Ask Dr. Marc: Timing Ovulation

Hi Dr. Marc.

 

I’m taking fertility drugs such as gonal f and/or clomid, I’m 37, I ovulate on my own, I’ve run the gamut of testing and everything on both my end and DH’s end is great. So I’m wondering if I will ovulate all eggs without a trigger shot – or will my surge only allow me to ovulate 1.

 

Thanks for your time.

TTCT

 

Hi TTCT,

 

Your natural surge is sufficient for all mature follicles to ovulate.  This is true whether you have 1 or many mature follicles.

Despite this, your doctor may recommend using a “trigger shot” to induce ovulation.  There are a couple reasons a doctor may choose the trigger shot.  First, in order to coordinate an insemination, we need some advanced notice to prepare the sperm and get you in for an appointment etc.  The trigger shot allows the timing of ovulation to be amenable to normal working hours when an insemination can be done.

Second, ovulation predictor kits tend to be less accurate when a patient is using injectable medication.  Thus, they cannot be relied upon to schedule an insemination.

Hope this helps TTCT, good luck!

 

Best,

Dr. Marc

Where Ricki Lake Went Wrong…

Infertility is bad enough on its own.

 

It’s overwhelming. It’s sad.  It’s frustrating.

 

Infertility leaves people feeling lost, broken, misunderstood, and forgotten.

 

Infertility is isolating.

 

When I saw the media blast stating that the Ricki Lake was looking for a couple to share the ups and downs of their infertility journey and discuss how infertility affects a marriage, I chose to see it as a positive.  At last, I thought, someone wants to raise awareness.  Someone wants to normalize it and bring it to the forefront of conversation.

 

Someone cares enough to make it a whole episode, not just a ten-minute segment buried in the final hour of a four-hour show.

 

So I reached out to the producer who sent the blast.  Let me know if I can help.  She hit back in minutes.  They were having difficulty finding a couple and needed to tape the show in two days.  If I could help find a local couple, it would be great.

 

I put the word out on Facebook and Twitter and waited.  But not for long.  I emailed the producer back and told her what she probably didn’t want to hear:  It can be hard for couples to come forward on a show like this.  Particularly if they are still in the middle of the battle.  I suggested a panel of women, all with different diagnoses and different outcomes.  Let’s put some faces to the struggle, I suggested.  Let’s make this real.

 

Let’s talk about the psychological component of infertility.  Let’s share the emotions, beginning to end.  Let’s tackle this head on.

 

No…they needed a couple for this particular segment.

 

And, in the final hour, I found them a couple.  They had endured quite a struggle and were happy to share.

 

When I sent that final email…good news, a couple is ready to come forward, I was caught off guard by the response.  The structure of the show has changed.  We decided to do a panel of women…like you suggested!  We would love to have you in the audience.

 

I wasn’t sure what to make of it, but I had a feeling that the show would not be what I had suggested.  I couldn’t shake the feeling that something just wasn’t right.  I politely declined the invitation to sit in the audience, and hoped for the best.

 

I tried to brush it off.  They were planning a show on infertility, after all.  Media coverage is media coverage, right?

 

Wrong.

 

This was the promo for the show…

 

 

They had an opportunity to raise awareness and break down the wall of silence that still surrounds infertility.  They had the opportunity to open up a dialogue and normalize the feelings that are impossible to escape.  They had the opportunity to help many if the 7.3 million Americans struggling with infertility.

 

Instead they chose to sensationalize it.  They chose to focus on “extremes” and highlight the outliers…the 1%.  They chose to make a mockery of the infertility community.

 

Here is what I know about the brave warriors of infertility, particularly those of you who connect here at Clomid and Cabernet:  We are brave.  We are strong.  We are fighters.  We lift each other up when we need lifting, and let each other fall when we need falling…because we know that sometimes we need a little bit of both.  We cheer for our successes and cry alongside one another when failure strikes.  We live this battle together.

 

We are not going to extremes.  We are not outliers.  We are not desperate.

 

We are fighting like hell to build our families and we are holding onto hope when all else fails.  We trust that, someday, our babies will find us.

 

We are the faces of infertility, and we are strong.

Ask Dr. Marc: BBT and the Trigger Shot

Dear Dr. Marc,

My main question/concern is about the trigger shot. I do BBT charting every morning. Does the HCG shot affect one’s temps? I had my IUI last Saturday- trigger shot Thursday night. Thursday AM my temp was at its lowest- after entering Sundays in the chart, it read that I ovulated Thursday. So I’m worried the IUI was done too late.

Thank you!

 

Hi Temperature Checker,

To answer this question completely, I need to give you some background information on eggs, ovulation and the hormonal activities surrounding this amazing event!

Women are born with all of the eggs they will ever have.  Those eggs exist within the ovaries in small sacks of fluid called follicles.  Beginning with the first few days of a menstrual cycle, one of the many follicles present in one of the ovaries is selected as the “dominant’ follicle.   Under stimulation form the brain, that follicle will begin to grow faster than the other follicles.  This process continues for about 14 days when the dominant follicle reaches roughly 2 cm in diameter.  At this point, the brain sends a hormone single to the ovary, which instructs the follicle to release its egg.  This is called ovulation, and the signal sent from the brain is a hormone called LH (luteinizing hormone).  Once the egg is released, it hopefully finds its way into the fallopian tube where, with a little luck, it can meet a nice spermatozoon and transform into an embryo!

Basal body temperature is related to all of this because once the follicle releases the egg its job is not over.  The follicle transforms in to a structure called the corpus luteum.  The corpus luteum produces progesterone, which is critical to maintain a pregnancy and has many effects throughout the body.  Once of these effects is to raise the basal temperature by about half of a degree (0.5°C).  In reference to ovulation, if we can detect this rise in temperature, then we can assume that ovulation has occurred within about 48 hours.

In your situation, you took an HCG shot.  HCG is structurally very similar to LH, but it lasts considerably longer in the body.  Doctors use HCG to induce ovulation in the same way that the brain induces ovulation with LH.  Ovulation almost always follows HCG injection by about 36-40 hours.  With this in mind, your IUI was perfectly timed.

Based on your BBT, a rise on Sunday can be consistent with ovulation on Saturday.  The only caveat is if your natural LH surge occurred prior to the time you took the HCG shot.  If you were monitored with ultrasound, this is pretty unlikely because your doctor would be able to see the dominant follicle.

If you were not monitored by ultrasound, there is a possibility that you ovulated early.  My recommendation is if you do not become pregnant this month, consider close monitoring with ultrasound next month.

I hope this is helpful, good luck

Dr. Marc

 

Four Candles

As many of you already know, today is Pregnancy and Infant Loss Remembrance Day.  It’s a difficult day for many of us. Although a day of remembrance comforts us, it also reminds us of the losses we’ve suffered along the way.

My sweet friend Jessica, whose loss is far greater than all of mine combined (and yet she listens to me anyway), organized a special event yesterday.  Lanterns were released in memory of little lost angels.  I spoke to her as she drove to the event.  The weather was touch and go.  It was sunny at times, but the clouds were rolling in.  She worried that the lanterns wouldn’t light, or that rain would stop the event from happening.

It didn’t.

And a little while after our phone call I received a tweet with a picture of the lantern she released in memory or my little boy…the one who made it 17.5 weeks.  The last little one who would have made three.

Tears streamed down my face as I stared at the picture for a while.  There goes a little part of my heart.  A little part that I hold tight…hoping to find peace with it one day.  I think of him almost every day.  He would be turning one next week…a fact that wakes me during the night and ignites silent tears under the duvet while my family sleeps peacefully throughout the night.

Tonight at 7pm all across the nation, people who have lost a pregnancy or an infant will light a candle in memory of that sweet little angel.  For at least one hour, those candles will burn to remember the little souls that didn’t make it.

Tonight I will light four.  Although that last loss stays with me day after day, the other three miscarriages will always be a part of me too.

We never fully move on, we simply start to move forward.

So tonight I will light four.  I will remember those pregnancies and the little heartbeats that I saw on the screen week after week.  13 weeks.  11 weeks.  7.5 weeks.  And 17.5 weeks.  I will remember each one of them.  I will pray that those little lost souls found their way to heaven where they can be comforted by my father and rocked by my Nana.

And I will probably cry just a little bit more.

Because even when you think you’re done…you’re never truly done.  The memories stay with us, even when we try to bury them deep within our souls.  Time heals all wounds, but some leave significant scars.

Sending good thoughts to all of you as we remember our losses and take another small step forward.

The Ferris Wheel

People always reference roller coasters and waves when discussing grief, sadness, and extreme stress.  The ups and downs and there and back again always seem to conjure this imagery.

 

Chances are, I’ve done the same.

 

I’ve experienced the ups and downs of grief more than once.  I’ve felt lost.  I’ve been found.  I’ve been stuck in the grey more than I would even care to admit.

 

I’ve taken that ride and surfed those waves.

 

But lately I’ve been feeling like it’s not so simple.  Roller coasters have a slow build and fast fall at fixed intervals.  If you take that ride more than once, you know when to scream and when to breathe a sigh of relief.

 

Waves crash down and then quickly double back.  Sometimes the waves come hard and fast, other times the water falls flat for a little while.  Either way, you can see it coming.  You can watch the tides and prepare for the weather.  You can make plans.

 

Infertility is a little less predictable.  In fact, it’s a lot more circular…

 

It was the first day that actually felt somewhat like autumn.  The air felt a little less heavy.  The colors seemed just a bit crisp.  A gentle breeze grazed the back of my neck at just the right times.

 

Surrounded by families with kids of all ages and babies at every turn, the longing returned.  I felt the pull as I stared at each little infant wrapped snug against a mommy.

 

Hand in hand with my not-so-baby boy, I listened as he described the scene around us.

 

Look, Mommy.  Look at the huge Ferris wheel.  I’m too small for that.

 

It’s beautiful, sweet boy.  It makes beautiful circles.

 

That’s when it hit me.  Infertility isn’t a roller coaster.  Infertility isn’t a series of waves crashing and retreating.

 

Infertility is a Ferris wheel.

 

Infertility is a continuous circle that never really leaves us.

 

In the beginning, we jump on ready for results.  We will do anything along that first rotation.  Just tell us how to fix it and we will comply.

 

But then we make another loop.  And another.  And another.  And before we know it, we are stuck in the rotation, searching for clues and answers.

 

We watch others get on and cheer when some get off.  And each time we head toward the ground we hope against hope that it’s finally our turn to get off of that ride, but often it’s not.  Often there are more pills, more shots, more suppositories, more tests, and more surgeries.

 

It’s hard to see the end when you’re stuck in the loop.

 

Some of us become to numb to the ups and downs.  Extremes start to feel a little less extreme over time.  At some point, it all begins to fade into the continuous circle.

 

Infertility is a Ferris wheel.

 

Enjoying the ride isn’t an option.  But you can bring some good music and fight like hell to make your exit.

 

Because your time will come.

 

One way or another, your time will come.   You will exit that ride…

Ask Dr. Marc: C-Section Scars

Dear Dr. Marc,

I am 30 years of age, have had my first child naturally (after one try!) at the age of 26.  For that birth, I ended up have an emergency cesarean due to preeclampsia at 38 ½ weeks.  In seeking answers for our inability to fall pregnant after a year, it was found that I have fluid in my uterus from my c-sec scar which is there throughout my cycle and I also have a very low AMH for my age (only 3.5).  In determining this I have had a laparoscopy, an attempted hysteroscopy and a successful hysteroscopy (different Dr).  I also had a HCG where they found my tubes were fine.  We have done IUI once and two cycles of IVF.  My husband’s sperm has also been tested and is fine.  I have had very few eggs from each cycle, but have managed to have two day 5 blastocysts the first time and 3 blastocysts the second cycle.  I miscarried two weeks after the transfer with the first cycle and got a negative from the second cycle.

My question is have you come across someone with fluid throughout their cycle from a c-sec scar before and have they successfully fallen pregnant?  My specialist is lovely but I don’t know that he has come across this before.  My low AMH also complicates matters.  With the IVF, he aspirated the fluid out of the uterus before transferring the embryos but I have my doubts as to whether implantation is possible because won’t the fluid just come back again and prevent implantation?

Thanks,

Trying for number 2

 

Hi Trying for number 2,

Your situation is quite interesting and somewhat unique.  First let’s talk about how a caesarian section is performed.  In most C-sections a horizontal incision is made in the lower (closest to the vagina) part of the uterus.  Importantly, the scar on a woman’s abdomen has nothing to do with the type of scar that is made on the uterus.  Through this horizontal uterine incision, which is about 10 centimeters in diameter, the doctor can access the baby and placenta and remove them from the uterus.  Following delivery of the placenta, the uterine incision is normally repaired with at least 2 layers of stitches.   In the vast majority of cases, this repair is quite strong and has no significant impact on the structure or function of the uterus.  In fact, many women are able to have normal vaginal deliveries after having a C-Section, this is called a VBAC (vaginal birth after caesarian).

 

 

In some circumstances however, the C-section repair is less than perfect and can affect future pregnancies.  It is important to know that this does not mean that your doctor made a mistake.  There are simply many factors that go into the healing of a C-section scar.  For you, it seems that these factors may have combined to cause there to be fluid in your uterus.

The fluid may be due to a gland that healed within the scar and secretes mucus into the uterus.  Alternatively, there could be a channel that allows fluid to flow into the uterus from the outside.  Either way, the best step to further explore the scar is a hysteroscopy and laparoscopy.  If there is a structural abnormality responsible for the fluid, then it should be identifiable and treatable through hysteroscopy and laparoscopy.

Moreover, some amount of fluid is normal in the uterus.  The uterus is full of glands and they produce mucus that is critical to the health of the uterine environment.  It is possible that you simply make more mucus than normal and that it has nothing to do with your C-section scar.

This brings us to the other issue, which is ovarian reserve.  We know that as we get older, each of our eggs is somewhat less likely to go on to become a baby.  The significance of age is different for each of us and unfortunately, some women experience decreased ovarian reserve earlier than others.  30 years of age is relatively young in the world of fertility, but some women do notice diminished ovarian reserve at 30.  I suspect that if you are not making many eggs per cycle, this is the case with you.  The good news is that although you do not make many eggs, the ones you do make seem to be of good quality.  Ultimately, this means that your prognosis good.

My advice to you is to have another doctor review the operative report from your surgery.  If the C-section scar was visualized and appeared normal, then there is not much more that can be done surgically.  At that point I would focus on the next IVF cycle and making it as optimal as possible.  It would be reasonable to remove any extra mucus from the uterus prior to transferring embryos.  Alternatively, a frozen embryo transfer may be beneficial because the uterus tends to produce less mucus during a frozen cycle.

In conclusion, my feeling is that the mucus is less important than embryo quality and quantity.  Hopefully it is just a matter of getting the right embryo in place and then nature will take care of the rest!

Good Luck!

Dr. Marc

The Power of Three

I tried to hide out as much as possible.

 

Part of me wanted to be as strong as everyone around me seemed to think I was.  Part of me felt ashamed and embarrassed.  And part of me knew that to tell the story over and over was to experience those gut-wrenching emotions over and over.

 

I wasn’t sure I could handle the pain.  I wasn’t sure I wanted to.

 

And so I tried my best to hide out as much as possible.

 

I went from home to work and back again.  I stopped walking with friends after work.  I ran on my elliptical behind closed doors instead.  I stopped going to parties or dinners…especially when my husband was on tour.  I stuck close to home and watched a little too much TV.

 

I read a lot of chick lit.

 

But a funny thing happened…

 

A couple of my close friends, one who was no stranger to miscarriage and another who just couldn’t stand to watch me slip away, decided that they had no intention of letting me hide out.

 

They called.  A lot.  And while they didn’t always mention miscarriage or infertility, they knew that I needed some space from it, they did let me know that they were right by my side.

 

They listened when I wanted to talk.  They said the right things…the only things you really can say from afar.  They asked other friends about their experiences and got back to me with ideas for different treatments.

 

They cheered me on when I went for my acupuncture appointments and laughed when I shared embarrassing stories after each appointment…as it turns out, it’s really hard to close your eyes and relax when you have little needles threatening to puncture your eyes if you happen to sneeze.

 

They cried on the other end of the phone when the second miscarriage started at almost exactly the same point in the pregnancy as the first.

 

They swore up and down that I didn’t eat something awful or walk too fast or sleep too little.  They reminded me 10,000 times that it wasn’t my fault.

 

They brought books when I needed books and wine when I needed wine.  They supported my Dark Chocolate M&M habit 100% and allowed me to be the third wheel…even when they probably really needed a date night.

 

Even though I still suffered in silence for much of the time and refused to tell another living soul other than them for a very long time…these two friends made the even the hardest days just a little bit easier to bear.

 

They did it simply by being there.

 

And that…is the power of three.

 

Infertility isn’t about hiding out…infertility is about reaching out to someone who understands.

 

This one’s for you Stacey and Stacey – I love you to the moon and back.