Fertility Seminar Questions
The following are some of the questions that we received from the audience at our recent Fertility Seminar. Some of these were addressed at that time, but we could not answer all questions. If there are other general questions that you would like to have addressed, please feel free to comment below, and I will answer them. — Dr. Duffy
1. Can you do an HSG (hysterosalpingogram) when a person has an allergy to IVP dye?
Yes, an HSG can still be done. Though the dye usually used is an iodine based dye, the procedure can also be done by using a type of dye normally used for MRIs that contain Gadolinium instead of Iodine.
2. With IVF with ICSI, do you choose any sperm to inject or do you get the best looking one before injecting into the egg?
During the process of ICSI, the embryologist starts by choosing a sperm that is very motile (moving). Most sperm that are significantly deformed aren’t as active. A needle is then used to cut or break the tail of the sperm so that it can be carefully loaded into the needle. This allows a closer look at the sperm as well once the movement stops. Using these techniques, allows us to achieve a very high fertilization rate.
3. In the state of Florida, does a gestational carrier have any legal rights to keep the baby?
One important aspects of third party reproduction, such as using a donor, surrogate, or gestational carrier is having a valid legal contract in place that has been created by lawyers familiar with the process. This routinely addresses the issue of later legal rights, and is clearly laid out in the contract. However, if this part were to be omitted, the carrier could have some legal bearing.
4. How many appointments can we expect for IVF from start to finish?
Once the initial consultation with the physician is performed, the next step is to schedule an appointment in which a “SonoHSG” is performed. This is a special ultrasound which allows us to clearly see that there are not any abnormalities in the uterine cavity that could interfere with the process. A “trial transfer” is also performed at the same time, which takes a measurement of the uterine depth, and ensures that a catheter can be easily placed in to the uterus. On the same day, you will have a consultation with one of our IVF nurses who will lay out the entire process with you, give you a schedule of all the steps, and order your medications. Once you are ready to start the ovarian stimulation, this usually involves between 4-5 ultrasounds to monitor your progress. After that, there is the day of the retrieval, the day of the embryo transfer (3 or 5 days later), and then the scheduled pregnancy test (usually 14-16 days after the retrieval). So in all, there would be about 10 visits for the average IVF cycle.
5. How long does it take from start to finish for an IVF cycle?
Most patients will initiate the IVF process by starting on a birth control pill. This is used to limit any interference that your natural cycle could have on the IVF cycle. This lasts for 3 weeks, at which time the stimulation phase begins, which lasts about 14 days until egg retrieval. A pregnancy test is performed approximately 2 week after egg retrieval. Thus, from starting the birth control pill to a pregnancy test takes approximately 7 weeks.
6. How do you test for ovulation and ovarian reserve in a women who has no uterus who would like to use a gestational carrier?
A woman without a uterus still has a hormonal cycle, and ovulates, but determining this timing is slightly more complicated due to the lack of menses which tells us where she is in her cycle. But with ultrasound monitoring and blood work looking at several hormones, we can still get the information needed. Determining ovarian reserve does not require the uterus to be present and is usually performed with assessments such as an AMH hormone level, and an Antral Follicle Count (AFC), which is determined by ultrasound.
7. How does PCOS affect fertility?
One of the hallmarks of PCOS is the lack of regular ovulation. This can be resolved through the use of medications (oral pills or injectable hormones). However, even once ovuation is established, patients with PCOS still have slightly lower conception rates and slightly higher miscarriage rates than those women without PCOS. The exact cause of this has not been clearly established, though excess androgens or the insulin resistance may play a role. The use of metformin in women who are trying to conceive has been associated with some improvement in pregnancy rates, and decrease in miscarriage rates, though this still does not result in full normalization of pregnancy rates.
8. What monitoring should I have when on a clomid/femara- IUI cycle?
There are several options for monitoring in this situation. Many times, patients may not be regularly ovualating, and in those cases, using an ultrasound to monitor for follicle development is usually the best choice. If a woman has been confirmed to ovulate, and can reliably detect her LH surge with an ovulation predictor kit, then that can be used to time the insemination. However, ovulation predictor kits can be frustrating to use for many women. If they work, then they can be successfully used, however, about 25% or more of women who are known to be ovulating won’t be able to detect the LH surge.
9. How many eggs/follicles do you like to see with a patient on clomid or femara?
The goal of oral ovulation therapy is obviously to induce ovulation. The number of mature follicles seen may vary among patients but usually is 1-2 for most patients. Studies have looked at pregnancy rates in comparison to the number of follicles developed, and with oral medications, it has been found to not be affected by whether there is 1, 2, or 3 follicles developed.
10. How many IUI cycles should you have before considering IVF?
We always try to use our experience and knowledge to help a patient conceive with the easiest, least invasive, and most economical method possible. Doing IUIs (intrauterine inseminations) is recommended for many different reasons as a first line therapy prior to going to IVF. It is difficult to judge exactly when a patient should go to IVF, but we have to take many factors into consideration, such as patient age, prior history, and infertility issues. In most cases, it is felt that most women who will conceive with a given therapy will likely do so in the first 3-4 months. Once a person approaches this time frame, it is logical to start making future plans and weigh options such as continuing with the current therapy vs progressing to IVF. For women who are older, we often encourage this transition earlier, as pregnancy rates continue to decline with age. Younger women have more flexibility in this aspect. There are many more factors to take into consideration, but in general, we will start to bring up the subject on the 2nd or 3rd cycle in order to have a future plan laid out that would best achieve the goal of having a baby.
11. How often can an HSG be performed, and is it recommended to keep the tubes open for conception?
We don’t recommend repeating an HSG unless something has changed recently, such as a pelvic infection, ectopic pregnancy, or other situations which could have caused scar tissue damage to the tubes. Pregnancy rates have been suggested to be slightly higher following an HSG, but there is not any role for repeating the test.
12. How important is sperm morphology in the setting of a good sperm count?
Criteria for what constitutes a “normal” sperm morphology percentage has changed in recent years, with criteria becoming more strict. Isolated cases of low morphology, with otherwise good counts are less troubling than having multiple abnormalities. Trying inseminations is a first line therapy, which may help in these cases, as a lot of the abnormal sperm are washed out in the preparation process, thus likely increasing the percentage of good sperm. With a good overall sperm number, even if the percentage of normal sperm is low, you will ultimately have a reasonable number of good sperm. To summarize, a small percentage of a big number is still a pretty big number. But if overall sperm numbers are low, and morphology is low, then conception rates may not be as good. But the primary numbers that we look at to judge conception chances for inseminations are still the total motile sperm count, which is calculated from the volume, total count, and percent moving. This has always had the highest predictive ability for predicting the chance of conceiving with inseminations.
13. Are egg donors from the same city?
Because of the close monitoring needed for egg donors, nearly all of our anonymous donors come from the greater Jacksonville area. We choose to limit the number of times that one person can donate to a total of four. There are no specific scientific reasons on limits in this area, but we feel that it is a reasonable limit. Many donors are split between two recipients. It is hard to estimate the number of children from each donor, but that number is likely to be a maximum of 6-8 from one donor who has donated the maximum number of foiur times.
14. How is the use of Testosterone (Testim, Androgel, etc) affecting sperm production?
I was asked this question by several people after the seminar in response to my comments during my male fertility lecture. The number of men that are treated with testosterone replacement continues to rise. The physician prescribing this may be a primary care physician or a urologist. Often they do not ask, or do not know to ask on plans for conception. The use of testosterone in any form (patch, gel, or injection) is associated with a rapid shut down of sperm production. This fact may not be known by all primary care physicians, but is known by all urologists. In most cases, this is reversible, but it can be expected to take 4-6 months to fully recover sperm counts. Men who are being treated with testosterone and wish to conceive should be evaluated by a reproductive physician. There are measures that can be taken to help get sperm production started back, but an endocrine evaluation is often necessary to look into reasons as to what may be affecting the normal testosterone production (the reason the medication was started in the first place).
15. Do you recommend an endometrial biopsy before an IVF cycle to theoretically increase the chance of successful implantation of an embryo?
This is a new area of interest in which I have participated in the past. It has been found by small studies that disrupting the endometrium before or during an IVF cycle may help to improve implantation rates. This injury stimulates the production of many chemicals and repairing mechanisms in the endometrium. There are several ways to cause an injury, but most usually would be by endometrial biopsy. I offer this procedure to my patients who have had otherwise unexplained implantation failures. However, because this procedure is painful, and not tolerated well by many patients, I do not think that it is justified in every IVF cycle. Hopefully future studies will help us determine the best way in which to do this procedure and what patients would benefit the most from it.