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Infertility FAQ's


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  1. #1
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    Infertility FAQ's

    What is the purpose of Lupron in IVF?
    The first fertility drug that most women use in an IVF cycle is Lupron. Lupron causes the pituitary gland to release high amounts of FSH and LH (luteinizing hormone) for several days until its stores are depleted. Since continued use of Lupron prevents the pituitary gland from producing new supplies of FSH and LH, the amount of these hormones being released per day becomes very low after 7 to 10 days. The goal that we achieve with Lupron is to ensure that blood levels of LH are low during the last few days of follicle growth, since we know that high levels of LH can lead to poor egg quality and stimulate progesterone production by the ovaries. A premature rise in progesterone may cause inappropriate maturation of the uterine lining and lead to a lesser chance of embryo implantation.
    Some women will be placed on a Lupron "flare" medication schedule. This involves starting Lupron early in the menstrual cycle after suppressing pituitary and ovarian function for up to one month of birth control pills. The Lupron causes a sudden flare in FSH and LH release by the pituitary gland and initiates follicular growth. On the third day after the Lupron starts, the woman begins shots of FSH or FSH+LH (brand names include Repronex, Bravelle, Follistim, and Gonal-F). This stimulates the continued growth of the follicles as the pituitary's release of FSH begins to decline. Women over age 39 and those with high day 3 FSH blood levels as determined prior to enrollment are typically treated with a Lupron "flare" schedule in order to maximally stimulate the ovaries. Repronex, Bravelle, Follistim, and Gonal-F are administered as subcutaneous injections (small needle placed just underneath the skin).
    Younger women or those with polycystic ovaries are usually treated with Lupron for approximately 10 days prior to beginning the shots of FSH. With this "long Lupron" schedule, the pituitary is no longer releasing large amounts of LH and FSH when Repronex, Bravelle, Follistim, or Gonal-F is started. Hence, the best treatment schedule is determined by the unique circumstances of the individual patient. The average number of follicles that develop is from 8 to 25, although some women will have more than 30 and others will develop less than 5.
    A new class of drugs called GnRH antagonists (i.e. Antagon) may be used in some patients over a shorten time course to prevent a spontaneous LH surge without overly suppressing ovarian function. The ideal candidates for the approach are being determined by research protocols.
    With either the "Lupron flare" or "long Lupron" schedule, the Repronex, Bravelle, Follistim, or Gonal-F shots are taken twice daily for 8 to 11 days, depending on how quickly the follicles mature. We can assess the ovarian response to these fertility drugs by measuring the follicle sizes with vaginal ultrasound and by following the increase in production of estradiol (estrogen) and progesterone by the cells inside the follicles. When the largest follicles reach approximately 18 mm in diameter, the woman takes a shot of hCG (human chorionic gonadotropin - brand name Profasi, Pregnyl, or Ovidrel). This hormone stimulates the final steps of maturation of the eggs. The egg collection occurs 35 hours after the hCG injection.
    What are the side effects of Lupron?
    Other than side effects due to the actual injection (i.e., infection, bleeding, bruising, etc.), most of the side effects of Lupron are due to the menopausal-like state that the drug induces. Some patients will complain of hot flashes, vaginal dryness, etc.; however, these often go away after stimulation begins since estrogen levels start going up with gonadotropin treatment.
    Why do I need a sonogram prior to the start of each new IVF, Clomid, or gonadotropin cycle?
    The presence of cysts and elevated estrogen levels early in the menstrual cycle can inhibit appropriate growth of new eggs. Clinicians often check for the presence of cysts before starting follicular stimulation.
    How much bed rest is needed after embryo transfer, and does it vary whether day 3 or 5 transfer?
    During natural conception, the egg is fertilized in the tube where it then floats down over 5 - 7 days until it reaches the uterine cavity where it implants in the endometrium. When embryos are transferred on day 3 or 5, they still need to go through those same developmental milestones for implantation to be accomplished.
    There is much controversy on how much bed rest is necessary after embryo transfer. During my career, I have seen recommendations change completely. During my residency at Hopkins, we used to admit patients to the hospital and have them stay absolutely still for at least 4 hours; they would then go home and stay at bed rest for one week. During my fellowship, we modified that recommendation and would have them stay down for an hour after embryo transfer then go home and rest for a few days.
    During my time when I worked in the Air Force's IVF program at Wilford Hall Medical Center, patients would come from all over the country for treatment. By necessity, many of them would have to be on a military transport airplane back to their home base right after embryo transfer, and we still had some of the highest IVF success rates in the state of Texas.
    Now, I follow our Colorado Center's protocol. We transfer either on day 3 or day 5 and have the patient rest at our center for one hour. They then go home and stay at bedrest for the day of the transfer and the following day. What I am trying to convey with this chronology of my experience is that there is very little science to the recommendations we make about bed rest after embryo transfer. My best advice is to talk to your doctor about his or her experience and results and then do what seems to make sense.

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  2. #2
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    Re: Infertility FAQ's

    What is a 'good' initial quantitative beta-hCG after transfer or IUI?

    The hormone, human chorionic gonadotropin (hCG), is secreted from the cells that form the placenta. The number one gets from a quantitative pregnancy test reflects how much placental tissue is releasing this hormone. In many normal early first trimester pregnancies, the number goes up quickly (up 100% every 48 hours). Therefore, initial values markedly vary depending on when one draws the first pregnancy level.

    Since many IUI or IVF cycles are triggered with an hCG shot, it is important to wait at least 10 days before checking a pregnancy level. If it is checked too soon, it is likely that the test will be a false positive (show positive when actually due to the shot instead of the actual pregnancy). For this reason at Houston IVF, we wait a minimum of 16 days after the hCG trigger shot. On our hormone analyzer, a level of beta-hCG of 100 mIU/ml is a "good" number; however, we have had pregnancies as low as 10 mIU/ml make it to term and deliver.

    When does implantation occur after IUI, day 3 transfer or day 5 transfer?

    For implantation to occur, embryos must go through a growth cycle which ends with the embryo at the blastocyst stage and hatching out of the zona pellucida. Therefore, one would expect implantation to occur about 5-6 days after an IUI, about 2-3 days after a day 3 embryo transfer, and the day of or the day after a day 5 embryo transfer.

    How many follicles is a 'good' number before getting hCG?

    In my practice, the maximum number of mature follicles I want a patient to have during an IUI cycle is 3 to 4. This decreases the chance of developing a high-order multiple pregnancy. During an IVF cycle, the minimum number of mature follicles I want a patient to have is 3 to 4. Since I can control the number of embryos that I place in the uterus, I want as many as I can safely retrieve hereby giving the patient more embryos to choose from to give her the best chance for pregnancy.

    How do you determine when to give hCG in respect to follicle size?

    In a natural (unstimulated cycle) or Clomiphene Citrate cycle, mature follicle size is between 18 - 30 mm. If triggered, these cycles are typically triggered when follicle size is between 17-26mm (dependent of the practice and IVF lab).

    In a gonadotropin cycle, mature follicle size is between 16 - 20 mm. These cycles are typically triggered when follicle size is between 16 - 20 mm.

    Can you have an ectopic pregnancy with no tubes?

    An ectopic pregnancy is a pregnancy which implants outside of the uterine cavity. Over 95% of ectopic pregnancies implant in the tubes. There are rare ectopic pregnancies where the pregnancy implants in the ovary, abdomen, or elsewhere.

    What are polyps and fibroids, and causes them to grow in the uterus?

    A polyp is a general term that describes any mass of tissue which bulges or projects outward or upward from the normal surface level. A uterine polyp is an outgrowth of the uterine lining. They may appear after prolonged exposure to unopposed estrogen or if the uterine tissue is not completely sloughed off each month.

    Fibroids are benign smooth-muscle growths that arise from the uterine muscle. Fibroids, also known as leiomyomas, are found inside the uterine cavity (submucous), within the uterine muscle (intramural), and on the outer surface of the uterus (subserosal). Fibroids grow in response to estrogen. Up to one third of all reproductive-aged women will have at least one fibroid in their uteruses.

    Last edited by Parasakthi; 26th Dec 2011 at 10:05 AM. Reason: Alignment

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    Re: Infertility FAQ's

    What are follicles?

    A woman's eggs develop inside fluid-filled cysts (sacs) inside the ovaries, called follicles. During a natural menstrual cycle in which no fertility drugs are taken, several follicles begin to enlarge around the time when the woman is having her period.

    However, over the course of the next few weeks, only one of these follicles develops to maturity, ruptures, and releases its egg during the process of ovulation. The other follicles that had begun to develop stop growing and degenerate (dissolve), therefore, only a small percentage of eggs present in the ovaries are ever ovulated during the woman's reproductive life span. We can "rescue" follicles and eggs that would otherwise degenerate by giving shots of fertility drugs which contain FSH (follicle stimulating hormone). This is the same hormone that the pituitary gland produces to cause one egg to develop. By increasing the woman's blood level of FSH, several follicles may grow at approximately the same rate allowing us to collect more than one mature egg.

    How fast do follicles grow?

    Follicles typically grow 1-3 mm per day in natural and stimulated cycles.

    Last edited by Parasakthi; 26th Dec 2011 at 10:06 AM. Reason: Alignment

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    Re: Infertility FAQ's

    Can you see eggs on an ultrasound?

    Eggs are microscopic and cannot be seen on ultrasound. A clinician can estimate the maturity of the egg based on the size of the follicle which contains it. There should be one egg per follicle.

    Why do a vaginal sonogram and not abdominal?

    The closer the ultrasound probe tip is from the object being viewed, the clearer the sonographic picture. The vaginal approach allows the probe tip to get much closer to the ovary than the abdominal approach; therefore, the sonographic clarity of the ovary is much better using the vaginal approach.

    How can you grow the uterine lining if it is not thick enough?

    The uterine lining (endometrium) grows in response to estrogen. Estrogen can be given to patients by oral pills, skin patches, vaginal pills, or intramuscular injections.
    My uterine lining has been 'homogenous' in preparation for my donor egg cycle, what can be done to make it 'trilaminar'?

    The endometrial cells in the uterine cavity respond to estrogen and progesterone. Higher levels of estrogen tend to produce a "trilaminar" or triple pattern. The presence of progesterone can make the lining appear homogenous. Some clinics will place patients on Lupron to try to prevent any endogenous production of progesterone.

    How thick must the uterine lining be for transfer?

    Most of the literature suggests that an optimal uterine lining should be somewhere between 7 - 12 mm in thickness on the day of hCG trigger. These values are not absolute. Our clinic has had implantation with a lining as thin as 3.5 mm.

    Last edited by Parasakthi; 26th Dec 2011 at 10:06 AM. Reason: Alignment

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    Re: Infertility FAQ's

    What should you see on sonogram in a pregnancy at 4, 5, 6, 7, 8, and 9 weeks?

    At 4 weeks of gestational age (2 weeks post conception), your doctor should only be able to see a thickened uterine stripe.

    At 5 weeks of gestational age (3 weeks post conception), the presence of a gestational sac and possibly a yolk sac are seen.

    At 6 weeks of gestational age (4 weeks post conception), your doctor should be able to see a gestational sac and a yolk sac. Fifty percent of the time, a fetal pole will be seen with cardiac activity.

    At 7 weeks of gestational age (5 weeks post conception), ninety percent of the time, a fetal pole will be seen with cardiac activity.

    At 8 weeks of gestational age (6 weeks post conception), your doctor should see all of the previously mentioned structures, including a fetal pole with cardiac activity. The fetal pole should be measuring appropriately for the gestational age and show appropriate interval growth between sonograms.

    At 9 weeks of gestational age (7 weeks post conception), your doctor should see all of the previously mentioned structures, along with increased detail in the fetal pole. There should now be evidence of a head, trunk, and extremities.

    What is wrong with fluid being in the uterus prior to embryo transfer?

    The presence of fluid in the uterus prior to embryo transfer has been shown to be a negative predictor of pregnancy.


    Last edited by Parasakthi; 26th Dec 2011 at 10:07 AM. Reason: Alignment

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    Re: Infertility FAQ's

    Are all fibroids bad for fertility?

    Fibroids are benign smooth-muscle growths that arise form the uterine muscle. Fibroids, also known as leiomyomas, are found inside the uterine cavity (submucous), within the uterine muscle (intramural), and on the outer surface of the uterus (subserosal). Fibroids grow in response to estrogen. Up to one third of all reproductive-aged women will have at least one fibroid in their uteruses.

    Fibroids which distort the normal contour of the uterine cavity may be detrimental to implantation. Submucous fibroids clearly can interfere with implantation. It is controversial whether or not intramural fibroids interfere with implantation, and subserosal fibroids most likely have no effect on implantation.

    How high is the hCG before you can see it on sonogram?

    Beta-hCG levels typically need to be above 1500 mIU/ml before a gestational sac can be seen on transvaginal sonogram.

    Is egg retrieval painful?

    Egg retrieval is usually accomplished by transvaginal ultrasound aspiration, a minor surgical procedure that can be performed in the physician's office or outpatient center. Some form of anesthesia is generally administered. An ultrasound probe is inserted into the vagina to identify the mature follicles, and a needle is guided through the vagina and into the follicles aspirated (removed) from the follicles through the needle connected to a suction device. The egg retrieval is usually completed within 30 minutes.

    Some women experience cramping on the day of the retrieval, but this sensation usually subsides by the next day. Feelings of fullness and/or pressure may last for several weeks following the procedure because the ovaries remain enlarged.

    What is estradiol?

    Estradiol is the most potent female sex hormone (estrogen) produced by the ovaries which are responsible for the development of female sex characteristics. Estrogens are largely responsible for stimulating the uterine lining to thicken during the first half of the menstrual cycle in preparation for ovulation and possible pregnancy. They are also important for healthy bones and overall health. A small amount of these hormones is also produced in the male when testosterone is converted to estrogen.


    Last edited by Parasakthi; 26th Dec 2011 at 10:10 AM. Reason: Alignment
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    Re: Infertility FAQ's

    Q. My husband and I have an active sex life, we are both healthy, and my periods are regular. However, we have still not conceived ! Please help !
    A. You need to remember that it's not possible to determine the reason for your infertility until you undergo tests to find out if your husband's sperm count is normal; if your fallopian tubes and uterus are normal; and if you are producing eggs. Only after undergoing these tests will your doctor be able to tell you why you are not conceiving. While testing does cause considerable anxiety, it's far better to intelligently identify the problem so that we can look for the best solution.


    Q. My gynecologist has done an internal examination and said I am normal. Do I still need to get tests done to determine why I am not conceiving ?
    A. A routine gynecological examination does not provide information about possible problems which can cause infertility, such as blocked fallopian tubes or ovulatory disorders. You need a systematic infertility workup.


    Q. Do painful periods cause infertility ?
    A. Painful periods do not affect fertility. In fact, for most patients, regular painful periods usually signal ovulatory cycles. However, progressively worsening pain during periods (especially when this is accompanied by pain during sex) may mean you have endometriosis.


    Last edited by Parasakthi; 26th Dec 2011 at 10:12 AM. Reason: Alignment
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    Re: Infertility FAQ's

    Q. My periods come only once every 6 weeks. Could this be a reason for my infertility ?
    A. As long as the periods are regular, this means ovulation is occurring. Some normal women have menstrual cycle lengths of as long as 40 days. Of course, since they have fewer cycles every year, the number of times they are "fertile" in a year is decreased. Also, they need to monitor their fertile period more closely, since this is delayed (as compared to women with a 30 day cycle).


    Q. My husband's blood group is B positive and I am A negative. Could this blood group "incompatibility" be a reason for our infertility ?
    A. There is no relation between blood groups and fertility.


    Q. After having sex, most of the semen leaks out. How can we prevent this ? Should we change our sexual technique ? Could this be a reason for our infertility ?
    A. Loss of seminal fluid after intercourse is perfectly normal, and most women notice some discharge immediately after sex. Many infertile couples imagine that this is the cause of their problem. If your husband ejaculates inside you, then you can be sure that no matter how much semen leaks out afterwards, enough sperm will reach the cervical mucus. This leakage of semen ( which is called effluvium seminis) is not a cause of infertility. In fact, this leakage is a good sign - it means your husband is depositing his semen normally in your vagina. Of course, you cannot see what goes in - you can only see what leaks out - but the fact that some is leaking out means enough is going in!


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    Re: Infertility FAQ's

    Q.My husband refuses to get his semen tested. He says the fact that it is thick and voluminous means it must be normal.
    A. Semen consists mainly of seminal fluid, secreted by the seminal vesicles and the prostate. The volume and consistency of the semen is not related to its fertility potential, which depends upon the sperm count. This can only be assessed by microscopic examination.


    Q.My sister conceived only after 6 years of marriage. Does this mean I will also have difficulty conceiving ?
    A. If your mother, grandmother or sister has had difficulty becoming pregnant, this does not necessarily mean you will have the same problem! Most infertility problems are not hereditary, and you need a complete evaluation.


    Q.My husband says we should be having intercourse every day to achieve pregnancy. Is this true ?
    A. Sperm remain alive and active in woman's cervical mucus for 48-72 hours following sexual intercourse; therefore, it isn't necessary to plan your lovemaking on a rigid schedule.


    Q. My sister in law is advising me to keep a pillow under my hips during and after intercourse . Will this increase my chances of conceiving ?
    A. Sperm are already swimming in cervical mucus as sexual intercourse is completed and will continue to travel up the cervix to the fallopian tube for the next 48 to 72 hours. The position of the hips really doesn't matter.


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    Re: Infertility FAQ's

    Q. I just had a HSG ( X-ray of the uterus and tubes) done, and this shows my tubes are blocked. I've never had symptoms of a pelvic infection, so how could my tubes get blocked ?
    A. Many pelvic infections have no symptoms at all, but can cause damage, sometimes irreversibly, to the tubes.


    Q. My doctor has advised me to take fertility drugs . I don't want to take them because if I am scared that if I do, then I'll have a multiple births.
    A. Fact: Although fertility drugs do increase the chance of having a multiple pregnancy (because they stimulate the ovaries to mature several eggs), the majority of women taking them have singleton births.


    Q. My husband's sperm count varies every time we test it ! How do we determine what the "real" sperm count is ?
    A. Even a normal ( fertile ) man's sperm count can vary considerably from week to week. Sperm count and motility can be affected by many factors, including time between ejaculations, illness, and medications. There are other factors which affect the sperm count as well, all of which we do not understand.


    Q. I have no problems having sex. Since I am virile, my sperm count must be normal.
    A. There is no correlation between male fertility and virility. Men with totally normal sex drives may have no sperms at all.


    Q. My semen analysis report shows I have no sperm in the semen (azoospermia ). Is this because I used to masturbate excessively as a boy ?
    A. Masturbation is a normal activity which most boys and men indulge in. It does not affect the sperm count. You cannot "run" out of sperms from masturbation, because these are constantly being produced in the testes.


    ref:fertilitytoday


    Last edited by Parasakthi; 26th Dec 2011 at 10:12 AM. Reason: Alignment

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