Ask Dr. Marc: What Should I Ask the Specialist?

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Infertility is full of questions, and often it feels like the questions go unanswered.  One of the most anxiety-producing experiences along the long and winding road of infertility is meeting with a specialist for the first time.  It’s difficult to know what to ask when you’re not even sure what the future might hold.  It can also be hard to share every intimate detail of your lives with a complete stranger, who might or might not even be the right specialist for you.

When Laura, one of our Facebook members, asked the group what questions she should ask, I immediately checked in with Dr. Marc.  Who better to ask than a specialist?  Dr. Marc has counseled countless couples down this road, and his bedside manner truly makes him one of the best specialists out there (biased, but true).

I hope Dr. Marc’s list helps you along the way.  But remember, it’s never too late to start asking questions.  So even if you’ve been in it a while, print this out and ask or ask again.  You can never ask too many questions when you’re trying to get pregnant!

 

Hi Laura,

The first interaction with an infertility specialist can be quite overwhelming.  Sharing the most intimate details of your life as well as your hopes, aspirations and fears with a perfect stranger is daunting.  Additionally, any strain which infertility has placed on a marriage is often magnified in the setting of a doctor’s office.

With this in mind, it is a good idea to prepare some questions for your doctor before going into the consultation.  The questions will serve you well not only through their answers, but if the doctor anticipates them and provides answers before you ask, that is a good sign!

Obviously, each patient and situation will have its own unique set of questions.  The following list is general questions and should apply to most people speaking to a fertility doctor for the first time.

1.     What is my diagnosis?

-While this sounds like an obvious question, it is hardly ever asked and even less frequently answered.  I like to think that a diagnosis provides patients with a “target.”  Once they can identify what the problem is, it is easier to overcome.   While your doctor may, or may not be able to provide this to you on your first consultation, you should at least receive some possibilities.  Even if your doctor says you have “unexplained” infertility, at least you will be able to label the cause and move on from there.

2.     What is my chance for success?

This is useful for planning, and setting appropriate expectations.  In some situations the doctor can be very specific.  For example, most IVF clinics publish yearly success rates broken down by age.  Your doctor should be able to provide these to you.  If you are not doing IVF, the doctor should still be able to give you some general guidelines as to the chance of conceiving as well as the chance of delivering a healthy baby.

3.     What is my chance if I keep trying naturally?

This may not apply to single patients, same sex couples or those with blocked tubes or no sperm; however for patients with “sub-fertility” they still have a chance for natural conception each month.  It is important to consider this chance in comparison to the success rates your doctor provides you.

4.     Are there other treatment options available to me?

Some doctors will tell you what to do without offering alternatives. This is not necessary a bad thing, it is good to have a doctor who is decisive and confident.  However, fertility treatment is highly personal and most patients are well informed.  I feel it is better to provide several appropriate treatment options, recommend the best one and then allow for a joint decision between all parties.

5.     What are the risks to me?

As with any medical treatment, there are risks to fertility therapy.  In general, the likelihood of complications is low and most complications are minor, but I feel that one of the best ways to avoid complications is by acknowledging their existence.  Further, patients who are aware of potential complications are less likely to encounter them.

6.     What are the risks to my offspring?

There has been significant research looking for an effect of fertility treatment on offspring.  The truth is that there may be up to a twofold increased risk for fetal abnormalities (from 2% in the general population to 4% to those conceived with fertility treatment) in babies conceived through fertility treatment.  What is unknown is if that increased risk is due to the fertility treatment or simply a reflection of a greater risk of fetal abnormality in people who require fertility treatment.  Regardless of the cause the overall risk is low, but important for patients to discuss with their doctor.

7.      What would you do if you were in my situation?

This question is tricky and may not be appropriate for all doctors, but I think patients can get a good feel for their doctor’s personality through this question.   If your doctor is not comfortable sharing their personal views, that is fine, but what better way to get to their strongest recommendation than to find out what they would do for themselves.

So Laura, this is really only a partial list, but having a game plan and some prepared questions before your consultation will help ensure that you get the most out of your time with the doctor.

Good luck!

Dr. Marc

p.s.  As for question #7, I have personally used that one on Dr. Marc more than once, and his answers have helped me through some very difficult scenarios.  Don’t be afraid to ask!

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Ask Dr. Marc: Unicornuate Uterus

Dr. Marc,

 

My name is Kristin, I am 31 and my husband Aaron is 39 (he has a 16 year old daughter from a previous marriage). I am currently seeing a fertility specialist and recently had cycle day three testing, ultrasound and an HSG. Upon completion it was determined that I have Diminished Ovarian Reserve and a Unicornuate Uterus on my left side (one Fallopian tube that is completely healthy on my left side as well as a good looking uterus on my left side, both ovaries, although, are small). My husband had a sperm analysis done as well and his Count/Motility/Volume were more than double the normal range. So we now know that the infertility issues are due to my body alone. We have discussed our options with our Dr and have decided to go ahead with medicated IUI cycles starting in May 2013 although our Dr thinks IVF is a better option. We cannot afford to do IVF at this time, IUI is far more cost effective for us. My question is how likely am I to conceive from IUI. My Dr only gave me a 2% chance of conceiving naturally, 5% with medicated IUI and 30% with IVF each cycle. Is that accurate? Or is it possible my chances may be higher given that my husband has exceptional sperm and even though I do have DOR I am still fairly young?

 

I appreciate your taking the time to answer my question. Thank you in advance.

 

Sincerely,

 

Kristin

 

Hi Kristin,

As I see it, there are a few issues to discuss.

First, I think it is important to recognize that infertility is NEVER due to one partner alone. Remember that making a baby is a team effort.  Just because one partner’s tests are normal and the others are not, does not necessarily mean that one person is at fault or responsible.  Further, remember that women have many more variables at play in this situation.  Men only have to have a few normal sperm; women need normal tubes, ovaries and uterus not to mention the hormonal environment for the 9 months of pregnancy!  It really is a lot, so don’t get down on yourself!

Second, the unicornuate uterus represents abnormal embryonic development.  The prognosis of a unicornuate uterus can range from poor to good, but it depends on how small the uterus is.  From your letter, it sounds like your uterus is of decent size so as not to be too much of a problem.  One thing I would recommend however, is that your doctor evaluate your kidneys.  The kidneys and uterus form at near the same time and is not uncommon for women with a uterine abnormality to also have a renal (kidney) abnormality.

Third, the diminished ovarian reserve (DOR) is a bigger deal.  I am not sure what your doctor is basing the DOR on, but it is probably the most important factor facing you.  The medication should help with this and the fact that you are young is also a positive!

Fourth, the fact that your husband’s semen analysis is normal is a good thing, but it doesn’t trump the other factors.

As far as numbers, I’d say your doctor is pretty accurate.  Maybe your chance is 5-15% with medicated IUI, but it really depends on your response to the medication.

The bottom line is that doing something will increase your chance over doing nothing.  If you could easily afford IVF that would be great, however if you cannot, then IUI is a reasonable way to go.

 

Good luck!

 

Dr. K

 

 

Ask Dr. Marc: Weight Gain and Infertility Treatments

Dear Dr. Marc,

Nice to meet you my name is Marianella.  I live in Costa Rica and I have 34 years, almost 35. My case is not like the other cases. I have a son…for IA…after he was born I decide to get pregnant and went for 6 IAS…nothing happen, so the Dr. send me to the fertility specialist… He made me a laparoscopy…clean on fallopian tube and he told me I had endometriosis.. I (2 focus) we did with him 2 IAs more…and nothing.

Desperate, I stop the treatments. I gain 27 pounds in this 2-year process… and I am losing weight since I decided it to stop. The Dr. told me not to let go the birth control pills and maybe do a FIV. Right now I am not in position of invest…my husband lose his job…and is really hard to find another one.

In all my IAs I had 2-4 eggs 18-25, most of them break …other made cyst..

So my question:
What can I do more? Is the FIV an option for me? Or the TIFG? Can I have option to get natural pregnant??? Is my weight affecting me?

 

Hola Marianella,

I am sorry that you have had such a string of bad luck; hopefully we can straighten some things out and get you on the right tract for the future.  Lets address things one at a time:

1. The fact that you became pregnant through insemination (AI as you said) previously, bodes well for you now.  Importantly, we need to figure out why insemination worked for you in the past.  Was there an issue with your husband’s sperm?  If so, that issue may now be worse.  Just because they have used his sperm for inseminations recently, does not mean that they have performed a complete evaluation of the sperm.  You should have your husband’s sperm evaluated completely.

2. Your history of endometriosis is important.  We know that endometriosis can contribute to infertility.  Although it sounds like your endometriosis was not severe in the past (only 2 focuses) it may have progressed.  With your history, it may justify another laparoscopy, or at least an HSG (hysterosalpingogram) to be sure that your tubes are still open.  I would do this before any more treatment.

3. Weight can be an issue.  We know that it is harder to get pregnant for women who are significantly over or under weight.  Ideally your BMI should be between 20 and 30.  To check your BMI you can go to (www.nhlbisupport.com/bmi/).

4. IVF is the best bet for you now.  After 6 inseminations with 4 to 8 eggs each time, you have exhausted the usefulness of insemination.  As for cost, IVF is more expensive than IUI, but it is not more expensive than multiple IUIs.  From that point of view, it is probably more cost effective to not do any more IUI and save up for IVF.

5. Natural pregnancy is always a possibility!  To that end I want to share a story of one of my recent patients.  She had gone through multiple IUIs over a 2-year period and never conceived.  Subsequently, the couple resigned themselves to IVF and took off a year to save up enough money.  She was supposed to come in this month with her period to start medication but her period never came!!! Low and behold, she was pregnant!!

The point is that you should not give up Marianella! Formulate a long-term treatment plan, save up for IVF and while you are getting prepared for the treatment, continue trying the old fashioned way!

Good luck,

Pura Vida,

Dr. Marc

 

 

Ask Dr. Marc: IVF and Breastfeeding

Dear Dr. Marc

Is it safe to go through IVF while breastfeeding? I have extensively researched the safety of the meds for me to take so that it doesn’t harm my daughter who’s nursing, but my doctor seems to think it could decrease my chances of getting pregnant (as in, decrease my response to the meds).

Thanks,

Nursing Mom

 

Hi Nursing Mom,

You pose a very interesting question with both medical and ethical implications.  The benefits of nursing are significant for both mom and baby.  Some maternal benefits include faster recovery after delivery, weight loss, lower long term chance for breast and ovarian cancer and lower risk of cardiovascular disease.  For baby, the benefits include less short-term illness like ear infections, less long term illness like cardiovascular disease or obesity, less allergies and even a slightly greater IQ!  To achieve these benefits, nursing should continue for a minimum of 6 months

Despite this long list of benefits and the fact that I encourage all of my patients to breast feed, I feel that IVF and nursing do not mix.

The main problem is due to the hormones prolactin and oxytocin, which are integral to milk production and release.  These hormones, produced by the pituitary gland, affect many organs throughout the body including the uterus, brain, intestine and ovary.  They are the reason why most women do not ovulate, and thus do not conceive, while breastfeeding.  One can think of these hormones as nature’s birth control.  Additionally, there are some rare types of brain tumors that produce prolactin, not coincidentally; infertility is one of effects for women with these tumors.  Lastly, some experts believe that elevated prolactin levels play a role in miscarriage.  For all these reasons, it seems like a good idea to keep prolactin and oxytocin levels as low as possible while trying to conceive.  In your case, that means cessation of nursing.

My view is that IVF requires such an enormous investment in terms of time, emotion and money, that it makes sense to make every effort to optimize the environment as much as possible.  My advice to you is to decide whether it is more important to continue nursing, or to try and conceive.  This decision should be based on your age, the amount of time you have been nursing and the reason you need IVF.

Despite my opinion that IVF and nursing do not mix, nursing during IVF is probably not dangerous.  If you decide to undergo a cycle and continue to nurse, you will probably just have a lower chance for success and maybe a slightly higher chance for miscarriage.  If you are okay with these risks, then I think your doctor should respect your wishes.

Good luck Nursing Mom,

Dr. Marc

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Ask Dr. Marc: IUI to IVF

This week Dr. Marc answers a Facebook member’s question about when to make the transition from IUI to IVF.  Send your questions through Facebook or email me: katiehurleylcsw(at)gmail(dot)com.

Dear Dr. Marc,

We are preparing for our fourth IUI.  We don’t know how many times we should try this.  We can’t afford IVF and it’s not covered, so we are trying to decide if we should take some time off to save up for IVF or keep trying.  What are the chances that this will work if we just keep trying?  I’ve heard of people doing 10 rounds with no luck.

Thanks,

Hoping for Success

 

Hi Hoping for Success,

Many patients question when they should move on from IUI to IVF.  The answer to this question depends on a multitude of factors including age, the amount of time trying, the medications taken with the IUIs, sperm quality, how you responded to the medication, emotional state of mind, ovarian reserve and more.  Regardless of these factors however, there are a few facts about IVF that you should keep in mind:

  1. IVF usually represents the best chance of getting pregnant on a per month basis.
  2. The cost of 3-4 IUI cycles with injectable medication is similar to the cost of an IVF cycle
  3. The efficacy of IUI diminishes after 3-5 attempts

With these factors in mind, a reasonable strategy is to forgo more IUIs in an attempt to save-up for IVF.  Now this doesn’t apply to everyone, especially if the IUI cycles were sub-optimal and can be improved.  However, if the IUI cycles went well and there is no good explanation as to why they didn’t work, IVF likely represents your best chance.

One more thing to remember is that while you are waiting to do IVF, you should continue with properly timed intercourse.  The truth is that you will continue to have a chance of natural conception each month, and sometimes when the pressure is off, great things happen!

Good luck,

Dr. Marc

Ask Dr. Marc: When to See a RE

Dear Dr. Marc,

I am trying anything right now, any thing to have a child. We have tried for what feels like eternity, and been tested. We have had blood work done, they say that’s normal, my husband has had his sperm count checked, and that came back normal. They say everything is normal……I am 28, my husband is 32…..but we both are losing hope, and I don’t want that!!!

We have tried diets, changes, exercise, and nothing is working. We have cut back on sweets, drinking, and bettered our diets…we have tried this for a year now.  I was on YAZ for 4 years before stopping. Last night we went and got a belly rub done, trying anything out there!

Is there anything else I am missing?

L.

 

Hi L,

First of all, don’t give up hope!  From the information provided, it sounds to me like you stand an excellent chance to conceive!  With that being said, it is probably time for you to take some specific steps towards your goal.

First, you should meet with a fertility specialist, otherwise known as a reproductive endocrinologist (“RE” for short).  To find a good one, you may want to ask your primary OB/GYN for a referral, or consult with friends, or look to Google and review practices in your area.  In addition, the Society of Assisted Reproductive Technologies (www.SART.org) is an excellent resource to compare fertility doctors and review their success rates.

Once you meet with the RE, they will review the tests you have already had, and ask you and your partner about medical, environmental, pubertal and surgical history.  You should be sure to come prepared with all of your old records and a calendar of your past few menstrual cycles (including the day they began and ended). The doctor will likely want to evaluate factors such as your fallopian tubes, your uterus, the environment, ovulation timing and more.  If all of your tests come back as “normal” then you would be classified as having “unexplained infertility.”  This diagnosis is given to approximately 30% of couples with infertility.  While it is highly frustrating to not know the exact reason you are not conceiving, couples with unexplained infertility stand a very good chance of conceiving with fertility treatments.

On another note, it is wonderful that you and your husband are watching your diet and have started exercising.  These steps will certainly help you lead a healthier and longer life.  Unfortunately, things like diet and lifestyle change have less of an impact on fertility than many people would like to believe.  This is especially true when there if there is a physical impediment such as blocked fallopian tubes or uterine fibroids.  So while I encourage you to continue your healthy lifestyle choices, I caution you against waiting very long to see if they impact your fertility.  In general, it is better to be evaluated by a doctor and then make the decision on what your next step will be.

Good Luck,

Dr. Marc

Ask Dr. Marc: Cycle Conversions

Dear Doctor Marc,

I am in the middle of a cycle now and we’re faced with more decisions. For our first, we did 9 rounds of IUI (started with just clomid, progressed to combo clomid and follistim, then only follistim to conceive).

We’re on our third round of IUIs this time around (on max dose of follistim) and are considering converting this round to an IVF cycle due to the risk of hyperstimulation. Just yesterday I had 6 follicles in the 9-11 mm range and today we had 19 in the 11-13 range! We’ve never done IVF so I’m slightly nervous about the conversion, especially the down time after retrieval and transfer with chasing another little one around.

Here are a few more details: estrogen in low 900s, can’t convert cycle because our clinic isn’t in an IVF cycle at the moment, monitoring again tomorrow morning, lower follistim dosage to 25 iu for tonight and possibly take Luperon tomorrow depending on lab work. Doc doesn’t think we have an overly average number of fully mature follicles but we are concerned about high order multiples and other risks (hyper-stimulation, etc).

Is conversion a good option?

L.

Dear L.,

Converting an IUI cycle to IVF is a very reasonable option in certain circumstances.  In fact, I can think of a couple patients, in particular, who have benefited greatly from this option.  In addition, the fact that you have completed so many IUIs indicates to me that it is probably time to move on to IVF anyway.  With that being said, there are a few factors you would want to be in order before converting up to IVF.

1. Your lead follicles should not be too big:  If the largest follicles are too big, the smaller follicles may not have time to catch up.  This could result in a lower number of eggs for IVF and potentially could affect your chance for success.  If there are indeed 19 follicles in the 11-13mm range, this does not seem to be a problem.

2. Endometrial lining:  Sometimes an IUI cycle that is converted to IVF may be a very long cycle (greater than 14 days).  Very long cycles can result in overstimulation of the endometrium, which could negatively affect your chances.   You doctor can get a sense of your lining by measuring it on ultrasound.

3. Timing: There are a multitude of variables which go into an IVF cycle.  Coordinating these variables is one of the most important jobs of an IVF center.  If your center is not prepared to coordinate an IVF cycle at this time, then you definitely want to wait until they are ready.

The bottom line is that conversion to IVF can be an excellent option, but it should only be used in properly selected patients.

Good luck,

Doctor Marc