Women & Infants Center for Reproduction & Infertility

Clinicians from Women & Infants Center for Reproduction and Infertility answered a range of questions about IVF and participated in a series of IVF-related podcasts as part of our ongoing "Ask the Experts" campaign. Become a "fan" of Women & Infants' Facebook page and learn more about our social media efforts.

Question: I have read about the use of DHEA in infertility patients with diminished ovarian reserve, is that something you use in your practice?

Answer: I am familiar with the use of DHEA in patients undergoing IVF treatment. In fact, two of my partners have published a case series using DHEA in women with "diminished ovarian reserve" or poor responders. Other groups have also considered using growth hormone.

Nevertheless, our group has decided that the evidence does not support using DHEA at this time. Most of the published studies on this topic are small and have various methodological limitations and routine use cannot be recommended at the present time. While our group is studying different growth hormones for women with poor responses, we prefer to only administer experimental treatments under a research protocol with appropriate Institutional Review.

Good luck with your treatments.

Question: Are there actually % out there for a couple trying to conceive naturally each cycle? 20%? 30%?

Answer: This is a great question. The chance of getting pregnant each month depends on the length of time that a couple has been trying. When couples first start trying, the chance of them becoming pregnant each cycle for the first 6 months are relatively high, with a pregnancy rate per cycle of 20-30 percent. As time goes on, those couples that have not become pregnant by 6 months of trying will have a decreasing chance of getting pregnant in the subsequent 6 months with a pregnancy rate per cycle of 5-10 percent.

Keep in mind that the pregnancy rates reflect the chance of becoming pregnant each month for couples that did not get pregnant the previous month. At the end of one year it is expected that approximately 15% of patients will not conceive despite trying, hence they are considered infertile (or subfertile) and an infertility work up is recommended.

Question: I had a uterine prolapse when I was six weeks old, and I think it may be causing my infertility at the age of 31. My RE tried to do a hysteroscopy a few days ago and wasn't able to pronate the uterus, so the procedure was worthless. My HSG showed I have a mass growing inside the uterine cavity, but he isn't able to see it. He told me I have the option of having him do a laparotomy to see how the uterus was attached, and if there is any scar tissue. I am very scared and nervous about the surgery and the possibility of having this scar tissue or mass causing me to be infertile. What are your recommendations about this surgery?

Answer: It does sound like you have had a difficult history and challenging situation. I understand your fears. Without having examined you myself, it is very challenging to say for sure whether you need a surgical procedure. We do know that intrauterine masses can adversely affect implantation. That said masses such as fibroids, that are outside the uterus would not affect your fertility, unless there was associated pelvic scarring that would block the fallopian tubes.

The mass inside your uterus is concerning and I understand your physician's desire to further explore. Having not examined you, I cannot comment on the difficulty in performing the surgery, but it seems likely that your uterus may have developed abnormally when you were born, and that is creating some difficulties in performing hysteroscopic surgery.

I would recommend for you to discuss with your physician the option of performing a pelvic MRI prior to pursuing additional surgical procedures as that might be an effective modality and much less invasive way of evaluating not only the uterine cavity and uterine mass but also the adjacent structures. Hence, a pelvic MRI may further facilitate and better delineate the uterine anatomy and assist in the planning and performance of the most appropriate surgical intervention be it laparotomy, operative laparoscopy or operative hysteroscopy.

Good luck. I am sorry you are having such a difficult time.

Question: I am a 47 year old women who is very healthy who has had a partial hysterectomy 3 year's ago and want to know if my eggs can be removed and implanted and fertilized via a seragate?

Answer: Infertility treatment has been able to overcome many obstacles for couples desiring a family. Unfortunately, at age 47 your eggs are not healthy enough to use for IVF even with the use of a gestational carrier (surrogate). If you wanted to have a child, you would need to use both an egg donor and a gestational carrier. Sometimes I feel like the media has made it seem like anyone can have a child (like the older celebrities) but they have failed to give the whole story. I wish I had better news for you.

Question: My husband did a reversal vasectomy 6 months ago. After semen analysis the report is mobility "0". Is it possible do a fertlization in vitro or artificial insemination?

Answer: Thank you very much for sending us your question.

It is still possible to get pregnant with sperm that are not moving but it would require some additional help. In your particular situation, we would recommend doing in vitro fertilization (IVF) with an additional procedure in which the sperm is injected directly into the egg (Intracytoplasmic sperm injection or ICSI). Even though the sperm are not moving, a certain percentage of them may still be alive and able to fertilize an egg.

A sperm viability test, which could be performed by the IVF laboratory or your partner's urologist, may give you and your physicians a better sense of your chances of getting pregnant. The test would tell us what percentage of the sperm that aren't moving are still alive and able to fertilize an egg.

Artificial insemination (IUI) and regular IVF (putting sperm and eggs togther in the lab) would not be options since immobile sperm would be unable to fertilize the egg on their own.

Question:My husband and I have been trying to get pregnant for about 8 or 9 months now with no luck. I have been using ovulation kits and most of the time I get a clear reading and we try to have relations within the recommended time period, still nothing. I'm getting frustrated, I know it hasn't been nearly as long for us as for some, but I would like to know if there is anything else I can do. Thank you.

Answer: It certainly can be frustrating to have no success so far. You should definitely talk to your gynecologist or primary care doctor to see if there is anything that he or she would recommend based on your detailed history.

Although you don't mention your age, in general if the woman is under age 35 and the couple has been unsuccessfully trying for one year, we recommend there be a complete infertilty evaluation.

If the woman is 35 years old or over and has been trying for 6 months to conceive without success, she should be evaluated. The evaluation consists of blood tests, sperm count, and an evaluation of the tubes and uterus. This evaluation can be done by a primary care doctor or you can be referred to an infertility specialist.

Question: My grandmother (on my fathers side) died of ovarian cancer. Does this put me at risk when Im using fertility meds? I've done clomid, Gonal F/IUI and 2 IVF cycles that have failed. Thanks.

Answer: That is an excellent question. The good news is that with just your grandmother with a history of ovarian cancer, your risk in not any higher than the average woman.

In terms of fertility medicines, there is some old data which suggests that the use of the oral fertility medication clomiphene citrate for more than 12 months has been linked to a slight increased risk of borderline ovarian tumors. Nothing has clearly shown that with a family history of ovarian cancer there is any higher risk with fertility medication.

As more and more studies have been done, it has been found that infertility itself is a risk factor for ovarian cancer. Patient with irregular periods also had a higher incidence of ovarian cancer even among infertility patients. Pregnancy, birth control pills and breastfeeding are all protective against ovarian cancer.

The bottom line is that your grandmother's history should not impact your treatment and I encourage you to persist in your efforts to become pregnant as long as your doctor thinks it is reasonable.

Question: My husband and I have been trying to get pregnant for a little over a year now. In the last year I've been pregnant twice and lost both. I lost the first at 10 weeks and the second at 6 weeks. I am 31 years old and until my first pregnancy a year ago I have always had irregular periods. Since the initial pregnancy and loss my period has been on a 28 day cycle. I started using ovulation test strips to track my ovulation and I track my period every month. This last month for some reason my cycle lasted 35 days (ovulated on day 21 instead of 18). Sadly I thought I was pregnant but I either was and lost it or I wasn't at all. Since I have "only had" 2 M/C's I am told I am not a candidate for infertility. Do I really have to wait for 3 before I can see specialist? If I were interested in clomid can that come from my OBGYN or do I need a specialist to start on that. Am I even a candidate for that at this point. Thank you so much!

Answer: On the basis of the limited history I have to conclude the following:

1. You have been pregnant at least once in the last year. By definition, infertility is defined as "inability to get pregnant over 12 months of engaging in regular unprotected sex." So you do not actually fit the criteria for infertility. Some insurance companies do accept 6 months as the cut-off in women over 35 years of age and certainly, most doctors would encourage earlier investigation in women over 35 years.

2. It appears from your history that one pregnancy loss is clearly documented, and there may be insufficient documentation of the second pregnancy loss. By definition, three consecutive miscarriages are required before attaching the label "recurrent pregnancy loss" (RPL). The current trend in the medical community is to start investigation of recurrent pregnancy loss with two consecutive miscarriages. If there is clear documentation (increased pregnancy hormone levels in blood and pregnancy sac in the uterus seen on ultrasound) of two consecutive miscarriages, most physicians will start investigation for RPL, and some insurance companies may will be willing to cover the associated cost.

3. The need for use of clomid requires further details of your history and can be prescribed by your OB/GYN if indicated based on their detailed knowledge of your health history.

Hope these address your doubts, and I wish you the best.

Question: How many times do you recommend doing an injectable/IUI cycle for unexplained infertility before moving on to IVF if I am 27 years old?

Answer: The general recommendation is three cycles of IUI before beginning IVF. However, based on individual history and circumstances, this number may be more or less.

Question: I'm 32 years old and am about to undergo chemotherapy for breast cancer. I have no children yet, and I'm worried about my ability to conceive after chemo. Do you have any suggestions?

Answer: From birth, the ovary contains all of the eggs that a woman will ever make. In order to ovulate and be fertilized, these eggs undergo a process of maturation. Because chemotherapy targets dividing cells, the medications may attack these dividing eggs cells. Reducing the number of eggs that you have may make it harder for you to become pregnant. It may also cause early menopause. The likelihood that this will happen depends on your age, the type of chemotherapy that you will be receiving, the amount of time you will be treated, and your medical history.

There are ways to preserve your fertility. The most common technique is to freeze tissues to be used when your treatment is over. Tissues that can be frozen include the ovary, eggs removed from the ovary, and embryos that are created with eggs and sperm in the laboratory. The decision to freeze a tissue depends on many things including your disease, the type of treatments that you will have, and the amount of time before treatment begins.

In certain instances, when radiation treatment is being used, you doctor may be able to protect your ovaries by surgically moving them to a different place in your abdomen. This procedure, called ovarian transposition, is done in the operating room using a video camera (laparoscopy). Not every patient getting radiation treatment is a candidate for this procedure.

Question: I am 33 years old, have PCOS, and am having difficulty becoming pregnant. I've recently read about IVM – is this something I should consider?

Answer: IVM, or in-vitro maturation, may very well be a viable option for you, considering both your age and your diagnosis of PCOS – or poycystic ovarian syndrome.

IVM is a process by which immature eggs are harvested from the ovaries and matured in the laboratory. During traditional IVF treatment, medication is used to encourage the production of multiple mature eggs. These eggs are then harvested and fertilized.

With IVM, less medication is used. Immature eggs are retrieved and are then matured in the laboratory before fertilization. This shortens the treatment cycle and decreases the chance of side effects from the medication.

This is definitely something you should speak with your physician about.

Question: What is the most amount of times you've seen someone do IVF and did it eventually work?

Answer: I personally have seen patients conceive on their 6th cycle of IVF. There is certainly the possibility of conceptions occurring further out, although I have never witnessed this personally. The best data available on this topic was recently published in the New England Journal (Jan 15, 2009. Malizia et al.).

Patients with repeat failed cycles do get pregnant with each successive cycle even out to cycle number 6. In this study, the chance of having a live birth per cycle dropped from 24.5% on their first cycle to 13% on their 6th cycle. These rates vary by age as does the chance of success with repeat cycles.

Unfortunately the emotional and financial toll of each cycle makes it challenging for many patients to persevere to 6 cycles (this accounts for the difference in the "optimistic" and "conservative" lines. The conservative estimate assumes that none of the patients who stopped trying would have conceived after additional attempts. Since most of our patients stop because of emotional or financial pressures, we think the optimistic curve is probably closer to reality.

The bottom line: Deciding when to stop is a personal decision and one that is best made in consultation with your physician. At frequent intervals, it is important to assure that the IVF treatment plan is optimized for your best care. If you are able to get eggs at retrieval, there is probably still hope for finding that "good egg."

Question: I have pcos and 2 miscarriages, am ong metformin. Is there anything else I can do to help have a healthy pregnancy and have it go to full term?

Answer: If your periods are not regular on Metformin, adding clomiphene citrate to induce ovulation could help. Even if your periods appear regular, it may be useful to confirm that you do ovulate every month. With two (consecutive) miscarriages, current practice is to start looking into causes for recurrent miscarriage as well.

Question: My husband and I have been trying for 2.5 years. We got pregnant twice on our own within the first year of try but m/c (both about 6.5 weeks). His sperm analysis is normal and my CD 3 labs are normal and HSG is normal. THe only thing they found is that I am comp hetero MTHFR and was put on baby asprin and extra folic acid. We have done clomid/IUIs, injectables/IUI and 2 failed IVFs. We are "unexplained infertility". Im just wondering what the next step would be for IVF #3? IVF#1 we had 14 eggs, 7 fertilized naturally and 3 made it to day 5. we transferred 2 and the other didnt make it to freezing. IVF#2 we had 14 eggs, 7 fertilized naturally but only 2 made it to day 3 (2-8 cell embryos). Would PGD be a good thing for us to look at? Why are they dying off so soon and not freezing? At least I know we can get pregnant as we did before. Thanks so much for your time.

Answer: You have two of the most frustrating and difficult diagnoses: recurrent early pregnancy loss and unexplained infertility. I will try to address both of these conditions, as well as your questions.

"Unexplained Infertility" is defined as a failure to conceive after one year of trying, despite regular cycles with ovulation, a normal semen analysis and no anatomic abnormalities (such as blocked tubes). We know that with Clomid/IUI we can increase the chances of you conceiving and that with injectable gonadotropins with IUI we can improve your chances even more. IVF offers the best per cycle probability of pregnancy. Of course the likelihood of you conceiving depends on a number of factors including your age. All of these treatments have risks and benefits that are specific to your individual case and that you should address with your physician.

In your case, it is promising that you we able to obtain 14 eggs on each stimulation. However, it is important to know how many of those eggs were mature because only mature eggs will fertilize. We usually expect about 70% of mature eggs to fertilize, and if your results have been less than this it would be worth discussing a procedure known as "ICSI" with your physician. In this case, single sperm are injected directly into the oocyte with a goal of improving fertilization rates. This is not always necessary, nor effective, and can increase the cost per cycle. But when less than half of the eggs fertilize, it is definitely worth considering.

The fact that there has been disappointing development of your eggs is unclear. This may be related to your age (which I do not know), the quality of your eggs, or the quality of your husband's sperm. Although he had a normal semen analysis, this test may miss some forms of male factor infertility. Therefore, I would suggest reviewing the fertilization rates of mature sperm and an evaluation of the appearance of the sperm and eggs on the day of fertilization.

In most cases like this Preimplantation Genetic Diagnosis (PGD) would not have been helpful, since in cycle two you put back all the embryos that were available, and in cycle one you only had one extra embryo that was not suitable for freezing. PGD has been disappointing for patients with unexplained infertility as it requires a large number of embryos to begin with at day three. Typically we want embryos that will be biopsied to have at least six cells. PGD is very helpful for women with multiple embryos on day three who are trying to screen for known genetic mutations. Unfortunately, our science has yet to catch up with our desire to help genetically normal couples conceive successfully.

The second diagnosis is "Recurrent Early Pregnancy Loss." This is even more painful and frustrating for our patients. Typically, it is defined by three consecutive pregnancy losses. This is because the rate of miscarriage in a normal patient population is very high. Most patients, even those with multiple miscarriages, will have a normal pregnancy. Abnormalities of the MTHFR gene have not been clearly linked to infertility or pregnancy loss. Given that you have one working MTHFR gene this is very unlikely to be the cause of your losses. Nevertheless, taking extra folate is often a good idea and certainly makes both our physicians and patients feel better.

Regarding aspirin therapy: There are definitely proponents of aspirin treatment, and there are small studies that show aspirin may be beneficial. This data is not conclusive, and many well designed studies have shown no benefit of aspirin. No studies have shown low dose aspirin to be harmful so many people will try it. We do not feel strongly about that as long as our patients are aware of the controversy and the evidence behind it.

In short, I empathize with you and your husband. Unfortunately, I can not make specific recommendations regarding your next IVF cycle without a more comprehensive review of your medical history and prior IVF attempts. However, it seems to me that you are receiving excellent care. Continuing with another cycle of IVF seems like your best chance for pregnancy and you may consider adding ICSI. Although PGD sounds like a new step, I think it is unlikely to increase your chances of having a baby.

Good luck and stay optimistic.

Question: I was trying to get pregnant for about 10 years and had five IVF's with no success. I was diagnosed that my eggs do not mature. I took a break after my last IVF and got pregant one year later on my own. I have a beautiful 2 year old girl. My question is what's my chances of my becoming pregant again, and should I seek medical help after one year of trying again?

Answer: Congratulations on your two year old daughter!! The fact that you were able to get pregnant on your own is proof that your eggs do mature. Unfortunately, without knowing much more information about you (for example- age, medical history) I can not estimate the likelihood that you will get pregnant again. There have been some new techniques and developments in infertility treatment since your last IVF cycle 3-4 years ago. Therefore, I think that it is well worth your while to reestablish care with an infertility specialist.

Question: I know there are a number of drugs being used for infertility. Can you tell me which ones work best?

Answer:

Clomiphene citrate (Clomid R) - this is an oral medication used to stimulate ovulation. It is most commonly used to treat ovulatory failure associated with polycystic ovarian disease, but can be used for other conditions.
Letrozole (Femara R) - this oral medication is used to stimulate ovulation much like clomiphene citrate. Because its mechanisms of action are different than clomiphene, however, it may be successful in inducing ovulation when clomiphene is not.
Metformin (Glucophage R) - an oral medication, this was historically used to treat diabetes because it enhances the effects of insulin. It is commonly used to facilitate ovulation induction for patients with polycystic ovarian disease when one of the features of the condition is resistance to insulin. Normally it is used in association with other drugs to induce ovulation.
Human menopausal gonadotropin or hMG (Repronex, Menopur®) - this is an injected drug often used to induce ovulation in women who are unable to ovulate effectively with oral medications. It is also used to induce superovulation for women undergoing IVF treatments.
Follicle stimulating hormone or FSH (Gonal F, Follistim®, and Bravelle®) - an injected drug, this is often used to induce ovulation for women who are unable to ovulate effectively with oral medications. It is also used to induce superovulation for women undergoing assisted reproductive technology treatments such as IVF.
Gonadotropin-releasing hormone (GnRH) analogue (antagonist or agonist) - these are injected drugs modified from the natural brain hormone that controls ovulation. They are used in various ways to induce or suppress ovulation.
Bromocryptine (Parlodel R) - this oral medication is used to induce ovulation in women who have problems with excess pituitary prolactin, the hormone that normally induces lactation.

Question: My husband and I had no trouble getting pregnant with our now three-year-old. But it's been nearly a year, and no second baby. Should I seek help?

Answer: The fact that you did not have difficulty conceiving your first child is reassuring. However, secondary infertility, defined as couple with a child/children who is unable to conceive after 12 months of trying to get pregnant, is not uncommon. As a general rule we advise couples to seek consultation from their obstetrician/gynecologist or from a reproductive endocrinologist after unsuccessfully attempting to get pregnant for one year. Therefore, I would advise you and your husband to have a consultation appointment. There are several risk factors that this consultation will evaluate, including age-related factors, hormonal changes since your prior delivery, anatomical changes, and sperm count. In approximately 20% of cases, no specific diagnosis can be made, and your specialist will discuss ways to increase the probability of conception.

Question: I had a baby last April 2008. I have not had a period since Aug 2008. I have no libido or sex drive. I have been worked up for hypothyroid and low testosterone by my gyn(normal). How can I restore my menses so I can get pregnant in the future. I am of normal weight 5 ft 117lbs. I eat well and exercise 3-4 times a week. I have developed a new symptom of fatigue and I can express a small amt of breast milk from right breast. I have another follow up with my gyn but something else needs to be done, i.e. referral to specialist. Thank you for any suggestions.

Answer: Not having a period following delivery, also known as secondary amenorrhea, is common but still does require a thorough evaluation. There are several causes which, including hormonal imbalance, anatomic problem, drug induced problem, and psychosocial. Hormonal imbalance may lower your estrogen levels and result in several of the symptoms that you are experiencing including no menses and low libido. This imbalance may be due to an increase in a hormone called prolactin that is made by your pituitary gland. An increase in this hormone may also result in milky discharge from your breasts (galactorrhea). I would also repeat the testing on your thyroid. Anatomic problems may result in postpartum amenorrhea. The most common cause of this is an infection that occurred in the postpartum period which can cause scarring inside the uterus. Drugs can also cause amenorrhea, and this is sometimes prolonged. This can be illustrated by the effects of a contraception called Depo Provera. This shot is often given to postpartum women, particularly if they are not breatfeeding. Although this shot is required every three months for contraception, it may cause prolonged loss of menses and may affect libido.

To determine if there are any medical issues that care causing your amenorrhea, I would recommend a complete physical and evaluation by your ob/gyn. Most ob/gyns are very comfortable with the evaluation of secondary amenorrhea, particularly in the postpartum period. A consultation with a reproductive endocrinologist may be necessary if no obvious cause of your symptoms is discovered.

It is important to note that the postpartum period is very stressful and requires significant life modifications. These stresses can manifest as somatic illness like amenorrhea and may manifest as low libido. Stay tuned, as our reproductive psychologist will address these issues in a future posting.

Question: I have been having a really tough time getting pregnant. Everyone around me seems to be pregnant but me. I feel like I'm the only one who's infertile. How common is it?

Answer: Infertility is very common. According to estimates from the National Center for Health Statistics of the Centers for Disease Control and Prevention, 12 percent of women (7.3 million) ages 15 to 44 years were having difficulty becoming pregnant and carrying a baby to term. In more recent years, there has been a slight decline in infertility because of effective treatments and shifting age demographics. Those statistics, however, will probably increase again for demographic reasons.