Recently, I got a message from her that she wanted to share some good news about her new baby. When I returned the call, I was curious why she didn’t come back to us for THIS cycle of IVF. To my surprise, she bubbled enthusiastically about an amazing miracle. She shared that she had given birth to this recent baby after getting pregnant spontaneously without any medical treatment. She shared that her son (one of the original twins) had told her last year “Mommy, I’m going to pray real hard for a brother or sister this year”.

From a medical perspective, it is not entirely implausible for a woman diagnosed with blocked tubes to ever conceieve. Having blocked tubes diagnosed via laparoscopy or HSG does not mean 100% sure that they are blocked or will always stay blocked. Having said that, I would certainly put it at less than a 1% probability that a patient in this situation is going to get pregnant naturally. Put that together with the finding of all the years that went by without her getting pregnant and you have the occurrence of something that is estimated to have less than a 1 in 1000 chance of happening. No, I don’t recommend that women with blocked tubes should wait patiently for a miracle to happen, but I also recognize that sometimes, miracles DO happen.

Usually, we love it when someone rates us or evaluates us and tells us that everything is all right with us! This is not the case for those afflicted with unexplained infertility. For them, after enduring month after month or even year after year of being infertile, they finally get the courage to go to their OB or family practice physician with their problem. A few tests are run and they are told “Congratulations! Everything came back fine!” The temporary feeling of relief quickly disappears when they go back to their previous routine and find themselves still not pregnant after another year. This makes them want to scream because they would almost rather have heard their doctor say “We found a big problem so now we know exactly why you’re not getting pregnant”, especially if followed by “and this is how we’re going to solve that problem”.

Asking yourself what’s causing your infertility is very tricky because most times, we can’t find just one single concrete reason. The best examples of times when we can is if we find that a husband has absolutely zero sperm, or if we find that the wife’s Fallopian tubes are both blocked or if we find that a woman is now menopausal. Aside from these scenarios, there are rarely any clear cut answers. Why? Because, as I’ve stated many times on this site now, getting pregnant is usually a matter of probability. So many couples out there who aren’t pregnant after a few years are that way not because they have zero % chance of getting pregnant each month, but rather because they have something like a 3% chance per month in contrast to normal couples who have a 20-25% chance each month.

EXAMPLES:
Jed and Dorothy have been married for three years. Despite having regular sex every 2-3 days and not using any contraception for the past two years, they are still not pregnant. The workup reveals Jed’s sperm count slightly below average at 37M / cc. Dorothy’s HSG is clear and both tubes are proven patent, but there is some sequestration of the contrast seen after it emerges from the Fallopian tubes, hinting at the possibility of loculations or adhesions. Dorothy’s monthly periods are extremely painful, hinting at possible endometriosis. They have been labeled with the diagnosis of unexplained infertility.

Eduardo and Joy have been married for five years and actively trying to conceive. Eduardo’s sperm count is 200 M / cc. Joy has undergone laparoscopy and was told that her pelvis was immaculately clean and normal with dye seen freely spilling out of both tubes. Joy has had a period exactly every 28 days since age 14 and for the past three years, she has the charts to prove it. Despite all this, they are not getting pregnant. This couple is the extreme example of unexplained infertility.

SO WHAT SHOULD WE DO?
The frustration of unexplained infertility stems mostly from our innate human psychology and the absolute need for an explanation. Remember back in high school when there was that boy you had a crush on and you were so hopeful that he would someday reciprocate the feeling? However, when things didn’t work out, you weren’t content with the rejection because you wanted to know WHY? WHY didn’t he like you and want to date you? That’s the natural way we think. However, that doesn’t mean it’s the best way for us to think. What if, instead of demanding a reason, we just shifted our minds into ACTION-MODE? This might consist of accepting that person as just a friend and finding ways to interact with him in good, fun, non-threatening ways so as to improve his positive associations with you. This would serve to improve the odds that he might even change his mind about you someday. Or in other cases, the best action would be to focus your attention on someone better (yes you probably thought that he was your perfect soulmate and that there is nobody in the world better), but if your goal was to be in a relationship, then there are other ways and other candidates to explore.

So how does this relate to the approach to infertility? Well sometimes, it’s better to focus on what we can do rather than demand some specific explanation that’s not really there. This brings us to the time-proven correct approach to unexplained infertility. Always be asking “What can we try differently?” A good RE will guide you through your options which may include aggressive techniques like IVF, moderate techniques such as IUI and natural techniques such as weight loss, stress reduction and smoking cessation.

Here are two relevant posts, one reinforcing the concept that in reality, most cases of infertility are somewhat unexplained and another on breaking down the options of the best actions to do next.

Good luck!

By the way, I really enjoyed my four-month break from blogging (more on that later), just as much as I hope to enjoy my return!

The NON-OVULATOR:

You have to ovulate in order to have a baby.

It’s considered normal to ovulate thirteen times a year, which means thirteen opportunities to potentially get pregnant. Some women ovulate fewer than thirteen times per year. Either their cycles are more days apart from each other or they just skip some cycles completely. This means that while the same twelve months is going by in life and they are getting the same one year older just as everybody else is, they are missing out on chances to get pregnant.

WHAT ARE THE DIFFERENT LEVELS OF NON-OVULATION?
The number of ovulations every woman has per year varies greatly. In a best-case scenario, a woman with regular 26-day cycles could potentially have a perfect year when she ovulates one egg fourteen times, giving her fourteen opportunities to get pregnant. It’s also possible for a women to, every once in a while, have a double ovulation month in which she fires off two eggs. This does not happen often, but in women with a family history of twins on their mother’s side, it happens more than it does in other women. These are the good extremes. In the worst-case scenario, you have women who go through an entire year without ovulating even once. Unless this problem is solved, they are not going to get pregnant. The rest of the population fall somewhere in the middle between zero and fourteen ovulations per year.

EXAMPLES:

• Jamie’s periods come like clockwork every 29 days. In the past year, she tried ovulation testing three times and each time, her sticks eventually turned positive. In one month, she even had her RE do serial ultrasound monitoring. With that, she saw her follicle grow bigger and bigger before finally disappearing on day #15. CONCLUSION: The best estimate is that Jamie is a normal ovulator with 12 to 13 chances per year to get pregnant. If she’s still not getting pregnant, it’s best to look for other factors, such as tubal or sperm problems.
• Heather has very irregular periods. In the past three years, she estimates having about 3 periods per year. CONCLUSION: If each of Heather’s periods is an indication of ovulation, she is having, at most, three chances to get pregnant per year. However, it’s also possible that her three periods per year are not all ovulatory cycles, in which case, she might be having zero, one or two ovulations per year. Yes, it’s possible to have bleeding without actual ovulation that month. Attempts to help her conceive should focus on getting her to ovulate more frequently.
• Leslie has regular cycles which consistently come every 36 days. Her ovulation testing lately has shown that she is consistently ovulating around day 21. CONCLUSION: She is likely ovulating. Buyt, because it takes longer than average for each ovulation, she is ovulating at most, 10 times per year. She is missing out on about three chances per year to get pregnant, compared to Jamie.
• Anne used to have regular periods in the past, but her very last period came when she was 38. After she turned 39, she did not have any more periods and she is now 41. Her random FSH value is 39 IU/L. CONCLUSION: Anne is most probably a non-ovulator due to menopause. Her condition is permanent.

HOW DOES OVULATION TRANSLATE TO CHANCE OF GETTING PREGNANT?
The focus, so far, has been on the number of times of ovulation. The number of eggs you ovulate per year is your QUANTITY of ovulation. But often, we hear talk about the QUALITY of ovulation. First of all, there is no universally-accepted definition of what egg quality means. In fact, we use the word quality, in everyday language to generally mean something that is “good”. But just ask people and you’ll get differing views on what constitutes a quality friendship or a quality tomato. So I will define for myself that when I use the term “egg quality” here, I’m referring to the percentage chance of making a baby with that egg. Someone who is ovulating a high quality egg might have a 30% chance to have a baby with that egg. On the other hand, someone with poor quality ovulations might only have a 1% to conceive a baby with each egg. So our wish list should include not just egg number but also egg quality. After all, would you rather have a single “30% egg”? Or would you rather have a dozen “1% eggs”?

WHAT ARE THE DIFFERENT CAUSES OF NON-OVULATION?
There are many different reasons for ovulation problems, but they can be broken up into two main categories. One is actual problems with the eggs themselves and the other is problems with the hormonal system that is supposed to mature and develop the eggs. Think of it as a hardware issue vs a software issue. Some women fail to ovulate because their remaining eggs are poor quality and resistant to growing well despite sincere efforts by her hormonal system to nudge them along. This is most often due to age and can be detected by checking FSH levels. Other women fail to ovulate even though they have lots of fantastic eggs. However, their problem is that their brain is not programming the eggs to mature and develop correctly. This is a much easier problem to solve. Again, just as with the computer analogy, a software problem can be fixed by changing the programming while a hardware problem cannot be fixed by anything other than replacing the components.

WHAT ARE SOME CLUES THAT YOU ARE A NON-OVULATOR?
You may be a non-ovulator if you have irregular or absent periods (anything other than a standard regular 11-13 cycles per year) or if you have consistent failure to have positive ovulation testing.

WHAT IS THE BEST APPROACH TO HELPING A NON-OVULATOR?
Find out the cause of her non-ovulation. Fix it if possible. If ovulation is restored and pregnancy still does not occur, then it’s time to look for other problems.

SUMMARY:
Some non-ovulators can be helped to ovulate quite easily. If so, and if that’s their only problem, meaning no coexisting sperm or tubal problems, they can get pregnant fast. Other non-ovulators have coexisting problems, so that resolving the ovulation issue is only part of the game. Still other non-ovulators are in a sadder state because it is nearly impossible to help them achieve a good ovulation. If you suspect that you are a non-ovulator, please consider getting help right away.

This has been suspected by RE’s for a while when we noticed that CC can succeed in inducing ovulation about 70% of the time. Yet, only about half of these patients wind up getting pregnant with just CC alone. So the ovulation problem was being fixed, but yet, we weren’t seeing anywhere near as many pregnancies as we would expect. One possibility is that these couples had multiple problems, besides just ovulation issues. Another possibility raised was that while CC was helping with ovulation, it could be hurting with other things.

So, at what locations and in what ways might CC be harmful. I gently use the word ‘might’ because for many patients, the bad effects are not significant. Remember that people are different and respond to medications differently. Don’t go throwing away your CC and angrily calling your OB. However, while CC works great for some people, in others, it fails to solve the problem, partially because of CC’s bad side. The potential harmful effects of CC on the uterine lining are supported by a study that used special ultrasound to look at uterine blood flow. They found that CC use was associated with decreased uterine blood flow. It did not actually affect the thickness of the lining, but it did lower the propensity for the lining to be that ideal “triple-layer” appearance that we all wish for.

Another area where CC can cause problems is at the level of the cervical mucus. CC can have a tendency to interfere with the formation of that favorable stretchy mucus that sperm like.

So what can you do? Bear in mind that for most people, the downside of a three month trial of CC is just a loss of three months. While you might argue that three months is critical for someone over 40 years old, I would agree, but also add that experimenting for three months is quite feasible in almost all women in their 20’s and early 30’s. Having said that, I’m also reminded of a recent experience when a patient told me that she absolutely did not want CC because she had had a bad experience with it in the past. She told me that her OB had prescribed her CC and that it had “made her gain 20 pounds.” Not only that, the stress of gaining that 20 pounds caused her to gain an additional 50 pounds. This is the only time I’ve ever encountered such a report, but it goes to remind me that every patient is different.

Anyway, back to the lining and mucus, how do you get around the potential harmful effects of CC on these areas?

With respect to the lining, my favored approach is to abandon the CC and move on to injectables, which can be very friendly to the lining. With respect to the mucus, my favored approach is to punch past the unfavorable mucus by doing simple IUI’s. So, the bottom line is that if you have successfully ovulated on CC, but are still not pregnant after three cycles, it’s time to discuss the above issues with your doctor, keeping in mind that in some cases CC is your friend and in others cases, CC can be your enemy.

It’s true that everyone is different and no two fertility patients are exactly alike. However, RE’s very naturally speak of categories, such as tubal factor, unexplained, diminished ovarian reserve or male factor, for example. Labeling patients with these labels can generally help guide our treatment. However, we sometimes have to be careful not to let labels make us too narrow minded. There is going to be a lot of overlap between the different types, especially when many couples have more than one factor.

Anyway, starting later this week, I’ll begin posting on different “types” of fertility patients. If you have any suggestions on what “types” you’d like to see profiled, let me know.

As I complete each post, I’ll put a link at the end of this post, so if you would like, you can bookmark this page now and come back later to check for updates. This should be fun for me and informative for you!

What kind of fertility patient are you?

1. The NON-OVULATOR
2. The UNEXPLAINED-INFERTILITY SUFFERER
3. ????????

A month ago, I wrote Part 1 and Part 2 of this series on Georgia Senate Bill 169, a proposed legislation which slams into conflict two groups of people. The supporters of this bill view that laboratory embryos should be afforded the same rights and protections as a live-born child. The other group opposes the bill and believes that infertile couples who are trying to have a baby should not have their options overly restricted. So just what is this bill all about?

There are multiple components to this bill. The first part reads:

(a) It shall be unlawful for any person or entity to intentionally or knowingly create or attempt to create an in vitro human embryo by any means other than fertilization of a human egg by a human sperm.
(b) The creation of an in vitro human embryo shall be solely for the purpose of initiating a human pregnancy by means of transfer to the uterus of a human female for the treatment of human infertility. No person or entity shall intentionally or knowingly transfer or attempt to transfer an embryo into a human uterus that is not the product of fertilization of a human egg by a human sperm.

In our program, there’s only one way we know how to create embryos, namely by fertilizing human eggs with human sperm. I don’t know of any other programs that are doing it any differently, such as any using kangaroo eggs or hamster sperm, but if there are, I guess they’d be in trouble if this bill passes. Granted, this clause could also be interpreted to ban cloning. However, that would be redundant as there are already federal provisions in place aimed at banning cloning. This part of the bill doesn’t affect my patients, as we presently don’t do cloning.

The next section addresses financial compensation given for embryos or gametes. It reads:

No person or entity shall give or receive valuable consideration, offer to give or receive valuable consideration, or advertise for the giving or receiving of valuable consideration for the provision of gametes or in vitro human embryos. This Code section shall not apply to regulate or prohibit the procurement of gametes for the treatment of infertility being experienced by the patient from whom the gametes are being derived.

In a free society, people enter into agreements based on mutual benefit. Infertile couples sometimes need help from other people in the form of donor sperm or donor eggs in order to fulfill their dreams of parenthood. As a way of thanking the donors, financial compensation is routinely offered. To do away with this option would be disastrous if we look to the UK as an example. Over there, paying for donors is forbidden. This all but eliminates anyone from wanting to participate, leading to a loss of options for most couples, unless they are willing to resort to drastic risky behavior. For some of them, there is the option of coming to the US. In the past two years, I’ve had the chance to help four couples from countries in which paid egg donation is banned. After they got pregnant, they vented their anger at the unfair restrictions in their home countries which compelled them to come to the US. Well, if this happens in the US, I’m not sure where patients would go for their treatment, maybe Mexico?

The next section reads:

The in vitro human embryo shall be given an identification by the facility for use within the medical facility. Records shall be maintained that identify the donors associated with the in vitro human embryo, and the confidentiality of such records shall be maintained as required by law.

This is just plain meddlesome and seeks to slap a regulation onto something that is already routinely done out of common sense. We already document and label meticulously, so again, this would not affect us much.

Going on, the next paragraph reads:

19-7-64. (a) A living in vitro human embryo is a biological human being who is not the property of any person or entity. The fertility physician and the medical facility that employs the physician owe a high duty of care to the living in vitro human embryo. Any contractual provision identifying the living in vitro embryo as the property of any party shall be null and void. The in vitro human embryo shall not be intentionally destroyed for any purpose by any person or entity or through the actions of such person or entity. (b) An in vitro human embryo that fails to show any sign of life over a 36 hour period outside a state of cryopreservation shall be considered no longer living.

Here’s where it starts to get a little annoying. This vague statement suggests that the writers of this bill are not familiar with what actually happens in an embryology lab. When we put the sperm and egg together from a husband and wife couple, we have to assign somebody the power to determine what is done with that embryo — whether it is transferred back into the wife, transferred into someone else or frozen for the future. Whether or not it is labeled as the “property” of anyone, we have to give someone the legal authority to make the call of what happens to the embryo. This is like passing a law stating that a child can not be labeled as the property of his parents. That’s fine and dandy, but then is it OK for someone to grab a baby out of a stroller at the mall and take the baby home because it wasn’t the “property” of the parents? Very silly. Whether or not you label it a property, there HAS to be some legal designation, enforced by contract, to confer rights to certain people regarding the embryos, because you know what? The embryos can’t make decisions on their own.

The next clause appears redundant because it states:

Only medical facilities meeting the standards of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists shall cause the fertilization of an in vitro human embryo. A person who engages in the creation of in vitro human embryos shall be qualified as a medical doctor licensed to practice medicine in this state and shall possess specialized training and skill in artificial reproductive technology in conformity with the standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

IVF is a medical procedure and as such, can only be done by medical doctors. There is no real need to restate it. Again, this is verbose, but not really changing anything that we already do.

The next section is where it starts to get really intrusive:

In the interest of reducing the risk of complications for both the mother and the transferred in vitro human embryos, including the risk of preterm birth associated with higher-order multiple gestations, a person or entity performing in vitro fertilization shall limit the number of in vitro human embryos created in a single cycle to the number to be transferred in that cycle in accord with Code Section 19-7-67.

In order to grasp the impact of this intrusion, let’s review how IVF works. When a couple make the decision to do IVF,  our goal is to help the couple create some healthy embryos that will grow into healthy babies. We help do this by putting their eggs and sperm together. The procedure take a lot of dedicated work from a team of many people. The main labor is the surgery involved in extracting the eggs. The good thing is that each additional sperm or each additional egg does not add all that much cost to the process.  Therefore, it would be highly wasteful to do IVF with just one egg and one sperm. We can’t know for sure how many of the eggs we get will successfully fertilize. Out of those that do, we can’t know for sure which will continue to survive until the day of transfer. Can you imagine a lawmaker telling you that you can’t put more gasoline in our car than you’re going to use each day?

On the day of an IVF egg retrieval, we surgically remove all the eggs that stimulated for that month. We try our best to fertilize every one of them, because we know that most of them will not end up capable of becoming a healthy baby. By attempting to fertilize all of them, we get the best chance that at least one or some of them will end up being good. In a good scenario, we get enough healthy embryos to transfer as well as some additional ones to freeze for future attempts. For many couples who fail IVF in the first fresh attempt, those frozen embryos are the difference between their ending up with a baby in their home vs. remaining sadly childless.

The rest of the bill piles on further restrictions by telling us how many embryos we can transfer. This issue of embryo number is such a loaded issue that I’m going to save it for the next post.

It would be a shame if overreactive legislation were passed to further impede the hopes of infertile couples all because of this one case.

By the way, there is no truth to the rumors that Dr. K has applied for a trademark on the term “OctoDoc”, although he HAS been heard to have jokingly referred to himself as that during a conversation at a recent pharmaceutical company-sponsored event that he attended this past month.

A teenager diagnosed with leukemia was advised to save his sperm before undergoing his cancer treatment. Now, 22 years later, he and his wife are parents thanks to this forethought. For patients newly diagnosed with cancer, there is an organization which provides information regarding fertility options.

Many patients are referred to me for guidance after finding out they have cancer. Often, after learning about their options, they end up saving their sperm or embryos so that they can have children in the future. While some patients will need these preparations in order to conceive, there have been other patients who make these arrangements, but then end up getting pregnant on their own afterwards.

I have been involved in such a case myself. I can only share the basics without divulging the details. This was a couple who were in the middle of infertility treatment when suddenly the husband took ill. He went to the doctor and was diagnosed with cancer. The couple halted their treatment, but deliberately took action to freeze many vials of sperm. The husband did not survive his disease, but made it clear that he wishes to give his wife the option of using his sperm. She came back after a time and did just that. Now she is successfully raising happy healthy children conceived from her deceased husband’s sperm.

The difference in the case of Nikolas Colton Evans is that he never explicitly expressed his permission to do this. In fact, he never even went to the trouble of saving sperm ahead of time. So this is not just a case of using posthumous sperm, it’s a case of harvesting posthumous sperm.

Instead of arguing the merits of doing it, one might present the counterargument of why NOT do it, as long as the mother wishes to. Well there is the question of the rights of the deceased. Do dead men have the right to not have their sperm taken and used? What about the rights of the future children? Do future children have the right not to be conceived if their biological father is already deceased?