Can Scar Tissue Affect Fertility?

Question:
I have never been pregnant or on birth control pills or had surgery but I have scar tissue so bad they can't see my reproductive system. Will I ever be able to conceive? Is this fixable?

Answer:
Hello Sarah from Canada,
　
I am not sure how your diagnosis was made without having had surgery. Scar tissue is usually only diagnosed by a surgery called a laparoscopy.

But, assuming you have scar tissue, and it is bad, this could be caused from a previous pelvic infection, called PID, due to bacteria that ascends through the vagina, cervix and uterus, or it could be caused from a disease called endometriosis that causes severe inflammation of the pelvis. In either case, severe scar tissue is caused in the pelvis and obstructs the egg's ability to reach the Fallopian tube.

In some cases of pelvic scar tissue (adhesions), surgery can be performed to try to reduce the scar tissue, but this doesn't always work because scar tissue can form as a result of the surgery as well. The best option would be to do IVF (In Vitro Fertilization) whereby the eggs are removed directly from the ovaries and the pelvis is bypassed completely. The chances of pregnancy are age dependent but are very good and can be as high as 63% per attempt.

You don't need to worry about never getting pregnant. The technology has advanced quite a bit and we can get almost anyone pregnant. The only consideration is what has to be done to get you pregnant, and what you are willing to do to get pregnant.

Sincerely,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check me out on Facebook and Twitter with me at @montereybayivf

Oral vs. Injectable Fertility Drugs

Question:

What's the difference between oral and injectable fertility drugs?

Answer:

They are completely different classes of drugs. The oral fertility drugs are called Clomid and Femara. Both of these are Estrogen receptor blockers. The brain modulates ovarian function by checking the estrogen levels. By blocking the estrogen receptors, the brain is fooled into thinking that there is inadequate estrogen production, so it increases the amount of FSH and LH hormone to stimulate the ovary. In this way, the ovary is stimulated to ovulation, in non-ovulatory patients, or to incerase the number of eggs ovulated, in ovulatory patients.

The injectable fertility drugs are FSH and LH. Previously, these were purified, human hormones, but now they have been able to be synthesized. They are the same hormones that the brain sends to stimulate the ovary, so they stimulate the ovary directly, instead of indirectly like the oral drugs. They are stronger and work better because of the direct stimulation. That is why we use these preferentially with IVF. They are more expensive.

I hope this answers your question!

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

for additional information check me out on Facebook and Twitter with me at @montereybayivf

Elective Single Embryo Transfer - Notes from this year's ASRM meeting

At the annual American Society for Reproductive Medicine meeting one of the many courses I attended was one entitled "Elective Single Embryo Transfer". Perhaps no issue in assisted reproductive technologies (ART) is as controversial as the selection of the optimal number of embryos for transfer. Single Embryo Transfer or SET is a method being heavily promoted by the fertility specialists to reduce the incidence of a multiple getstation. Of course, the recent New York Times article about twins that were born with severe deficits was a source for discussion ("The Trouble With Twin Births" Oct. 11, 2009 Opinion").

Indeed, in current years the number of triplets resulting from ART has diminished; but the number of twins has not declined. The most recent guideline published by SART indicates that the number of embryos to transfer in women age 35 and under is 1 - 2 embryos for "favorable prognosis patients and 2 for all others".

The panel consisted of two Physicians and a PhD Embryologist. Both Physicians came from states where IVF is a mandated benefit, so their patients don't pay out of pocket. They presented their data and arguments for proposals to enact a SET policy on good prognosis patients under 38 years old. They condemned all multiple gestations, including twins, because of the increased costs of the medical care.

The main data they showed to support their argument was that cumulative pregnancy rates (PR) (fresh transfer plus frozen attempts) were the same as PR from transferrring 2 embryos (DET) in one cycle. Transferring SET had a lower PR than transferring DET in a single cycle if you did not add the frozens. Because IVF was mandated, the extra cycles were at no extra cost. The other point that they made was that if the patient failed in the 1st cycle, they transferred 2 (DET) embryos in the subsequent cycle. So in essence, in order to achieve the same PR as the DET in 1 cycle, they had to transfer 3 embryos over two or more cycles.

Their final point was that as reproductive specialists and physicians, we are bound to an ethic of "do no harm" and having a multiple gestation is "harm" as explained in the NY Times article. They professed that we should choose for our patients to transfer only one embryo and not let the emotions and "desperation" of patients to choose more than one embryo for a higher PR.

Personally, I too strive for a singleton pregnancy for all my patients. That is the ultimate goal. I am in favor of SET if the PR per cycle is equivalent to DET. We, ASRM, SART and reproductive specialists, are trying to move toward SET as the gold standard. But, we are not there yet! And, when patients have to pay for their cycles, as they do in California, I believe that we also have an obligation to them, as the consumer, to give patients the highest chances of success for the least cost. A "cumulative PR", especially when more than one embryos is transferred in subsequent cycles, with a higher twin PR, is NOT equivalent. This is a fudge of statistic and not truthful counseling.

Also, one has to remember that the NY Times article is an anecdote about a specific couple and should not be interpreted as the "majority" or "usual" outcome of patients or twins. It is absolutely not. With the advances in Obstetrics and Perinatology, most twins deliver at term and do fine, and have no deficits. We should therefore not fear twin gestations. A NY Times article such as the one recently published, is biased and sensationalized, and not based on scientific evidence. Triplets or more is a different story, however, and should strongly be avoided.

In addition, we Do Not have the knowledge or ability to choose the ideal embryo at this time. It is still a best guess. We choose based on external characteristics "best looking" but that doesn't guarentee a perfect internal structure. Many of us have had terrible looking embryos turn into pregnancies and beautiful children. So in fact, although we think we know best for the patient, we may not be doing the best for patients if we limit their choices.

So, I think that DET may still be the best for the patient at this time, in order to give patients the highest chances for success per cycle with a small twin risk and even smaller twin deficit risk. I don't think that patients should be forced into SET but should be honestly and comprehensively counseled regarding the potential risks of twins (as it is, most of our patients are already taking an increased risk of genetically abnormal babies due to age in attempting pregnancy). They the patients should be allowed to choose without interference from the Physician or the Government. After all, they are paying for it. In states or countries where their insurance or government is the payor, then it can be mandated by regulation, and the insurance or government has the right to decide instead of the patient.

When the technology reaches the point where we can accurately distinguish between good and bad embryos with certainty, and SET offers the best PR for the patient, meeting our obligation to the patient, then it will be time to only transfer one embryo per cycle. Until then, we can keep this as our goal and do the best that we can with the information that we have to work with currently, and strive to reduce the higher order multiple PR (triplet or more). We should strive for singletons but allow twins. We cannot forget that success is what serves our patients best.

Edward J. Ramirez, M.D., FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF Program

Monterey, California, U.S.A.

for additional information check me out on Facebook and Twitter with me at @montereybayivf

Increasing Sperm Count

In my capacity as volunteer infertility expert on About.com's All Expert site, I get questions from all over the world. Here is one from Egypt that many of you might relate to, regarding male infertility as a factor in reproductive failure.

Question:

Hi sir,

I am 28 years old man from Egypt. I got married from 7 months ago. My wife still not pregnant. So recently I did a semen analysis and I got the following result:

Sperm count is 18.4 million (regular is 20 million)
Abnormal morphology is 79% while regular is less than 70%
But sperm motility and volume is ok

My question is:
What is your suggestion or prescription to increase the number of sperms and to enhance the shape of it?

Thank you!

Answer:
Hello,

Unfortunately there are not a lot of options for the treatment of sperm defects, but here are a couple of suggestions. Sperm morphology is determined by the actual production of the sperm at the testicular level. Very little is known as to what controls that production, and therefore, what could be causing your sperm to be formed abnormally. It could be genetic predisposition or an environmental toxin such as pesticides, radiation exposure, medication or the like. Your count is probably adequate because it is borderline normal, but fertilization won't occur if most of the sperm are abnormal.
The ideal treatment would be to do IVF (in vitro fertilization) with ICSI (intracytoplasmic sperm injection) because a minimum amount of normal sperm will be required in that case. But if you want to continue to try naturally, here are two options:

1. Proxeed, Fertility Blend or Fertilaidmen which can be ordered via the internet (one such site is: http://www.fertilaid.com/male-fertility.asp ). These are vitamin supplements with ingredients that are supposed to enhance sperm production and motility, and possibly morphology. You will need to use it everyday, as recommended, for at least three months to see an effect since sperm production is in 90 day cycles (that is the sperm forming today won't come out for 90 days).
2. Clomiphene citrate, a fertility medication used mostly in women, can also be used in men. In general it is used to increase sperm count, which in your case, may get you to produce enough normal sperm to lead to pregnancy. You would need to take 1 tablet (50 mg) per day. Again, you will have to use it for a minimum of 90 days before you can see an effect.

Because of your sperm problems, you might want to consider insemination (IUI) as a treatment as well, again, to get the maximum number of normal sperm inot the tube for fertilization.

Good luck,


Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
Monterey, California, U.S.A.

for additional information check me out on Facebook and Twitter with me at @montereybayivf

44 Year Old with High FSH "Can I Get Pregnant?"

Question:
Hi,
　
I just turned 44 (today!). My periods were pretty regular up until 16 months ago when they suddenly stopped. I've had one period in 16 months, and have had my FSH levels tested twice in the past twelve months. The first time they tested, it was 112. The second time, it had dropped to 86. Estrogen levels were "normal," but they didn't give me a figure. Both doctors who have tested me said that I'm in full menopause, though I've had no other symptoms other than the missed periods.
　
I've recently started seriously dating someone. He's been tested for all STDs (and is fine, as am I), and we had unprotected sex yesterday. And suddenly, this morning, my period seems to have started!
　
I assumed because of the FSH levels and the missed periods that I cannot get pregnant, but was hoping to confirm this--is it possible to get pregnant given the FSH levels and missed periods?
　
Thanks in advance for any help you can provide!

~beth (in Baltimore)
　
Answer:
Hello Beth from the U.S.,
　
Happy Birthday! Based on the FSH levels, you are in menopause, and by the way, congratulations on the new relationship. I can't explain the bleeding but that is definitely abnormal. I doubt that it is due to pregnancy, but cannot be sure without any further testing. I recommend that you get checked. In addition, considering how young you are to be in menopause, you might want to consider starting on some form of hormone replacement therapy. The lack of estrogen production will be detrimental to your body in many ways, including vaginal lubrication. Despite all the negative press releases about hormone replacement, recent studies are showing benefit if the woman starts at the time or near the time of menopause. That is why I recommend it. I use a low-dose birth control pill in my young woman because the menopausal formulations are not made for the estrogen requirements of the younger woman's higher metabolism. That should take care of any more abnormal bleeding episodes and make your cycles regular again. More than likely, the bleeding was a last hurrah from your uterus. We call it dysfunctional bleeding, but it still needs an evaluation.

Good Luck,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf

Tips On How To Boost Your Fertility & National Infertility Awareness Month

The month of October is National Infertility Awareness Month. Understandably, we appreciate the opportunity to educate the public regarding issues and current advances in this field. The American Society for Reproductive Medicine's annual meeting will be held in Atlanta October 18 - 21st. You can follow along on Twitter to see some of the issues that will be discussed by entering #ASRM09 on those days!

I would like to share some tips on how to improve your fertility. This issue affects some 7.3 million women and men in the United States, representing 15% of couples in their prime reproductive years.

AGE
I want to start with age, because it is one of the biggies. Women are born with 1-2 million eggs and by the age of 37 they have 25,000 left. How well you reproduce depends on an number of factors but one of the most important is the age factor. The quality of those eggs begins to deteriorate after 30, and more significantly after 35, due to poor egg quality. There is no way to change egg quality. Consider trying to start your family earlier rather than later. If that is not possible, staying on birth control pills might extend the viability of the eggs in a woman's ovaries by putting the ovaries at rest. Seek out help for infertility issues early instead of putting it off. If you are over 35 years old, make a well defined, aggressive treatment plan with a set time-line. Don't let your doctor reassure you that "everything is just fine and you just need to wait for it to happen." Basically I counsel my patients over 35, if no pregnancy after 6 months, see a fertility specialist for a complete and thorough evaluation (which should only take 1-2 months to complete), create a treatment plan in a set amount of time and move through that plan sequentially. For example, if you start with ovulation induction and intercourse, use that for 4-6 months, then move to IUI for 4 attempts only, then move to IVF. As time passes, your chances are only getting less, even with IVF.

HEALTH
The key ingredient here is good health and exercise in the years before trying to conceive. Exercising for at least 5 hours each week is recommended. Good habits start early, but it's never too late to start! Weight can also affect your ability to get pregnant, in some cases, and being too much above or below your ideal BMI (body mass index) can be detrimental. See the National Institute of Health's website to calculate your BMI: www.nhlbisupport.com/bmi/. Aim to be at an ideal BMI, however, don't postpone pregnancy for weight reduction if you are over 35.

DIET
A good diet prior to beginning your efforts to conceive is important as well. It makes sense to eat plenty of fruits and vegetables, but did you know that it's been found that milk products and yogurt are equally important? A Harvard Medical School study suggests that whole milk products, not skim, are responsible for protecting against ovulatory infertility. Another interesting finding has been that folic acid improves ovulation in women, and in men, sperm quality! It can be taken as a multi-vitamin and found in foods such as oranges. Eliminating trans fats in women who have diabetes seems to help as well. Moderate caffeine and alchohol intake is important as well. Again, ideal weight is beneficial. No matter what anyone says, there are no diets or foods that "enhance" fertility, but a healthy diet can help overall.

TIMED SEXUAL ACTIVITY
Many couples trying to conceive use over the counter ovulation kits. There are some things to keep in mind though. Most women ovulate 14 days before their next period. For example: If your cycles are 25 days, then you are most likely ovulating around cycle day #11. Your fertile period would then be CD# 9-13. Those are the days I would recommend intercourse. You should stop intercourse on CD#7 and wait until CD#9 to start. Have intercourse once per day on those five days, only one ejaculation per day. Start using your ovulation kit on CD #9 (counting back 16 days from the end of your average cycle). Remember, once the egg is released from the ovary, it’s only receptive to sperm and able to be fertilized for about 12 hours. If you have irregular cycles you may have another problem and you need to see a specialist to determine what is going on. But the absolute bottom line with timing is this, make it fun NOT scientific!! You husband will become a reluctant participant if it is forced. Don't tell him, "honey its my fertile time again we have to have sex", rather, he shouldn't even know. You should just set the stage to get him interested, excited and "horny." That way, you'll both enjoy the experience, and trying won't be a chore.

KICK THE SMOKING HABIT
Virtually all studies show that smoking impairs fertility. In women, 10 or more cigarettes a day reduces egg quality. Post-conception smoking has been linked to miscarriages and ectopic pregnancies. In men who smoke there is a problem of lower sperm counts and lower sperm motility as well, which means, lower sperm functionality. Even worst is smoking marijuana. Any chemical that goes into your body, goes into your blood stream, into your cells and into your sperm and/or eggs. This is an absolute no no! Same with other forms of recreational drugs including large amounts of alchohol. My rule of thumb is, if it affects your brain cells, then it affects your reproductive cells as well.

RELAX
Couples who are trying to conceive can become stressed, especially if they have been trying for more than a few years. Yoga, acupuncture, massage and meditation tapes expressly made for infertility patients all help. My patients are encouraged to use relaxation techniques. It helps them through the emotional ups and downs of the IVF process. The patients approach the procedure day in a much calmer, relaxed manner and it may make a difference in how well the retrieval and transfer goes. Going to see a therapist for massage therapy or meditation therapy may also be covered by insurance, if it can be shown that there is an anxiety disorder. As mentioned above, make it fun and enjoyable, not homework.

SCRUTINIZE YOUR DOCTOR

You want a doctor that knows fertility through and through. Most of these types of doctors will be able to offer ALL levels of infertility treatment. Just as you don't want a doctor that only does Clomid, your don't want a doctor that only does IVF. You'll be thrust into the only thing they can do for you, Clomid or IVF. It is easy to screen for this. . . just ask, "what levels and types of treatment can you perform for me?" Most importantly, infertility needs to be diagnosed and treated by a Physician specialist, not general practitioners, nurses, PA's or medical assistants.

IF ALL ELSE FAILS...
If your fertility journey is meeting too many roadblocks, then you may need to explore other options. Keep in mind, that if you fail to achieve pregnancy naturally, that is NOT the end of the road. I counsel my patients, "Nowadays, we can get almost anyone pregnant, it just depends on what I need to do to achieve the pregnancy". There are many reasons why a woman or man may be infertile and a visit to a good fertility specialist will certainly narrow down or actually pinpoint where the problem lies. Treatment often varies from person to person so don't expect to find the answer on a forum or in a chat room! Blocked fallopian tubes, high FSH levels, abnormal sperm count or low motility, all these and more account for infertility problems in many couples.

A diagnosis by a physician is necessary in order to effectively identify the best course of action for the couple trying to conceive. But, don't let your doctor just put you on Clomid without a good reason. Clomid is NOT a miracle drug. It has a specific purpose, which is to induce ovulation in women that don't ovulate. If you have regular cycles, that is a sign that you are ovulating. That means that the problem is something else and Clomid won't change that. Make sure that the treatment you are receiving is treating a specific problem. Ask you doctor to explain his/her strategy, why they are using the treatment they recommend and what they are treating. Treatment without a specific reason is a waste of time and money, as is treatment without the completion of a complete infertility evaluation. I can't tell you how many patients I have seen who have been on multiple cycles of Clomid or IUI's only to find out that her tubes are blocked!

Above all, stay positive, we are here to help!

Edward Ramirez, MD, FACOG

Executive Medical Director

The Fertility and Gynecology Center

Monterey Bay IVF

Monterey, California, U.S.A.
Check me out on Facebook and Twitter with me at @montereybayivf

Concerned About Tubal Blockage

Question:
hello i am 23 and married, i have had a very hard life, i was raped when i was young and acted out as a teen, i recently had a HSG done and found out my tubes were block well the doctor said my right tube is definitely blocked and that he was not sure about the left. i would want nothing else but to have a baby it will mean the world to me. i am graduating from college and this will be my final goal. i know i can't afford IVF, and i don't want to adopt, so please tell me how you can help.

Answer:
Hello Concerned from the U.S.,

You basically have two options:

1. You can assume that your left tube is open, normal, undamaged and functioning normally.
2. You can assume that whatever caused the right tube to be blocked, also damaged the left tube, albeit only partially, and the tube does not function.

If you assume # 1, then you can try to get pregnant naturally. You would have the same chances of pregnancy with one tube so you should be able to get pregnant within 12 months (85% per year in your age group). If you don't get pregnant after 12 months of trying, then you will have to change your assumption to #2.

If you assume # 2, then the only option you have is to do IVF because tubes cannot be repaired or transplanted at this time, and are absolutely essential to get pregnant naturally. IVF works by bypassing the tube and performing all the functions that would occur in the tube, in the lab. In your age group in our center, you would have a 63% chance of pregnancy, and most reputable clinics are about the same rates.

I know that this is not necessarily what you wanted to hear, but it is the reality of the situation. In my position, I usually have to assume #2. Since you are so young, you have time to work with since your pregnancy rates will not be affected until you are 35. In the meantime, if you have to do IVF, you could begin saving up for the procedure (approximately $20K will be needed for one try), get a good job with good health car benefits that cover infertility/IVF, marry someone wealthy enough to afford IVF, or move to a mandated state such as Massachusetts where IVF is required in their health care coverage. These are alternatives that you could consider.

I hope this helps,

Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
http://www.blogger.com/www.montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com/ check me out on facebook and twitter with me at @montereybayivf