One of the reasons for this is that you have instinctively learned to associate politics and government with a general yukky feeling of dread within the pit of your stomach. Why is this? Isn’t government just another business that we patronize. After all, when we deal with government, how is it different from when we deal with a regular free-market non-government business? In both instances, we pay a price in exchange for something. In the case of government, that price is money (via taxes) and loss of freedom (via regulations). What we get back is a whole other matter and subject to a whole other discussion. For today, let’s dissect the reasons how government interactions differ from other transactions and we’ll better understand why we love shopping but why we hate politics.

You may or may not agree with me on this at first, but I sense that in the end, your gut feeling will be one of agreement. There are two important things that shape whether or not a particular business entity will make us happy. The first is the presence of COMPETITION or from the consumer’s viewpoint, the presence of choices. The second, which helps keep the competition honest, is ACCOUNTABILITY.

Allow me to expand on this, OK? Let’s begin with the concept of COMPETITION. If you think back to some of your best experiences as a customer, what were they? Was it a 5-star restaurant or some luxury resort hotel? Was it that clothing store in the mall with the great deals or that friendly-service mom-and-pop grocery store? Now contrast this with some of your most frustrating experiences. You all have your own. Was it the DMV or the traffic court system? Was it that doctor’s office that you are forced to go to because of your HMO?

Let’s analyze the differences between the good experiences and the bad. Is there a correlation between how good something is and the degree of competition that they face? You bet! And why? Well, it’s just natural that a business can’t afford to be bad and have unsatisfied customers if it is to survive in the face of nearby competition. When disgruntled clients can easily walk away and take their business elsewhere, you can bet that the business will bust their butt trying to be the best it can be. However, if there is no competition and it’s the “only game in town”, or if people are forced to spend their money at that business no matter what, then of course, there’s little drive for the entity to excel.

When it comes to politics, there’s really zero healthy competition to give us options. Sure, there’s this illusion that we can choose between the Democratic and Republican candidates. But really, what kind of choice is that? Pardon the bluntness, but it’s like telling a slave that they should be grateful for having a choice of slavemaster for the next four years. I know that this is a little different because we have the option to leaving this country, but is that really a valid excuse? We, the people, own this country. It’s not the handful of people called politicians who own it or who own us. Our economic and social freedoms are increasingly being squeezed away by both parties in this alternating back and force dance where one side gains power and saps our economic freedom and then power switches to the other side who then suck away our social freedoms without returning a single inch of what the other side stole. Deep down inside, what most of us want is individual liberty and the chance to thrive as a free community. So if that’s the case, then why doesn’t a candidate run on the platform of reducing government and increasing freedom? Well, that’s what they often do, but once they get into office, they are no longer bound to deliver what they promised. And as for the honest candidates who will abide by their promises, well, THEY never make it onto the ballot. The barrier to entry is too great. In order to even make it onto the ballot, you would have to have played the politics game and survived for quite a while. And by that time, you’re already bought-and-paid-for by special interest groups with their fat political contribution checks.

That’s where the second factor, ACCOUNTABILITY, comes into play. If you walk into a free-market store and they treat you rudely, you have the absolutely liberating choice to smile and walk out. If you’re so inclined, you can even eliminate the smile and add a rude gesture back. If you have a bad experience in a restaurant, then you have the option of making that the very last time you ever bring your dollars to that particular establishment, and even leaving a bad review on Yelp to warn others. How does this differ in politics? Like night and day. Once a politician is elected, he is set for the entire term, usually four years. If politicians renege on their promises, it matters little to them because accountability is now out the window. By the way, it’s certainly not just our current president who is egregiously guilty of breaking promises. The one before him who asked you to “read my lips, no new taxes” was every bit as bad. I won’t go into the technicalities and semantics of “new” taxes vs just raising preexisting ones, but clearly, the spirit of the promise was broken without regard. Another thing that reduces accountability is the great distance between the controller (the politicians) and the controlees (we the people). If it’s our mayor or our neighborhood association president who does something we hate, we can let our voices be heard. But if it’s some politician 2000 miles away, you can just give it up because in that case, our voice is heard as strongly as a whisper at a rock concert. Our current system of a representative democracy where a few out-of-touch people control the lives of a great majority, is horribly flawed and clearly not the best way to live.

I’m not alone in being intrigued by yesterday’s turn of events in Massachusetts, what is rightfully being hailed as the political “Upset of the Century”. It stunned me and has given me a glimmer of hope for this country. Why? Because, it could well be interpreted as a sign that the Star of Accountability is trying to shine again in politics. Hooray! Recall that in November 2008, a new president was elected on promises of hope and change by a nation sick and disgusted by the corruption and oppressive practices of the former president. However, once the new guy gets into office, he proceeds to unleash a surprisingly bold set of unpopular policies to further destroy our country’s freedom and economy. It got to the point where this new president and his ruling party got so arrogant as to try and shove down the people’s throats a massive government takeover of the enormous sector known as healthcare. Then, with no remorse, when the people voiced that they didn’t want this, the politicians proceeded to resort to every last bit of political trickery to bribe a vote here and there, just to pass something that the people don’t want. In the past, the collective passive mind of the American people would have been tricked into going along complacently. But thanks to the power and transparency of the internet and our gradual liberation from a biased media, last night’s shocking results give some hope that people are actually getting smart enough to say “enough is enough” and caring enough to do something effective. Wow!

One more thing. It’s certainly tempting to give in to the adversarial two-party game of politics, with half the country cheering raucously at yesterday’s Massachusetts results, and taunting the other side, just as that other side cheered and taunted when Obama was elected, reminiscent of when UCLA beats USC in football or vice versa in basketball. But the wiser approach is to realize that we’re all in it together and cheer it as a minor victory of the people vs the corrupt oppressive big government.

Now before all of us freedom-loving people can rest and celebrate, we have to be wary. What if the Republican party continues this trend of regaining power, but then does nothing to offer tax relief, nothing to lessen oppressive regulations and nothing to reduce runaway government spending? It has happened before and might happen again. Stay tuned and stay alert. But for now, we can focus on the positive, that maybe there is some hope that political accountability is slowly emerging.

In any case, as unpalatable as it can be, we can’t afford to ignore politics, because it’s not merely a remote scorecard of who is in office and which side has more. It’s a matter of what you can eat, whom you can marry, what your children are taught and what you are allowed to do in your life. It’s a matter of how much money is stolen from you every month and how much killing and bombing is being done with that money. So let’s all discuss, read, learn, debate, reason and question as if our lives depended on it, because, as you all know, it really does!

Daniella

Dear Daniella
Thanks for the question. I’m sorry to hear that you were only given 10 minutes with your doctor on a complex issue such as infertility. I understand that you have government-run healthcare over there in the UK, but do you have any option to choose another doctor? The thought of being given 10 minutes with zero choice of choosing a different doctor would scare a lot of the people here in the US as we try to fight off our own government’s attempts to take over this vital part of our lives.
In any case, with respect to your question above, what you have shared are test results regarding your hormones. The FSH and LH are made by your pituitary and are involved in your body’s way of modulating your ovaries to make eggs. The next three ( testosterone, progesterone and estradiol ) are the products of your ovaries.
Depending on your age, you could have a less than average chance of conceiving or an average one. Based on those tests, you probably wouldn’t expect to have a higher-than-average chance of conceiving. As for what you should do, it depends on your age, how strongly you want to have a baby, how long you have been wanting one and what treatments you have already tried in the past. The value of doing those tests is not that great unless one of them comes back as off the charts and grossly abnormal. That’s about the best answer that I can give you without knowing your history and goals. Good luck!

I just went to the Re office for my 3 day fsh level to start ivf last month it was 10.5 and e2 was 69 this month i wanted to start and now my fsh is 15.5 and e2 is 89 my follicle count was 9 no other problems is it possible i need egg donor they told me I have to wait till it goes down what would my options be at 37

Tracey

Dear Tracey,
At 37, your options would be to go ahead and attempt a stimulation and then see how many follicles your body produces or to not take a chance, but go directly to donor eggs. Without knowing the rest of your history, I can try and assume that you have never done IVF before. Depending on how much it would cost you if you were to have a cancelled cycle and how much value it is to you to try with your own eggs, you would balance these two factors out and make a choice that is best for you. Best of luck!

hello
in 2007 I had a fsh of 6.9 in 2008 I had a successful ivf resulting in my little girl.?from that ivf I got 9 eggs out of 13 follicles.with low drugs
we have been considering ivf no2 in the hope for a sibling
my fsh is now 10.2 ( which is the higher end of normal ) and my AMH is 8 not sure is that is normal ???
I am 27 and ivf is the only way for me as have no tubes ( 3 ectopics )
so my question is with my fsh on the rise should I be having ivf sooner rather than later ? are my levels abnormal for my age ?
any advice would be much appreciated
natalie

Dear Natalie,
Yes, assuming that your FSH was drawn near day #3 of your cycle, then the value is considered less favorable than what would be expected in the average 27-year-old. As for going after your second baby sooner than later, in general, you know that conceiving at a younger age results in higher odds of success, lower risk of miscarriage and lower risk of birth defects. So if you mentally and financially ready and are really sure that you want more children, then what’s the reason for waiting? Right? Good luck!

Hi Dr. Lee,
I have followed your blog for several months now. It has been so helpful, and I thank you for that. My husband I have been trying to conceive for 3 years now, and under the care of an RE since October of ‘08. We’ve had 5 IUI’s and 2 IVF’s. Long story short, the first IVF resutled in OHSS and the 4 embryos were frozen. The second IVF only resulted in 2 embryos surviving to day 5 and they were both transferred, but I was hospitalized with the flu AND we got a negative on a pregnancy test. We had a FET this past summer and transferred 2 of the embryos. (Many details to my story but they believe the blood thinners helped us as I was diagnosed with MTHFR.) I had a successful, singleton pregnancy but delivered stillbirth at 20 weeks, 5 days. I was diagnosed with an incompetent cervix. I have read on line that this is not uncommon in infertility patients. In a nutshell, I was wondering if you would consider blogging about any of these topics in the future: blood disorders like MTHFR, recurrent pregnancy loss, incompetent cervix, and high risk issues in IF patients like incompetent cervix or placent previa. Thanks for your time, Jennifer A.

Dr. Lee,
So sorry… I left a few things out in my post. I was diagnosed with PCOS and poor egg quality. My husband was diagnosed with slightly low testosterone (I want to say just two points below normal). He had the varicocele surgery and now the urologist in the IF practice says his testosterone levels are ‘great.’ The most important part I left out was this; I have two frozen embryos left. We want to try another FET. What could/should I know about incompetent cervix that could make a different and save the next baby’s life, or is it a ‘crap shoot.’ Also, would it be safe to trasnfer two? If we chose to transfer only one at a time, are we lowering our chances of that ‘one’ embryo implanting? I have heard that women often transfer several because it increases their chances at getting pregnant. So, does that mean transferring only one will ‘lower’ your chances? Hoping my story will inspire future blog topics for you to research and discuss. Thank you again, Jennifer A.

Dear Jennifer,
In my 14 years of practice, I’ve encountered at least 20 patients who after getting pregnant with IVF or IUI have gone on to be diagnosed with incompetent cervix. Most of them went on to have a healthy baby in future pregnancies. In the majority of cases, the presence of an incompetent cerivix is picked up only after a tragic pregnancy loss. The only other way to detect it would be to monitor the cervical length meticulously. For you next pregnancy, I take it you will be under the care of a high-risk OB specialist who will likely discuss with you the option of having a cerclage, which as you may know, is a stitch to tighten up your cervix. As for your question of transferring one vs two embryos, bear in mind that each embryo you transfer gives you one “roll of the dice” to get a baby. So, of course, rolling the dice twice makes the odds of hitting a winner more likely. However, you would have the same general chance in the long run whether you transferred both embryos in two separate transfers or if you transferred them both at once. I hope that makes sense. I have discussed recurrent pregnancy loss in previous posts, but I appreciate your suggestion and I will likely revisit this issue in future posts. I hope all goes well with your next pregnancy.

The one part of my work that has the greatest variety, and a “you-never-know-what-you’re-gonna-get” component to it is the New Patient Consultation. If you want to know what keeps my work day fresh and exciting, well… this is it. Picture this. I’m sitting in my office working on charts when I get a notice on my computer screen from my staff that a new patient is ready and waiting. I leave my desk and head for the consultation room. I pick up the blank chart and all I see are the patient’s name and her date of birth. And then the fun begins. When I open the door to greet the patient or couple who are waiting, I know that I will spend the next hour engaged in a fascinating conversation with someone whose goal is to have a baby and who is researching to see if they want to enlist my help.

The first few minutes consist of simply introducing ourselves. There is great value in really getting to know someone, learning about a patient’s life, her philosophies, her values and her anxieties. This requires time. I sympathize with my medical colleagues in other fields who are called upon to see five or more new patients an hour. Of course, if a patient is in the ER with a laceration that needs suturing or a sprained finger that needs splinting, then a more specific problem-oriented approach might be OK. But in our field, it doesn’t work that way. Ironically, I’ve brainstormed and toyed with that notion in the past - specifically conjecturing about the feasibility of someone opening up a dedicated artificial insemination express station so that infertility patients could have the option of being helped without an extensive doctor-patient relationship. For patients who wish to save money and time, but who just wanted to have an IUI done, they could choose to assume responsibility for  predicting their ovulation day on their own and then go to some novel walk-in IUI center. Bring the sperm in. They’ll prep it and inseminate it. No questions asked. While something like that might work theoretically and might have some economic advantages, it would never fly in the real world given the strict regulations that govern us. For one thing, here in California, we need to have a set of infectious disease screening tests done on the husband before we can even process the sperm. Anyway, as I said earlier, there is great value in getting to know a patient, because in the field of infertility, there are usually multiple options available for some patients and the choice of the best option is based not solely on cold hard medical criteria, but also on personal preferences of urgency, frugality, risk aversion and religious views.

So, while the patient and I gradually get acquainted, we will intersperse the communication with me asking them questions about their health and with them asking me to explain some of the medical aspects of their situation. It’s a very fun process, because both parties get to learn. While I am learning about their medical history, I am intermittently teaching them about the medical facts and ideas which pertain to their case. Some of my questioning is done in a rigid checklist style, because I always need to know about certain mandatory things such as their drug allergies and past surgical history. However, a lot of this process is done with a great deal of improvisation. I teach the medical students at UC-Irvine and Western University of Health Sciences during their OB/Gyn rotations and over the years, I’ve tried to come up with the best way of teaching how to take a history on an infertile couple. I’ve come to learn that it’s hard to teach, because unlike other fields of medicine where the history taking is more amenable to a checklist approach, infertility requires a lot of improvisation. That’s why I’ve decided that the best way to teach it is through role-playing. The times in the past where I had a kind student volunteer offer to play the role of the infertile patient being interviewed are the times that were the most educational. If you are a regular reader of this site, you might have noticed that the previous posts with the detailed case histories were especially helpful to you, again, for this very reason.

So after we’ve gotten acquainted, processed all the mandatory medical information and sufficiently answered the patients’ questions, we wrap up the visit by exploring if we’ve achieved the following objectives.

1. The patient now has a better understanding of her fertility situation, with regards to what might be contributing factors, potential options and overall prognosis.
2. We have outlined the potential treatment options with a rough estimate of how much they will cost, what risks they involve and what is the estimated chance of success.
3. The patient knows a bit more about my own values and philosophies which will greatly shape my role as their guiding physician.

Then the patient will go home and decide, based on my medical suggestions, which treatment option is right for them, if any, and then we move forwards to do the next step that it will take in order to get them a baby.

Let’s picture that you want to be pregnant and have been trying for almost a year. With your job and all your other obligations, you just haven’t seen any opportunity to take action on this just yet. Besides, you and your husband are healthy and can clearly picture it happening naturally, right? Occasionally, during random moments of browsing the internet, you see some flashes of information that makes you inspired to take action, but then the motivation fades and you are back to your busy life. Over the next year, the pages on your calendar cascade down month after month, and still nothing has happened. Now it’s been two years, so you stare at your phone and eventually pick it up and call.

The voice on the other line is pleasant and you are told about the office policies, the initial consultation fee and you are given a choice of times. You and your husband decide to take the leap and book an appointment.

You arrive at the unfamiliar office and are warmly greeted with a smile, but you are immediately taken aback by the pile of forms to fill out and sign.

The first is a demographic sheet asking for your contact information, so we can facilitate reaching you, especially in an emergency. Besides the personal data, you are also asked for any insurance information that is needed. So this has practical value and you don’t mind filling it out.

The next form you will have to read and sign is the HIPAA agreement. You will have to bear with me while I gripe, but this is another reason why we should hope and pray that government-run universal healthcare never becomes a reality. Sure, everyone agrees that privacy is important, but it should not be the way it is, where physicians are made to be so terrified of a perceived infraction that we are all forced to take drastic measures. Anything that takes up our undue attention will distract from the pool of attention resources we can devote to more meaningful things, such as patient care. So we had to pay attorneys to draw up legal documents for our patients to sign. You see, while the government mandates us to abide by the rules, they don’t provide any acceptable standard documents that we can use, so we have to expend major time and energy each time there is a HIPAA revision. Also, we used to have a convenient sign-in sheet. But now we had to hide it. Technically, we also can’t risk saying hi to anybody by their name if it can be heard by anybody else in the waiting room. Basically, we walk on eggshells for something that was never a significant problem even before HIPAA. And yet, ironically, now with HIPAA, it still doesn’t prevent those news stories of people leaking celebrity medical information to the press. OK, thanks for listening. Let’s go on.

The next piece of paper is the Arbitration Agreement outlining that any disputes will be addressed by a legal professional and not by a random jury of medically unsophisticated people.  This document benefits us by protecting us from lawsuit abuse in many ways. It sets up a fair system and it also weeds out the litigious fringe problem patients who jack up the costs for everyone.  There have been a handful of people who refuse to sign the form and therefore, refuse to be our patient. One such person went on to see another doctor whom she wound up suing for something silly. She also sued her landlord for mold and sued her employer and this one store she went to. (I later found these cases listed on the internet). With an arbitration agreement, while we can still be sued if we do something wrong, it’s less likely that someone is going to file an nuisance suit against us just to exploit and intimidate us. And actually, it also benefits the patient. How? Well, in almost 13 years of practice, I have yet to be named in a lawsuit, so that helps keep our malpractice costs low. Don’t underestimate the significance of this. Due to arbitration and legal protections (MICRA) against lawsuit abuse, OB/Gyn’s in Orange County CA pay about 50K each year in malpractice costs. In contrast, OB/Gyn’s in Long Island NY pay 168K and those in Dade County FL pay 203K per year. You can probably already guess that these costs will get passed down to the patient somehow. I believe it also gives good doctors an incentive to avoid those places, thereby depriving the people in those regions of more good doctors from which to choose.

So after all this gruelingly painful paperwork, you will finally get to meet with the doctor, which we’ll discuss next post.

In my practice, the couple will sit across from me and we’ll spend about an hour together. Sometimes it’s just the wife who comes by herself and other times, both partners are present. There are several goals to accomplish for this visit:

I get to know the couple. I find out what their daily lives are like, what their priorities are with regards to fertility treatment and what their specific concerns and special needs might be.

The couple gets to know me. They get a feel of my communication style and my philosophies regarding the doctor-patient partnership. Some doctors are very dictatorial, meaning they pretty much call the shots regarding what happens. Generally, my style is different. I like to present options including the pros and cons of each alternative. After going over this in detail, then I’ll reveal which choice I would personally lean towards, but I prefer to let the couple make their own choice. However, it all depends on what the patient’s want. Some patients clearly don’t want to discuss the logic behind each decision, but would rather just leave it all up to me.
I gather all the medical information though questions and answers, as well as via an ultrasound examination plus review of any previous records or test results.

I offer treatment choices. Sometimes, there are a couple choices, all of which are reasonable. Then, as I previously mentioned, we’ll go over the plus’s and minus’s of each route before deciding on the final plan to take. Other times, there’s really only one best plan. In this case, we will spend time going over this process in detail, making sure to tackle all the questions that come up.

In the next post, we’ll describe an example of the paperwork involved in a New Patient Consultation visit.

Remember that this early in the cycle, all the follicles for that month should be very small. I tend to use 13mm as a cutoff, but I have colleagues who have a slightly smaller or slightly larger cutoff. The rationale is that if we already see something larger in size, then the cycle will be suboptimal because that cyst can grow and disrupt the course of development of any new upcoming follicles.

Another purpose of this visit is to discuss the exact formula or protocol to use for the upcoming cycle. There have been times when a patient came in to start injectables and after discussion relating to her particular case, we change our minds and decide to do Clomid-only or a combination of Clomid with injectables. We may make our final decision regarding doing IUI or just timed intercourse. We might have some adjustments regarding the dosage, as well.

By the way, sometimes for the sake of convenience, we can actually do the baseline scan a few days BEFORE the period starts. Let’s say for example that the patient is here to pick up some medications or settle her account and hasn’t started her period yet. However, she is expecting it to come any day now. We can do the baseline ultrasound today; then she can call with her period and get instructions on when to start her meds.

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.