How Can I Have A Year Of The Dragon Baby?

Question:
Dear Doctor,

We are a Chinese couple who would like to have a baby this year. We have been trying for many months in the natural way for timing the baby for the Dragon year but we are not successful so far. We are thinking that maybe we can make our chances better for a baby this year if we go see a baby specialist here in Hong Kong. My wife is 34 years old and I am 38 years old. We have been trying for six months now. If we try for test tube baby, can we choose for a boy or girl? What would you suggest would be the proper next step for us?

Thank you, you are very kind for your advice. L. from Hong Kong

Answer:

Dear L. from Hong Kong,

I appreciate the fact that many Chinese couples are looking forward to having a child in the Year of the Dragon. If you wish to time your wife's pregnancy for a delivery within this Chinese lunar year, you do not have much time to spare! In essence, since you have been trying to conceive already for six months, it may be time to look at alternatives. I will go over all your options, from least complicated to the most aggressive:

First option:

What I would suggest if you still choose to go the "natural way" for just this month, is that your wife begin taking prenatal vitamins that have at least 1 mg of Folic acid within it, and that you keep in mind that the actual fertile days are pretty narrow - 2-3 days. If your wife has regular and predictable cycles, you can predict ovulation by counting back 14 days from the period. That would show where ovulation probably occurred in the previous cycle and by counting from the first day of her period, gives you an idea of what cycle day ovulation occurred. Then with this information, you can use the calendar method by counting from the period the number of days where you can both expect ovulation to occur. You need to stop intercourse 5 days from that anticipated ovulatory day, then start intercourse two days prior and have intercourse daily, once per day, with having only one ejaculation per day for five days.

Second option:

I think that an IUI (intra uterine insemination or artificial insemination) is a better starting point and should be done right away, but you need to make sure that the appropriate treatment is being done to increase your chances. IUI's are better than trying naturally because the number of eggs ovulated are increased with fertility medications, timing is better known by ultrasound surveillance and the sperm is injected into the tubes to await the egg. Ideally, your wife should be ovulating 3 eggs per cycle, or have 3 eggs of ovulatory size (18-24 mms) so maximize the chances that an egg will find and get into a tube. You did not say if either one of you have been tested for infertility. In your age group (34yo), your chances of natural pregnancy are about 10% per month and with IUI, up to 24% per month.

At my center, typically, we do an hsg (hysterosalpingogram) to see if the woman's tubes are open and viable. We also do a semen analysis on her partner. A negative result in either of these tests would make it quite difficult for you to immediately succeed with either an IUI or naturally.

Third and probably best option:

Considering the fact that you do not have much time and that you are considering gender selection, then IVF (in vitro fertilization) or "test tube baby" may be the best choice if you wish to conceive within the next few months.

With IVF the woman can produce many follicles and as long as you get at least one good embryo, IVF has a better pregnancy chance than IUI because it is accomplishing 7 of the 9 steps your body goes through to achieve pregnancy (IUI only accomplishes one). The remainder have to be accomplished by your body. That is what gives IVF a pregnancy rate of 60-76% per cycle in your age group.

If you wish to do gender selection, then IVF with PGS (pre implantation genetic screening) is the only option you have. A microscopic biopsy of the trophectoderm (the outer cell layer of an embryo) is done by the embryologist and sent to a lab for analysis. Recently it has been shown that the pregnancy rates from a single PGS-selected euploid embryo were 58% and 60.7% compared to 42% and 40.7%, respectively, from a morphologically comparable but non-PGS-selected embryo. Interestingly, the miscarriage rates were seen to decrease to 6% and 6.3% from 12% and 12.5%, respectively. With transfer of one embryo, the risk of multiple gestation is essentially eliminated.

I know that in China, Korea and Japan, genetic screening for gender selection is not allowed. Here in California it is, though. We have had Asian patients come to us who have chosen to have PGS for gender selection and succeeded. Your chances would be reasonable if normal embryos were obtained and transferred. You can choose to freeze or vitrify some embryos and transfer one fresh (vitrification is a method of rapid cooling of embryos that minimizes ice crystal formation which has further improved success). If one is transferred and it takes (implants), I would expect that there would not be any abnormalities in the fetus or child.

I wish you luck in the Year of the Dragon and hope that you will find a good physician in Hong Kong or abroad that will be willing to work with you and help you succeed in your quest for a child this year.

I hope all this information is helpful.

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

34 Year Old With One Tube, Endometriosis, Abnormal ANA: What TTC Strategy Do You Recommend?

Question:

Hi Dr. Ramirez,

I am writing to you as I am now desperate with our situation and hoping to get some push from someone who is knowledgeable in this field. I am 34 and my husband is 40. No kids from both sides. We've been TTC for 2.5 years now. When we started, our bloodwork both came back normal as per my family doctor although he mentioned that my ANA (anti nuclear antibodies) is out of the normal but he said he's not sure if it has something to do with fertility or not and he'll leave it up to our RE to decide. My ANA is positive 2+ speckled pattern.

I've always been regular with a 26-29 day cycle. We first visited our RE in April 2011 and he said I should go for additional bloodwork which I did and came back normal. So he said I am generally healthy, no weight or smoking problems. My husband didn't smoke too. I also did BBT (basal body temperature) charting and my RE confirmed that I am ovulating regularly. I went for an HSG (hystergosalpingogram) in June 2011 and they said they can't get the fluid to get into my cervix or uterus so they considered me blocked.

I went for laparoscopy on July 2011 and my RE told me that I have stage 2 endometriosis but he was able to clear it out and my left tube is open while the right is still blocked. He said we only need 1 tube to get pregnant so he prescribed me with Clomid in August and did a scan at cd 12 and he saw 2 mature follicles in my left ovary. We didn't get pregnant that month so I went for another month of Clomid but I noticed that month, I didn't get the cervical mucus that I usually have during my fertile days. I told my RE so in October he switched me to femara and had another HSG done. He said he unblocked my right tube so I am perfectly healthy. We did another scan at CD 12 and my RE confirmed that I have 2 mature follicles, one from each side so he said I should get pregnant pretty soon. He gave me 2 more prescriptions of femara and told me not to come back to him until Feb 2012 or when I am pregnant. I am now in my final dose of my femara and really desperate :(. While taking femara I didn't notice my cervical mucus coming back to normal. I think it was the same case as with clomid. I am dry during my fertile periods so I started using preseed in November.

Now my questions are, what do you think are the other options that we can take besides IVF? I've never tested positive in a test since we started TTC. I've never taken birth control pills in my entire life. Do you think my positive 2+ ANA has something to do with our infertility? My RE seems to ignore it and I am not too sure if I still have to remind him about it. What do you think about the fertilaid supplements? I am just in a desperate mood now so I think I am taking any chances. Any advice on the next steps to take?

Sorry for the long post. I would really appreciate your reply on this. I hope you had a fantastic holidays!

Here's my husband's numbers:Volume 3.5 mlpH 7.6Motility 50%Speed 4Count 48 million/mlMorphology 80% normal. I don't have some of my bloodwork numbers so I cannot post but my RE said it looks ok. Thanks in advance for your reply. F. from Canada

Answer:

Hello F. from Canada,

First let me say that you should not feel "desperate" at this time. You have plenty of time to work with because you are young, and options open to you. You are just beginning your journey so you just have to accept your situation and move forward through it, do what must be done and look forward to your eventual success.

It is worrisome to me that you only have one tube open. Why is there a tubal problem at all? Could this imply that although the tube is open that it is not functional i.e. that there is internal damage? If the tube is not functional then natural pregnancy cannot occur as the tube is an essential part of the process required to become pregnant by natural means.

The second problem you have is the endometriosis. Endometriosis, even if treated surgically, can still be present in microscopic form. It is surmised that this ectopic tissue, i.e. tissue that is not supposed to be present in the pelvis, causes a low level inflammatory reaction that that interfere with the egg in its travel from ovary to tube and therefore prevent pregnancy from occurring. One consideration would be to undergo a 3 month treatment with Lupron in order to get rid of any microscopic residual endometriosis followed by aggressive treatment to achieve pregnancy.

The alternative is IVF to bypass the pelvis altogether. Yes, Clomid and Femara (to a lesser extent) can block estrogen receptors and therefore lead to reductions in cervical mucous and endometrial thickness (that is how they work..they trick the brain into thinking it is not making enough estrogen so that it stimulates the ovary harder, which in turn makes more estrogen). These are side effects. These can be treated by giving vaginal estrogen tablets.

I don't think that the ANA is having any affect on your lack of pregnancy at this time. But, you could take an 81 mg tablet of aspirin daily to help overcome this. It's an easy treatment. (For my readers information, an ANA test detects antinuclear antibodies in your blood. Normally your immune system makes antibodies to help you fight infection. In contrast, antinuclear antibodies often attack your body's own tissues — specifically targeting each cell's nucleus. But some people have positive ANA tests and are perfectly healthy.)

I am not a proponent of fertiliaid. I think the product is just preying on people like you who are desperate and will try anything. I don't think that it helps.

In terms of other options, if the simple ovulation induction with Clomid, Femara or injectables is not successful, and I would not recommend continuing with this strategy if no pregnancy occurs within 6 months, then the next level of treatment is IUI. I would not recommend more than 4 attempts at IUI. If all the above don't work, then you should move to IVF.

Good Luck,

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

Woman Wonders: Natural FET Cycle Vs. Controlled FET Cycle?

Question:

Dr. Ramirez, I have some embryos frozen. I have adenomyois and endo and chronic endometritis diagnosed.

Have done antibiotic treatment with uterine lavages and IVs.

After depot lupron treatment, is it better to do a natural FET (frozen embryo transfer) or medicated FET. Since it takes about 2-3 months to wait for period to arrive is it better to do a medicated FET? I am concerned about medicated FET as the last time I did a medicated FET I had fluid in the uterus although nearer to transfer it disappeared and I did go on to transfer although BFN (big fat negative).

My RE seems to want to wait for a period before transfer but would not that waste 2-3 months since you said the endo can return in 6 months? Will the cycle be regular and as in ovulation or will it be not regular when I do FET. At the moment my cycles are regular. I have also heard of high dose progesteone treatments treating endo and adeno. Can you explain how this works?

I am confused what to do as we have limited embryos and want to do everything as possible as once the embryos are used up we are done.

Thank you. R. from Rhode Island

Answer:

Hello R. from the U.S. (Rhode Island),

Your RE should have explained that one of the critical steps in getting pregnant, natural or with IVF, is the state of the uterine lining at the time the embryo reaches it for implantation. We know that there is a very limited time that the embryo can implant and the endometrial lining has to be in a very specific and correct microscopic state for implantation to occur. This is where timing is absolutely essential. If you miss this "implantation window", then it will fail.

Conceivably you could do this with a natural cycle, but then there is a wider margin of error because we don't know exactly what the timing is or what is going on microscopically in the uterus. For this reason, we do not do this in FET cycles. FET cycles are always done as a controlled and programmed cycle. With this protocol, you can have a period induced artificially with medication and then start the cycle, but most clinics will want their patients to be on the birth control pill for at least two weeks period to the FET cycle in order to suppress the ovaries, which then allow complete control of the FET cycle.

If this is in fact gong to be your last attempts at getting pregnant, then I would make absolutely certain that you are in the best clinic that you can be in and that it will give you the highest chances of success. A good clinic would be able to answer these questions and make sure everything is clearly laid out.

Finally, in terms of progesterone treatment with endometriosis and adenomyosis, progesterone has suppressive action or counteracts estrogen in estrogen receptors. AS you probably know, endometriosis/adenomyosis are stimulated by estrogen and therefore, will be somewhat suppressed by progesterone. However, there is still some small amount of stimulation so progesterone is not the perfect treatment. Estrogen receptor blockers such as Lupron are better at suppressing endometriosis. Progesterone is used mainly to slow down the recurrence of the endometriosis after they have been treated with surgery or Lupron.

Good Luck,

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

Congenital Adrenal Hyperplasia & Infertility

Question:

Dear Dr. Ramirez,

Thank-you for reading this message, I greatly appreciate your advice.

My husband and I have been trying for a baby for just under 3 years. During the last year we have had 3 cycles of IUI and 3 cycles of IVF all of which have been unsuccessful.I have PCOS (although the lean variety with normal BMI) and my husband has an above average sperm count, no issues with motability etc etc.Recent blood tests revealed a chemical pregnancy with a level of HCG at 25(this was outwith IVF) and a very high 17-OHP level (13 x normal level). DHEAS level was normal. The tests were repeated however they have refused a follow up 17-OHP due to costs and have just tested DHEAS as my doc is now saying these levels should ALWAYS correlate.

I am worrying that I may have late onset Congenital adrenal hyperplasia (I am aware that sometimes PCOS is mistaken for this) and that the lack of treatment may be preventing pregnancy. I have asked for the ACTH test but have been told i dont need this as DHEAS levels are normal.Can you advise if it is normal to have a markedly elevated 17ohp in the absence of raised DHEAS? Could this be late onset Congenital Adrenal Hyperplasia?Your advice would be most appreciated. From K. in the U.K.

Answer:

Hello K. from the U.K.,

Sorry for the delay in getting back to you. I had to do a little reviewing to answer your question.

17-OHP is a marker of adrenal function in the valuation of hirsuitism (increased hair growth in a woman). It is a good first level screening test. To be most accurate, it should measured first thing in the morning because there could be elevations from the intermittent diurnal pattern of secretion from the adrenal gland (ACTH). Levels should be less than 200 ng/dl whereas intermediate levels of 200-800 ng/dl require further testing. Levels over 800 ng/dl are diagnostic of a 21-hydroxylase deficiency, which is a form of congenital adrenal hyperplasia (CAH). In that case, the DHEAS would be normal.

The next step to diagnose this disorder would be an ACTH stimulation test, which is done by administering ACTH (Cortrosyn or Cosyntropin) intravenously in a dose of 250 mcg. Blood samples are then taken for 17-OHP at time 0 and 1 hr. The testing must be done in the morning (the levels of ACTH change with the body's natural 24-hour cycle of processes "circadian rhythms"). This test is most accurate if it is performed early in the morning. (Reference: "Clinical Endocrinology and Infertility" Leon Speroff et al).

Keep in mind that late onset COH is very rare. Both 17-OHP and DHEAS are measurements of adrenal function. In the cases of most adrenal disease leading to hirsuitism, both 17-OHP and DHEAS are elevated. Both may be elevated with hyperprolactinemia or adrenal tumor.

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

Comment: Thank you so much for your response, I will pursue the ACTH stimulation test. Thanks again!