctor is basing the DOR on, but it is probably the most important factor facing you.  The medication should help with this and the fact that you are young is also a positive!

Fourth, the fact that your husband’s semen analysis is normal is a good thing, but it doesn’t trump the other factors.

As far as numbers, I’d say your doctor is pretty accurate.  Maybe your chance is 5-15% with medicated IUI, but it really depends on your response to the medication.

The bottom line is that doing something will increase your chance over doing nothing.  If you could easily afford IVF that would be great, however if you cannot, then IUI is a reasonable way to go.

Good luck!

Dr. K

Infertility requires a lot of things.

Infertility requires patience, compassion, understanding, empathy, perseverance, and love.

Above all, infertility requires a listening ear.  Infertility requires just one friend who can be there, start to finish, to help you ride the waves.

When I launched this site one year ago, I had big plans.  I wanted to talk until everybody listened.  I want to break the silence in the strongest voice possible because, believe it or not, there is still silence.  I wanted to yell and scream and make waves, because sometimes the squeaky wheel does get fixed.

I wanted to join campaigns that are working hard to get lawmakers to pay attention – because we all know that if infertility belonged to the male population, it wouldn’t be so very expensive.  With that in mind, I wanted to encourage men to speak up.

So I wrote.  I shared my own stories.  I shared those of others.  I got Dr. Marc on board and he shared information, treatment options, and support.  Together, Dr. Marc and I have supported many, many women all over the world in the past year.

But then I slowed down a little.  At times, I feared that some of you might feel abandoned.  I worried that you would think I was bailing out.  That I had lost my fight.

I haven’t.  I would never leave all of you because we are all connected.  We all share our stories and journeys.  We succeed and fail and try again together.  Connection is the very soul of this site.

But a funny thing happened when I stopped to slow down.  When I took a break from talking and helping and trying to fix.  When I gave myself the opportunity to just listen…

The email increased.  Women, and a few men, from all over the world started emailing.  Many stated that they didn’t expect a reply.  Most simply wanted to vent.  And so I listened.  I read each email carefully, sometimes two and three times.  I cried over the losses.  I smiled when pregnancy announcements came in.  I felt hopeful for those embarking on new treatments.  And I wished for inner peace for those ready to move on.  And I responded to each one with kindness and empathy.  I didn’t offer solutions or resources when help wasn’t requested.

I just listened.

Part of the difficulty of opening up about infertility is the fear of the reactions that might come in.  It’s hard to know what other people will say, and so it requires a leap of faith.

More often than not, what a person struggling with infertility needs isn’t advice, a new doctor, or yet another story to process, but a person to listen.  Someone who can nod and comfort and hug and encourage without trying to fix.

There is no fix for infertility.  There are treatments, medicines, and research, but there is no easy button.

And so we need to open our hearts and really, truly listen.

This week is National Infertility Awareness Week.

For more information on infertility, please visit here.

For more information on National Infertility Awareness Week and how you can get involved, please visit here.

Please join the movement…please take the time to listen.

The tricky thing about infertility is that it never really goes away.  You might get pregnant.  You might use a surrogate.  You might adopt.  Chances are you will make some very big decisions along the way, and your dreams will change as you make those big decisions.

But the feelings will always linger.

Once you’ve struggled for something…I mean really struggled for something…it’s hard to shake the feeling that things don’t always go as planned.

I’m over at allParenting this week with a few thoughts on coping with the stress of pregnancy after infertility.

I am a 35 yo mother of one healthy 5 1/2 yo boy (conceived quite naturally on month 1 of trying).  When we began to try for our second child, we had troubles.  Tried for 18 months with just one chemical pregnancy.  When I was 32, I was dx with Non-Hodgkins Lymphoma and treated with 6 rounds of RCHOP and a month of radiation to my chest.  My period returned and I conceived spontaneously less than a year after completing treatment, which did leave me in remission; thank goodness.  However, an RE put me on progesterone, which I had an allergic reaction to and when I stopped taking it, I miscarried at 6 weeks.  My husband has also been through a number of SA with flying colors.

Now, we’ve been trying again for the better part of the past year with no luck.  One round of femara/IUI and I’m in the middle of a second.  I have now finally been giving a diagnosis of DOR, with an FSH of 15.5 this cycle and just 5 small follicles during the baseline u/s.  Do you have any thoughts or suggestions?  I am afraid that my body cannot handle IVF (nor do we have the money) and I’m wondering what you think our chances are with or without it.  I have read a number of articles on controlled ovarian stimulation but I am not a doctor and the language has been difficult to understand.

Thank you for your insight,

Mia

Hi Mia

First of all, congratulations on successfully fighting the lymphoma.  It takes a strong will and persistence to get through such a diagnosis.

Cancer therapy has come a long way in the past few decades.   With people now enjoying long healthy lives following cancer treatment, we are beginning to have to deal with the long-term effects of chemotherapy and radiation.   One of these effects is infertility due to diminished ovarian reserve.

In the future, most patients who are scheduled to undergo chemo or radiation will likely have the option of freezing eggs or embryos before treatment begins.  Until that time, however, we will see many more patients in your situation.

Fortunately, you are still cycling and therefore I believe that you still have some options.  First, I would recommend moving on to a more aggressive treatment than Femara.  Controlled ovarian hyperstimulation (COH) will stimulate production of more eggs than Femara.  This presumably would increase your chances of conception.  While COH does require daily injections and more frequent monitoring than femara, it is less intense and less expensive than IVF.

At the same time as pursuing COH, I would consider using some alternative methods to bolster your ovarian reserve.  Acupuncture is a safe and relatively easy step that is beneficial in some patients.  I would look to the American Board of Oriental Reproductive Medicine (www.aborm.org) to find a local qualified provider.  Further, there is a low dose androgen called DHEA that likely improves ovarian response.  You can ask your doctor to prescribe it.

Lastly, I would reconsider IVF.  I realize that it is a serious endeavor, but it also represents your best chance at pregnancy.  Considering your FSH level and the fact that women who have undergone chemotherapy tend to enter menopause early, I worry about missing the “window” where IVF can be successful.  If you were to use IVF, I would still recommend using the above alternative methods as well.

I hope this is helpful Mia and good luck,

Dr. Marc

Dear Readers,

I’m not sure how to start this letter because I’m not quite sure how I got here.

Lately, I feel like I’ve failed you.  I’ve been off the radar.  Silent, really.

You might think that I’ve simply been too busy to write here.  Life does get busy, and I could certainly make a case for that.

You might think that my freelance work takes top priority.  I do have specific deadlines each week, and I have to make sure that those deadlines are met.  So I could also make a case for that.

But that’s not it.  My silence can’t be blamed on daily life or deadlines.

The truth is that I struggle a little bit during this time of year.  I’m not sure what it is about March, but this is the time of the year when I think about the losses.  Perhaps it’s the feeling of being caught between winter and spring.  New beginnings always feel possible, but not necessarily the beginnings I might crave.

I’ve moved on from my infertility struggle as much as I ever will.  It was hard, depressing, anxiety producing, and downright devastating at times, but I’ve moved forward.

I know that I am one of the lucky ones.  I have my two and they are nothing short of miracles.  I enjoy every little thing with them, even the hard things.

But that last loss, the one that threatened to take my life, still haunts me.  Not every day.  Not even every week.  But when the memories of that horrible loss, of my baby boy – the one who would have been my third, come crashing in…I freeze.  I replay every minute of those 17 weeks over and over again wondering what I could have done to ensure a better outcome.  Alone, under the cover of darkness, I cry for his little lost soul and the toddler that he would now be, if only he had made it.  I wonder if I could ever convince my husband to give it one last try, knowing that I can’t.  He thought he might lose me that day – that’s the memory that he can’t shake.

And even though writing sometimes helps, I hesitate to share this story.  Because I am one of the lucky ones.

Many of you are still waiting on your first miracle.  You are fighting and praying and begging and hoping against hope that this one will take.  I remember those feelings well.  I remember the ferris wheel of hope and despair.  I remember the sadness and fear.

How could I possibly burden you with these thoughts when you are fighting so hard and taking every possible step?  I can’t.  So I went under.  I put pen to paper and used (gasp) a journal to work my through my sadness.

And I feel like I left you hanging in the process.

Know this:  You inspire me.  You continue to support each other and answer one another’s questions on the Facebook page, even when your not so fearless leader is hiding out.  You manage to cling on to hope when the months drag on and you cheer each other on along the way.  You are an amazing group of warriors, my friends, and I am so happy that you are making connections and checking in regularly.

I started this little community almost one year ago because I wanted something positive to come out of the negative.  I wanted to provide a place for you to chat, vent, ask questions, and find support.  I wanted to be there for you.

It’s time to get back to that.

I’m sorry that I’ve been so quiet – but now I’m ready to talk again.

Until next time…

I know it is hard answering questions with out seeing all the person’s info. Anyway I am 31 will be 32 next month I have gone through 2 failed IVFs. The reason being my FSH is a 15. The first IVF I had 4 eggs 2 fertilized and 1 made it to day 3 but was very poor. I went to a different clinic for my 2nd. I had 10 eggs 8 were mature 6 fertilized 4 made it to day 3 and 2 made it to day 5. I had one embryo that was a few hours behind and the other was almost a day behind. The doc said they would catch up. Everything was fine up until the embryos didn’t take – then I was told my eggs were no good. With this bit of info is there a chance or should I give up IVF altogether? I am looking for a new clinic now, one that is FSH friendly. I have also read DHEA can aid in helping. Is this something you encourage your patients to take?

Thanks for any insight.

Hi friendly FSH,

Let me give you a little background on FSH and then talk about what you can do to improve your chances going forward.

FSH (follicle stimulating hormone) is the primary hormone responsible for human egg stimulation.  FSH originates in the brain and travels to the ovary where it stimulates the egg through follicle growth. A follicle is a small sac of fluid within the ovary; each follicle houses an egg (oocyte).  The normal relationship between the brain and ovary, in terms of FSH, is that the FSH is released in a specific pattern and quantity in the first few days of the menstrual cycle.  The ovary responds through follicle/egg growth and estrogen production.  If the estrogen is produced in the appropriate amount, the brain will recognize the estrogen and will be “satisfied” with the ovarian response subsequently decreasing the amount of FSH it releases.  If the ovary does not respond appropriately, and the brain is not satisfied, then it will release more FSH in an attempt to further stimulate the ovary.  Thus, if the FSH on day 3 of the cycle is low, then the brain is satisfied with the ovarian response; a high level of FSH means that the brain is not satisfied because ovary is less responsive.  Another term used to describe less responsive ovaries is diminished ovarian reserve (DOR).

It is natural for the ovarian reserve to diminish over time.  In fact, menopause is defined by the absence of ovarian reserve and a very high FSH level.  Until menopause however, we spend a great deal of time and effort trying to assess the ovarian reserve because there is a correlation between ovarian reserve and pregnancy rate.

With that being said, FSH is only one way of assessing ovarian reserve.  In my opinion, too much emphasis is placed upon its value.  FSH should be interpreted in the context of the patient’s age, fertility history, antral follicle count and past treatments.  Further, it should never be used as the sole benchmark to determine ones fertility.

In answer to your question, there are a couple things that I think are quite encouraging for you.  First at 32, your oocyte quality should still be pretty good.  In many ways, your age trumps your FSH level!  This is because we know that in two different patients with the same diminished ovarian reserve, the younger patient will always have a greater chance of conceiving.

Next, it appears that your second IVF cycle was significantly better than your first.  This is not totally unexpected because I’m sure that a more appropriate stimulation protocol was used in the second cycle.  My guess is that a third cycle could be even better.

In terms of improving ovarian reserve, I often work in conjunction with an acupuncture practitioner and sometimes utilize DHEA.  The scientific literature for both of these methods is not perfect so you should definitely discuss it with your doctor.

In conclusion, my instinct is to encourage you to try again.  I believe that with the right stimulation protocol, a bit of pre-cycle preparation and a smidgen of good luck, you can be successful.

Best,

Dr. Marc