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www.fertilityneighborhood.com
March 22, 2005
Moderator
We are ready to begin our chat! Let’s welcome our guest host, Dr. Nancy Klein from Seattle Reproductive Medicine in Seattle, WA.
sapphires
I went to an Ob gyn about 2 years ago, and he put me on Prometrium for a luteal phase defect that I had. He then wanted to try Clomid, but nothing helped. What can I do short of losing weight, which is hard, to help my luteal phase defect straighten out?
NancyKleinMD
If you are having periods fairly regularly, with or without the clomid, then something other than the luteal phase defect may be going on. You should have a complete evaluation including semen analysis and x-ray test to look at your tubes.
imagine
Do you have any recommendations that you provide your own patients for limiting stress? Is there any point in the cycle that is more important to limit than another?
NancyKleinMD
This is always one of the hardest things to control. I have found that many of my patients respond very well to acupuncture as a stress-reliever, and I suspect this may be related to the reports of increased pregnancy rates when acupuncture is used with some fertility treatments. Eliminating any unnecessary stressors is the first step--no houseguests, don't volunteer for extra social and/or work activities...if it isn't necessary, try to say "no" and take time for yourself.
felixx19
Hi, I am 28 years old and thought my fertility problem was because both my tubes were blocked. I had a tubal legation, recommended by Dr.. I did my day 3 labs and the results show my fsh level at 17.8 this is high. I guess my question is how can I lower this? Lh-4.15 E2-41.7
NancyKleinMD
Unfortunately, there is no way to lower FSH. The FSH itself is not bad; the problem is that it is a sign of ovaries that are not responding well usually due to a low egg number related to age, prior infection, or simply genetics.
sapphires
I wanted to know if Lupron should cause muscle pains, I’ve been getting pain in both legs.
NancyKleinMD
Occasionally patients do complain of muscle and joint pain with lupron, especially if you are not also taking estrogen or ovarian stimulation. It is temporary, and does not indicate any serious or lasting problems.
egirl13
Any suggestions for a 45 yr old woman having trouble finding an RE to treat her?
NancyKleinMD
Most RE's do not have age limits for evaluation of infertility, but treatment options are poor for patients over 43 or so unless donor eggs are used. Whether or not clinics have age limits, most (if not all) RE's would generally not recommend extensive infertility treatment at that age due to very low success rates (< 5% per cycle).
felixx19
With such a high level do I have a chance?
NancyKleinMD
If you are ovulating, then yes, you have a chance. The more important factor is your age. Patients who are young (i.e., < 38) with FSH elevation have much better pregnancy rates than do older patients.
imagine
Is endometriosis a significant reason for failed IVF cycles or do you believe that failure is related more so to abnormal embryos?
NancyKleinMD
Most studies indicate that pregnancy rates are no different in patients with endometriosis except when the endometriosis has damaged the ovaries, reducing the ovarian reserve.
If you have had prior ovarian cysts removed, there is a high likelihood that some of the normal ovarian tissue was lost as well. As long as the response to medications is adequate, pregnancy rates are still very good.
kmgomez
Hello,I'm 30 and currently undergoing IVF and I'm on CD 8 taking Gonal F 450 and Repronex 2 units. On CD 4 I had 3 follies and on CD 6 I had 5 total, today I had another ultrasound and the dr. saw 6 total follies - is there still time for these 3 new ones to mature and can I possible still produce more? Tomorrow I will be adding Antagon. Thanks.
NancyKleinMD
At this point in the cycle, it is unlikely that you would recruit new ones. However, the doctor may only be "counting" follicles once they reach a certain size. Usually, even small follicles will continue to grow as long as the stimulation continues.
bianca2002
Can you please tell me if it's normal for embryos frozen on day three to lose cells during the thaw? If so, how many cells can they typically lose? Also, does a four cell embryo (after thaw) have a chance in a frozen embryo transfer?
NancyKleinMD
Yes, it is. Hopefully, the embryo does not lose cells. However, I have seen pregnancies when only one or two cells survive--at that stage, the cells are "totipotent", so there is hope. Yes, a four cell embryo (frozen on day 2 or 3 after retrieval) has a chance!
sapphires
What are the benefits and differences between someone taking Clomid Cycle Days 3-7 and cycle days 5-9? What days does someone normally ovulate on clomid 3-7? Thanks!
NancyKleinMD
No one has actually done a comparison that I know of, but the theory behind starting sooner is to try to increase FSH before you have recruited a dominant follicle. In theory, if you can stimulate when the follicles are at a more equal stage, you have a better chance of recruiting more than one. If you don't ovulate on your own or have very long (35+) day cycles, then you can probably start the clomid as late as day 7 or later.
imagine
If someone was diagnosed with graves disease and had radiation done on their thyroid to kill it, would they still be able to have children?
NancyKleinMD
Yes. Typically that kind of radiation does not in any way affect the reproductive system, as long as your thyroid hormone is adequately replaced.
karenkhan
If your tubes are block due you recommend surgery to correct or do IVF?
NancyKleinMD
IVF.
imagine
What makes someone a bad candidate for IVF?
NancyKleinMD
Age > 41, FSH > 15, previous multiple failed attempts, some uterine problems (such as scarring of the uterine lining)
sapphires
I am 33 yrs. old and I have been trying to conceive for 2 years. In January, I had surgery to remove both fallopian tubes. I had hydrosalyphinx in both. In March I was able to begin my first IVF cycle. When I went for my ultrasound, I was told to stop the Lupron. My doctor found endometriosis on both my right and left ovary. I had surgery to remove them in June and again I recently started Lupron again. I am concerned because I felt some sharp pain a few days ago on my right side. Is it possible for Lupron or prenatal vitamins to cause endometriosis to form? I thought Lupron is supposed to suppress cysts from occurring?
NancyKleinMD
Lupron usually will cause a transient stimulation of the ovaries due to a surge of FSH and LH, after which the FSH and LH fall and the estrogen falls as well. Occasionally, even this brief surge will cause pain, especially if you have endometriosis. Sometimes, with or without endometriosis, a follicle will stimulate (or more than one) in response to the lupron and will then persist as a cyst. For that reason, your doctor will do a baseline ultrasound before stimulation. If you have a cyst, it will usually regress on its own with just a few extra days of lupron.
fasn8tj
is a fertility monitor a waste of money for someone with pos
NancyKleinMD
Do you mean PCOS?
fasn8tj
yes
NancyKleinMD
Assuming that you are being treated for ovulation induction, then the fertility monitor can be very helpful because it is very hard to know when ovulation will occur. Just using the few day supply of test strips in most LH kits can be frustrating, because you may run out before ovulation occurs.
kmgomez
Are 6 follicles usually enough to go through with an IVF cycle?
NancyKleinMD
Yes. I would consider 4 to be a minimum to have a reasonable chance, and with 6, the chance of getting at least 2 or 3 embryos is good.
imagine
How many IVF attempts should one try before giving up?
NancyKleinMD
It depends (of course). Certainly after 3 attempts, it is time to sit down with your doctor and go over what went well, went wrong, and what could be improved. If there are persistent problems with poor response or poor embryo quality, additional cycles are less likely to result in pregnancy.
bianca2002
I have a question about implantation. How many days after transfer (3 day FET) does the embryo begin to implant? Also, what are your thoughts on early pregnancy symptoms? Is a general crampy feeling an indicator of pregnancy?
NancyKleinMD
We think that implantation occurs 6-7 days after egg retrieval. Crampiness is VERY common in IVF cycles and is usually related to the continued large size of the ovaries and/or increased blood flow to the uterus.
sapphires
What is best frozen or fresh cycle? My sister and her husband are both 31, no problems except slight endometriosis. She got pregnant on a fresh and miscarried. Since then has failed one fresh and two frozen. are her chances better for another fresh other than a frozen? Also, I've heard that most people get pregnant within 3 IVF's, is this true?
NancyKleinMD
Usually when we talk about number of IVF cycles to conception, we are referring to the fresh. Pregnancy rates are lower in frozen than fresh cycles (usually), particularly if all or most embryos are frozen, regardless of quality.
imagine
When should my progesterone levels be checked to see if I am ovulating?
NancyKleinMD
The best time is about a week after the LH surge, although any time from 3 to 12 days after ovulation, you would expect to see some elevation of progesterone.
imagine
Is it true that overweight women have a harder time conceiving?
NancyKleinMD
Women who are overweight are more likely to have ovulation disorders. Otherwise, unless there are issues with being able to have normal intercourse, fertility is normal.
sapphires
I am 29 and my doctor says I have small ovaries for my age. My day 3 fsh test showed 3.5 fsh and 95 estroidal. Is this an indicator of ovarian reserve issue? I also had a cyst noted on 7/21 that is still not gone as of yesterday. Can a cyst produce estrogen?
NancyKleinMD
Yes, most cysts are derived from follicles (the structures that contain the egg) and can produce estrogen. At your age, a high estradiol on day 3 can be due to decreased ovarian reserve or (more likely) due to a persistent cyst from the prior cycle. Short cycles and early ovulation are more concerning in the face of a high day 3 estradiol. You should repeat in another cycle.
bianca2002
However, if I had a FET and used DE embryos then my ovaries wouldn't be as large. I realize that increased blood flow may cause crampiness, however, do you believe it is an indicator of early pregnancy? Are there any other symptoms that could begin a few days after transfer in your opinion?
NancyKleinMD
I'm afraid that I have heard all of the symptoms (and lack of symptoms) in patients who do and don't become pregnant. Problem is that you really can't tell. The waiting can be the hardest part.
sapphires
What is IVIG? And why use it? What are side effects?
NancyKleinMD
Intravenous immunoglobulin has been proposed as a treatment for some patients with recurrent miscarriage. However, the ASRM and most reproductive endocrinologists are of the opinion that there is no role for IVIG in fertility treatment.
imagine
Would an FSH result determine what kind of protocol you would use? Could an FSH result change dramatically in a year?
NancyKleinMD
Absolutely. The FSH does fluctuate, even cycle to cycle. I have seen patients have FSH levels go from normal to "perimenopausal" and back. Problem is that, once the FSH is elevated, it is a sign that the ovary is beginning to decompensate or have trouble responding to normal stimulation. The antral follicle count, determined by ultrasound, is probably a better way to predict response to stimulation, especially in the context of variable FSH results.
bianca2002
What does it mean when an embryo is granular? Is this a bad thing? Also, if an embryo is asymmetrical is that a bad thing?
NancyKleinMD
Oocyte granularity and symmetry seem to have little to do (in our experience) with embryo quality or implantation rates. We always note it, don't like it, and worry about it, but I have seen lots of normal children from "grainy" eggs!
kmgomez
Does ICSI increase chances of fertilization, and can it also harm the embryos in any way?
NancyKleinMD
Embryos fertilized with ICSI have the same quality, implantation rates, and ongoing pregnancy rates as those fertilized by standard insemination. Occasionally, fragile oocytes may not survive the ICSI procedure. Fortunately, this is uncommon and is likely due to poor egg quality.
sapphires
I have PCOS... what do you recommend for PCOS patients to detect ovulation...OPKs or BBTs (temp taking)?
NancyKleinMD
BBT is free and gives you a good record over time. For prospective prediction of ovulation, the OPKs are better.
fasn8tj
I have heard that being tired can cause you not to conceive is that true
NancyKleinMD
Only if it means that you are unable to have intercourse at the appropriate times or, possibly, if your stress level is too high.
imagine
What about alcohol? How does that impact egg development and/or quality?
NancyKleinMD
We assume that any potential toxins, including alcohol, can be detrimental in excess. However, there is no evidence that alcohol in moderation has a negative impact on fertility.
imagine
I've seen on bulletin boards women having FET's. What is that?
NancyKleinMD
Frozen Embryo Transfer
bianca2002
Have you heard of prescribing patients with one dose super fact the day following a 3 day FET transfer to increase implantation? If so, what are your thoughts on it? Thank you!!
NancyKleinMD
I think it is too new to know. We do not use it and I'm not aware of any convincing studies.
imagine
Are generic pre-natal vitamins just as good as the prescription?
NancyKleinMD
Usually, as long as they contain at least 800 mcg of folate. Many prescription vitamins include a stool softener, which is helpful.
sapphires
I have unexplained infertility. I do not get my periods on my own and after 2nd m/c, I took some time off from treatments. I took the pill last month so I would have a regular cycle. At the end of my pill pack, I had a yeast infection, and then on Friday, I had my gall bladder out. I spotted but never had an actual cycle. Would you recommend using progesterone to start a cycle or wait and see what happens?
NancyKleinMD
If you don't get your periods on your own, your infertility is not unexplained (unless you have had numerous treatment failures with otherwise normal results). I would wait until you have recovered from your surgery, then take progesterone if no period in 3-4 weeks.
sapphires
Can a thyroid problem hurt fertility?
NancyKleinMD
Yes, if it is uncorrected. However, usually it takes a significant abnormality in the thyroid levels to affect fertility, and it does so by disrupting ovulation.
imagine
can you take allergy over the counter medicine after a transfer? What about exercise? (just riding the exercise bicycle or even taking a walk)
NancyKleinMD
We recommend avoiding any medications that aren't necessary, although probably benadryl is fine (just makes you sleepy). Walking and low impact exercise are great, although I recommend waiting 2-3 days for peace of mind.
imagine
Have you heard any feedback from your patients about the Follistim Pen? Is it easy to use?
NancyKleinMD
Yes, it is really easy. The only down-side in my mind with all of the "pens" is the fact that you may need to take 2-3 injections to use all the medication in the cartridge and get your full dose, especially if you are taking a combination of hormones.
sapphires
Will leftover follicles effect the growth of the next cycle's follicles and the estrodiol levels?
NancyKleinMD
They can. That is why we will recommend "sitting out" a cycle if there are significant or estrogen-producing follicles present at the beginning of a stimulation cycle.
sapphires
I would like your opinion on my next step. For IVF#1 i had 6 follicles (28 days of .1 cc lupron and 11 days of 225 IU puregon, e2 was 5000). All eggs fractured at egg retrieval. For IVF#2 I had 12 follicles, 6 eggs retrieved and 5 fractured at egg retrieval. (28 days of lupron, 10 days of gonal F 300 IU per day). I did make it to an ET at day 3 with a BFN. My doctor wants to do an IUI so he doesn't have to disrupt the eggs too much. He is also referring me to another doctor to discuss my situation. I have yet a 3rd doctor wanting to do IVF#3 because he hasn't ever seen eggs fracture during retrieval. Do you have any recommendations for a case like mine?
NancyKleinMD
Sounds like a very unusual case. We occasionally see fractured eggs, even several in a case, but it tends to be sporadic and not recur in future cycles. Did you have ICSI? I question if the eggs were "post mature" if you had an estradiol of 5000 with only 6 eggs...sounds like the second opinion is a good idea to get as much information as possible.
imagine
What is a laparoscopy?
NancyKleinMD
A surgical procedure where an incision is made at the belly button to insert a scope to view the internal pelvic organs (uterus, ovaries, and tubes).
sapphires
On average, how many women who are pregnant and have numbers like 77 hcg, 40 estrogen and 12 progesterone for their first blood draw go on to have successful live births?
NancyKleinMD
If the hCG is about the time of the expected period, 77 is in the low-normal range. I don't really have an exact percentage. The estrogen strikes me as a bit low and the progesterone low-normal, but I would monitor and keep fingers crossed.
Jumis
Hello. Sorry for joining late. I am 44 years old and had a frozen transfer Friday using donor eggs. They were 5-day blasts from a failed fresh cycle in January. How long can implantation take and are there any early signs that can give me hope before my beta test on the 30th? Thank you.
NancyKleinMD
Sorry, but I haven't figured out how to detect pregnancy or implantation based on symptoms yet! Day 5 blasts from donor cycles do have excellent implantation rates, so I would certainly be hopeful.
imagine
Is there a minimum dose of Follistim that you like to start your patients off with? How do you determine the dose when just starting a patient on injections?
NancyKleinMD
It is very individualized and depends on treatment type (IUI vs. IVF), antral follicle count, day 3 FSH, and prior response to stimulation. Most patients require 225 IU if they are on lupron as a minimum and 150 if not.
imagine
How does one know if she has pcos
NancyKleinMD
Hard question. True PCOS means that a patient never or rarely ovulates on her own and has excess androgen (male hormone) production, usually manifested by facial hair or acne.
sapphires
I'm 26 and husband is 30. We have unexplained infertility. We just had our 1st IVF. We did day a 5 transfer. We transferred 2 quality A and 1 quality B egg. I've been pregnant before on my own three times, but end up with a miscarriage. I've had one ectopic, one spontaneous abortion, and one partial molar pregnancy. When we had our transfer we also did ICSI. What do you think my chances of success are on the 1st try? I've been feeling really bloated, kind of gassy, and belching. Could these be pregnancy symptoms or is it the medicine? I'm only taking progesterone shots. What are some pregnancy symptoms? I know they are all different. I have my pregnancy test on Thursday.
NancyKleinMD
I think your chances are excellent based on age, prior pregnancy, tubal factor (since you've had an ectopic), and the fact that you had excellent day 5 embryos. It can be encouraging when you are having continued (or increasing) bloating symptoms this close to the test...
imagine
What is zift?
NancyKleinMD
Transferring fertilized eggs to the fallopian tube, rarely done or indicated.
sapphires
A friend of mine (she is here with me) is a recovering anorexic and an over-exerciser, (she has been at a healthy weight for some time) She & her husband have been trying to get pregnant for a year. She has been doing cycles of Repronex. Her problem is with ovulation. She doesn't have periods. Her last cycle was unsuccessful, yet her progesterone levels were good. My question is how many cycles does it take to get pregnant? What are the percentage rates with each cycle?
NancyKleinMD
In this setting, usually about 20% per month (assuming she is in mid-thirties or younger). It is difficult, since the cycles are costly in time and money and require uncomfortable injections, etc. After 3 or so cycles, IVF might be a good idea to increase the pregnancy rate and allow the possibility of freezing some embryos for later.
imagine
I use equal in everything - I've been on the South beach diet on and off. Could that not be helping things?
NancyKleinMD
I doubt that is a contributing factor.
fasn8tj
is there a way to help my body get to the right temp
NancyKleinMD
There is not necessarily a right temperature. The key is to be sure that you are ovulating--if you don't get a normal temperature rise, then you would need to be evaluated hormonally to confirm that you are ovulating.
imagine
What is decreased ovarian reserve?
NancyKleinMD
Low egg supply and resistance to the drugs that stimulate the ovaries to produce multiple eggs.
Moderator
We are very pleased to provide information in this forum. The information provided is for general educational purposes only and is intended to help users learn about health and diagnosed diseases. Information provided is based on customary practices and products in the United States that may or may not be approved, available, or authorized by laws or regulations in other countries. As always be sure to discuss matters with your doctor prior to making any important decisions regarding therapy choices. Your doctor knows you best.
Moderator
Thank you all for your questions. Unfortunately we are out for time for this chat. We would like to say a very big THANK YOU to our host, Dr. Nancy Klein, for sharing time and knowledge with us this evening.
To view this transcript on fertilityneighborhood.com click here.
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