Question 13. What is ureaplasma, and how did I get it?

Well I am trying to keep up with my schedule of daily posts but life and work keeps getting in my way. Spring Break starts this week so my ability to post daily bits of wisdom to the 3 regular readers of this blog may be limited. My apologies in advance.

Screening for ureaplasma is like religion....some people have religion and some do not! Many REs simply treat all patients and some treat none.... However, one issue is absolutely true and that is the presence of ureaplasma does not suggest marital infidelity. On the other hand, if your spouse likes to hang out with Tiger Woods then all bets are off...

13. What is ureaplasma, and how did I get it?


Most reproductive endocrinologists routinely obtain samples from the cervix (cervical cultures) to assess their patients for gonorrhea, chlamydia, ureaplasma, mycoplasma, and other bacterial infections. Gonorrhea and chlamydia are sexually transmitted diseases that can cause tubal damage and infertility when these bacteria travel from the cervix through the uterus and out into the fallopian tubes. Sexually transmitted infections can be passed back and forth between sexually intimate partners. Patients with gonorrhea may have a yellowish discharge associated with pelvic pain and fever. Although chlamydia can be associated with these symptoms, chlamydial infections are often silent; despite their lack of symptoms, Chlamydia infections may result in significant tubal scarring and damage.

Ureaplasma and mycoplasma are bacteria that can be commonly found in the reproductive tract of both men and women. It is somewhat more problematic to label these two bacteria as reproductive tract pathogens, because they are often found in fertile, healthy couples in addition to those with infertility. Although the presence of these two bacteria have been hypothesized to play a role in both infertility and miscarriage, the specific mechanisms by which they impair fertility remains unclear. The question of whether ureaplasma or mycoplasma can cause reproductive tract damage or whether their presence increases the rate of miscarriage has not been definitively answered. As a consequence, many clinics do not test for ureaplasma or mycoplasma routinely.

If cervical cultures for ureaplasma and mycoplasma are positive, both the patient and her sexual partner are usually treated with antibiotics such as doxycycline. As these bacteria may have been present for many years without causing any symptoms, the finding of ureaplasma and mycoplasma on cervical cultures does not in any way indicate infidelity or sexual misconduct.

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Question 12: What is a hysteroscopy, and do I need one? Is it the same as a water sonogram or a hysterosalpingogram?

Sometimes you have to learn a new language when dealing with medical issues. Fertility treatment is no exception. Unfortunately, some of our terms sound very similar....especially those that start with HYST. So we have hysteroscopy, hysterosalpingogram, hysterosonogram and hysterectomy. The last one refers to the surgery performed to actually remove the uterus. Clearly, hysterectomy is not a fertility preserving procedure! So when filling out your new patient information, make sure that you only check off hysterectomy if you have indeed undergone a surgery that removed your uterus!

So here is today's Question of the Day! Sorry I missed posting yesterday but it was a kleenex box type of day and I was too wiped out to post.

12. What is a hysteroscopy, and do I need one? Is it the same as a water sonogram or a hysterosalpingogram?

A hysteroscopy is a simple surgical procedure that is performed either to diagnose or to treat a problem within the uterine cavity. During hysteroscopy, the physician inserts a small fiber-optic telescope through the cervix and into the uterus. Either gas or liquid can be used to distend the uterus and allow the physician to directly visualize the uterine cavity. The physician may also introduce small instruments into the uterus to cut scar tissue or remove polyps or fibroids. Although diagnostic hysteroscopy can be performed in the physician’s office under local anesthesia, operative hysteroscopy usually requires anesthesia because of the cramping that occurs during uterine manipulation. Complications of hysteroscopy are rare but may include infection, bleeding, uterine perforation, damage to adjacent structures, and even death.

A water sonogram (hysterosonogram ) is a specialized ultrasound examination performed using a transvaginal ultrasound probe. First, a small catheter is passed through the cervix and into the uterine cavity. Sterile saline is then introduced into the cavity while a transvaginal sonogram is performed allowing the physician to visualize any uterine polyps or fibroids. Usually, a hysterosonogram does not provide any information about the status of the fallopian tubes. Nevertheless, hysterosonograms are helpful in identifying the presence of an endometrial polyp seen on routine sonogram or the location of a fibroid (see Figure 3). A hysterosonogram has limited benefit in evaluating for the presence of uterine scar tissue and is a diagnostic and not therapeutic procedure.

A hysterosalpingogram (HSG) is similar to a hysterosonogram in that fluid is introduced into the uterine cavity. However, the fluid is not saline but rather is a radio-opaque dye. This dye is introduced into the uterus and under fluoroscopy the dye is observed as it sequentially fills the uterine cavity and then passes out into the fallopian tubes and ultimately spills out of the ends of the tubes and into the pelvis . The HSG can be used to diagnose polyps and fibroids and is superior to hysterosonogram in evaluating the presence of uterine scar tissue. This imaging procedure also provides information on the status of the fallopian tubes, unlike either a hysteroscopy or a hysterosonogram. Because it employs traditional x-rays, an HSG is usually performed at a hospital’s radiology department or at a radiologist’s office, since few REs have this equipment in their offices.

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Question 11. What is a laparoscopy, and do I need one?

When I was a medical student at Duke back in the 1980s I spent a rotation with the fertility division that was headed up by Dr. Arthur Haney. Dr. Charles Hammond was the Chairman of the Department and was also an attending in that division. Every Thursday they would have 8-12 laparoscopic surgeries scheduled. A large percentage of these laparoscopies revealed either no problems or very minimal endometriosis. Over the past 20 years the surgical approach to infertility has been replaced by a more rapid move to IVF. However, some patients still benefit from laparoscopy which leads to today's Question of the Day:

11. What is a laparoscopy, and do I need one?

A laparoscopy is an outpatient surgery usually performed under general anesthesia. Most laparoscopies are completed in a hospital, but some physicians utilize freestanding outpatient surgery centers.

During a laparoscopy, the physician inserts a small fiber-optic telescope into the abdominal cavity through an incision made in the patient’s umbilical area (belly button). Most physicians initially distend the abdomen using carbon dioxide gas with a needle (Veres needle) to create what is called a pneumoperitoneum. A trocar—an instrument with a diameter similar to that of a pencil—is then passed through the umbilicus, allowing for introduction of the telescope (called a laparoscope) into the abdomen.

Using the laparoscope, a gynecologic surgeon can inspect the uterus, fallopian tubes, and ovaries. The appendix and upper abdomen are carefully inspected as well. Additional instruments may be inserted into the abdomen through incisions (ports) made along the hairline above the pubic bone. For example, the physician may use graspers, scissors, or suction irrigators to rinse the tissue and remove blood and fluids as needed. Some physicians insert a slightly larger telescope through the umbilical port, which allows them to use a carbon dioxide laser to cut scar tissue or destroy implants of endometriosis. Besides the laser, other instruments can be used to cut or burn abnormalities such as endometriosis or scar tissue.

During a laparoscopy, the physician typically introduces a blue dye into the uterine cavity while directly visualizing the fallopian tubes. If the fallopian tubes are patent (open) but are located in an abnormal location because of scar tissue, then the surgeon may try to free the fallopian tubes to improve the patient’s fertility.

If abnormal ovarian cysts such as endometriomas are present, then the physician may remove them during the course of the laparoscopy or, if necessary, perform a laparotomy. A laparotomy is a surgery performed through a larger incision, usually made along the bikini line. It may require the patient to stay 1 to 3 days in the hospital following the surgery. In addition, a laparotomy requires a longer recovery period and may create more new scar tissue than laparoscopic surgery.

Certain abnormalities cannot be easily treated through laparoscopy, including exceedingly large ovarian cysts, ovarian cysts that are suspicious for cancer, and fibroids that are deeply embedded in the wall of the uterus. Patients with these problems are probably better served by a laparotomy.

For many years, all women who were seeking fertility care underwent laparoscopy as part of the initial evaluation. In recent times, this practice has faded with increased utilization of IVF. Although IVF has essentially replaced tubal surgery in patients with tubal factor infertility, laparoscopy is still used to correct certain problems in patients prior to undergoing IVF. For patients uninterested in IVF (for religious, financial or philosophical reasons), laparoscopy may still represent an important part of their diagnostic and therapeutic options. Complications of laparoscopy are rare but can include injury to the bowel, bladder, and blood vessels; a need for laparotomy; and even death.

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Question 10. What is antimullerian hormone and what does this test tell my doctor?

TGIF. Yup, it is Friday afternoon here at Dominion and I am looking forward to a free weekend. For the past 10 years it has been just myself and Dr. DiMattina and I can tell you that every other weekend on call can wear you down....especially if the other guy has vacation. Before I joined him, Dr. DiMattina never took a vacation and at one point had to remove his own appendix with a spoon immediately following an egg collection which was performed at 2 am since this was in the days before Lupron...or ultrasound...or anesthesia....or electricity (if you catch my drift). Still as long as you give the staff bagels and muffins the weekends run quite smoothly.

So what about newer tests of ovarian reserve? The use of AMH is kinda like religion..either you are a believer or you are not. We are believers in AMH here at Dominion. I find it to be very helpful in assessing patients for IVF protocols and for making a host of other treatment related decisions. However, I would not ask your Ob Gyn to check this hormone as the interpretation of the results can be tricky.

Hope all of you have a great weekend and here is the Question of the Day!


10. What is antimullerian hormone and what does this test tell my doctor?

AMH is a protein hormone produced by the cells that directly surround the egg, called the granulosa cells. Granulosa cells (GC) also produce the hormones estrogen and progesterone. Since the cells that surround each egg produce AMH, we can measure a patient’s blood AMH level and get a good determination of her total follicle pool or total egg count. If her AMH level is low, then her total follicle pool or egg count is also probably low. AMH offers additional insight into the patient’s ovarian reserve in addition to the other tests such as serum day 3 FSH, day 3 estradiol, clomiphene citrate challenge testing (CCCT), or an ovarian ìantralî follicle count (AFC) using ultrasonography. Since cycle day 3 FSH levels often fluctuate widely, a single measure of FSH may not represent a patient’s true ovarian reserve especially if AMH and antral follicle count are normal.

The advantage of serum AMH testing is that AMH can be measured on any day of the patient’s menstrual cycle. In other words, its levels are cycle day independent, so patients don’t have to worry whether or not the blood sample is collected on day 3. Also, its levels tend to be more constant and more reliable for assessing ovarian reserve than day 3 serum FSH and estradiol. We often observe patients whose day 3 FSH and estradiol levels are normal indicating normal ovarian reserve, yet their AMH level is low and consistent with an observed low antral follicle count suggesting diminished ovarian reserve. Upon performing ovarian stimulation on such patients using gonadotropins, we often find that the AMH and antral follicle count properly identified the patient’s true ovarian reserve better than using serum day 3 FSH and estradiol measurements.

At Dominion Fertility, we place much more emphasis on AMH levels than we do on the other blood markers for ovarian reserve. In Europe, AMH is also the preferred biomarker for assessing ovarian reserve in many IVF centers but the use of AMH in the United States is becoming increasingly more popular.

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Question 9. What is ovarian reserve, and how is it tested?

Ovarian reserve is a very important but confusing topic. I would like to share an interesting story about ovarian reserve before getting to the Question of the Day on this day after Saint Patrick's Day. For those reading this blog on Fertile Grounds, feel free to skip to the Question if you have already read this story in my post.

DK is a 38 year old who came to see me in September 2008. She and her husband had undergone fertility treatment 3 years earlier at another center and conceived with CC/FSH/IUI but had a quintuplet pregnancy that ultimately ended up as twins. They were very worried about having another multiple pregnancy and wished to discuss options.

However, as part of the evaluation her FSH was found to be 14 with a normal E2 but an AMH of<0.1 and an antral follicle count of 2-3. Although they had originally considered stimulated IVF with single embryo transfer that option seemed unlikely given her diminished ovarian reserve. After failing a few natural cycle IUIs they decided to try Natural Cycle IVF in 2009. Their first Natural Cycle IVF was a biochemical pregnancy. They tried Natural Cycle IVF again in June 2009 and were successful. She was sent off to her Ob Gyn with a normal looking pregnancy.

But the roller coaster was just getting cranked up....

She underwent a CVS given her age and the results showed that some of the cells were normal but some were trisomy 9 (not compatible with life). Her Ob Gyn was suggesting a D&C so she called me just to let me know what was going on. I fired off an email to Dr Mark Hughes (the world's smartest geneticist). Since we know that the 8 cell human embryo can contain both normal and abnormal cells (limiting the usefulness of PGS) I was thinking that maybe the CVS results represented a case of placental mosaicism where the baby is normal but the placenta has both normal and abnormal cells. Dr. Hughes confirmed that was indeed possible.

The couple elected to continue the pregnancy and undergo amniocentesis. The amnio was totally normal and all sonograms were normal. She went full term and just went home from the hospital today after delivering a healthy 9 pound baby!

So this case demonstrates many interesting points. First of all, is Natural Cycle IVF appropriate in a couple with normal tubes, normal sperm and previous pregnancy? The answer was a resounding "yes" in this case. Secondly, can ovarian reserve drop dramatically in just a few years? The answer is "yes" and although this case is a bit unusual in that the patient went from quints to diminished ovarian reserve in just 3 years. Thirdly, this case does demonstrate again the limitations of PGD/PGS and even CVS in cases of mosaicism. Finally, this case shows how important it is to consider all options especially when confronted with an unexpected result (like mosaicism on CVS).

I am so happy for this family and considering that I am not a big lover of roller coasters, all I can say is a few more wild rides like that one and I probably wont have any hair left at all!

9. What is ovarian reserve, and how is it tested?

During a woman’s reproductive cycle, each month a single follicle is selected out of a group of potential follicles, reaches maturity, and ovulates a single egg. Many fertility treatments use medications to “rescue” other follicles from that group, so that multiple eggs are released during ovulation as opposed to just a single egg. If physicians could predict which patients would respond well to fertility treatments, then those women predicted to produce a low number of eggs with a poor chance of success with stimulated cycle IVF could defer this treatment and consider other options including unstimulated or Natural Cycle IVF. Those women who respond well to fertility medications are described as having normal ovarian reserve. Those patients who have a poor response to fertility medications are described as having diminished ovarian reserve. Although those patients with diminished ovarian reserve are likely to demonstrate suboptimal numbers of eggs during a stimulated IVF cycle, they may still conceive spontaneously, or with non-IVF treatments or with Natural cycle IVF.

Ovarian reserve consists of two separate components, both of which determine a woman’s chance of conceiving a child with IVF. The first component is the number of extra follicles that are available to undergo recruitment with treatment using fertility medications. This number depends on several factors, including the woman’s chronological age (as discussed below), previous ovarian surgery, genetics, and exposure to environmental toxins (most notably, tobacco usage).

The second component is the actual health of the follicles and the eggs within those follicles. First and foremost, egg quality is determined by a woman’s chronological age. Peak female fertility occurs when a woman is in her twenties and then drops significantly with age, especially following age 35. This fact has been conclusively demonstrated in many ways but is especially obvious when we look at IVF pregnancy rates. In patients who undergo IVF, studies have shown that around the age of 35 years old a marked decrease occurs in the chance of an embryo implanting successfully. In addition, the miscarriage rate rises with age, especially in those women older than age 40, in whom this rate exceeds 50%. Therefore, the age component of ovarian reserve is essentially immutable. In other words, unless she uses eggs from an egg donor, a woman cannot change her chronological age—and with increasing age, the number of normal eggs inevitably falls sharply. Although it is true that the percentage of normal eggs within an ovary is specific to the individual woman, even the most fertile women possess very few normal eggs after age 40.

The concept of ovarian reserve testing, therefore, represents a means by which the physician attempts to evaluate a woman’s reproductive potential both in terms of the number of follicles that remain and the health of those follicles. There are several ways in which one can assess ovarian reserve. First, the woman’s follicle-stimulating hormone (FSH) level can be measured on day 2 or 3 of a normal menstrual cycle. An estradiol level should be obtained at the same time, because the FSH level can be misleadingly low in women who have a high estrogen level early in the menstrual cycle. Alternatively, ovarian reserve can be assessed by performing a transvaginal ultrasound and counting the antral follicles present. In women with a slightly elevated FSH level, a transvaginal ultrasound may reveal a large number of follicles—somewhat reassuring the patient and her physician that perhaps her ovarian reserve is more normal than might otherwise be expected.

Unfortunately, normal FSH and estradiol levels do not guarantee a normal response to fertility medications. The clomiphene citrate challenge test (CCCT) was initially described as a means to identify those women with normal FSH and estradiol levels on day 3 of the menstrual cycle (day-3 hormones) who may demonstrate a suboptimal response to injectable fertility medications and poor IVF pregnancy rates. In the CCCT, the patient takes 100 mg of clomiphene citrate on cycle days 5 through 9. An FSH level is checked on days 3 and 10. If both of these levels are less than 10 IU/L (international units), then this represents a normal response. If the FSH level is greater than 10 IU on day 3 but less than 10 IU on day 10, then this represents a borderline situation, but potentially reassuring based on the response of the ovary to stimulation with clomiphene citrate. If the FSH level is normal on day 3 but more than 10 IU on day 10, however, the woman is likely to exhibit a suboptimal response to fertility medication, along with high IVF cancellation rates and poor pregnancy rates.

Antimullerian hormone (AMH) is another blood hormone test that is often used to assess ovarian reserve. Many experts believe that AHM is a better indicator of ovarian reserve than serum FSH as it has less cycle to cycle variability. See Question XX for more information on AMH.

A word of caution is in order regarding ovarian reserve testing, including the CCCT: Virtually all physicians have patients who have successfully delivered a child following an abnormal CCCT. An abnormal CCCT or elevated FSH levels on cycle day 3 do not preclude spontaneous pregnancy and delivery. Nevertheless, the miscarriage rate and the incidence of Down syndrome may be increased in such pregnancies. Patients with diminished ovarian reserve may have successful treatment with the combination of fertility drugs and intra-uterine insemination (IUI), or even with IUI alone. More recently, unstimulated or Natural Cycle IVF has gained increased popularity in treating patients with diminished ovarian reserve. A recent paper from Italy described 500 Natural Cycle IVF cycles in patients who had previously failed to respond to ovarian stimulation medications. In spite of having such a poor history, over 10% of the women under 40 years of age achieved a pregnancy. Considering that in the United States, most of these women would have only been offered donor egg IVF, we consider that pregnancy rate to be very remarkable.

The real benefit of the CCCT is its ability to identify often those patients in whom stimulated IVF is markedly less likely to be successful, allowing them to focus on other options such as unstimulated IVF, donor-egg IVF, adoption, or less invasive office-based fertility treatments. Overall, ovarian reserve testing represents an important factor when considering various fertility treatments and may be the final arbitrator in selecting the specific treatment plan.

Rebecca comments:

I first walked into my RE's office at the age of 39. I had just suffered the loss of a pregnancy that had taken me 8 months to conceive. I was very aware of the proverbial 'biological time clock' and was concerned that my husband and I may have run out of time. I was panic stricken about the tests that would evaluate my ovarian reserve, however my desire to have children was greater than the fear I had about the test results. Fortunately, we found an RE who did not rely solely on my chronological age when he discussed our treatment options with us. He reviewed all my medical tests with me and offered an individualized plan that included a number of family building options that might address my infertility issues (most likely age related). Looking back, I realize how important our choice of RE was. It is important for women of advanced maternal age (AMA) to quickly identify an RE that is willing to work with, and is experienced in working with, women of AMA. An AMA woman must find a fertility clinic that offers a variety of fertility treatment options; one size (or one treatment) does NOT fit all. And finally, an AMA woman must find an RE who is willing to be aggressive in her treatment, but is also capable of being honest about the limitations of those treatment options for an AMA woman.

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Question 8: What tests will we have to undergo as part of a fertility evaluation?

Happy Saint Patrick's Day from Dr. G and the rest of the staff here at Dominion Fertility. Let me tell you that Dr. DiMattina's outfit today puts mine to shame! If only all of you could see his day-glo green shoes, belt, tie and hat. Oh well. Perhaps I will post some photos of him this week so you can see what you missed by not hanging out at Dominion Fertility.

Most patients are anxious about coming to see the fertility specialist because they just don't know what to expect in terms of testing and treatment. In general, most REs approach the testing phase in a similar fashion as detailed below. The women are usually quite easy to work with while the men are usually pretty resistant. I think that getting reduced down to a number is problematic for many of us. Yes it can be embarrassing to have to do a semen analysis but that's just the way it is!

Happy Saint Patrick's Day!



8. What tests will we have to undergo as part of a fertility evaluation?

The basic infertility evaluation consists of a handful of tests. The woman typically undergoes a transvaginal ultrasound, hormone blood tests, an assessment of the fallopian tubes and uterus (by x-ray or by laparoscopic surgery). The man gets off relatively easily as he usually only undergoes a semen analysis.

Transvaginal ultrasound allows the physician to assess the appearance of the uterus and the ovaries. During this examination, the physician may discover uterine abnormalities such as fibroids (benign growths of the muscle of the uterus) or uterine polyps (benign growths of the lining of the uterus). Ultrasonography can also identify the location of the ovaries and determine the number of follicles present (antral follicle count), which correlates with the woman’s response to fertility medications. In addition, examination of the ovaries may reveal the presence of abnormal ovarian cysts such as endometriomas, dermoid cysts, or—in rare cases—precancerous and cancerous lesions.

In addition to the routine vaginal ultrasound, an assessment of the fallopian tubes and the uterine cavity is appropriate when the woman is having trouble conceiving. This examination is usually accomplished through a hysterosalpingogram (HSG: see Figure 2), an x-ray test that is performed under fluoroscopy by a gynecologist, a reproductive endocrinologist or a radiologist. Although it may sometimes cause mild uterine cramping, the vast majority of patients tolerate this procedure without difficulty. The individual physician performing this test can make a huge difference in the experience for a typical patient. For example, we utilize a soft catheter which is held in place against the cervix but is not actually passed into the uterine cavity. The use of this instrument rather that a balloon type catheter that must be introduced through the cervix and into the uterus can markedly reduce patient discomfort with this test. Similarly, only a small volume of dye is needed to fill the uterus and fallopian tubes. Excessive pressure and volume of dye can lead to much greater cramping and rarely improves the diagnostic accuracy of the test.
Alternatives to the hysterosalpingogram include laparoscopy and hysteroscopy; these outpatient surgical procedures are described in Questions 10 and 11.

Laboratory tests on the female partner of an infertile couple usually include routine screening tests such as those for blood type, blood count, and rubella immunity. In addition, most physicians perform tests that check the woman’s prolactin and thyroid-stimulating hormone (TSH) levels. Additional reproductive hormone testing for ovarian reserve is usually part of the routine evaluation as well (see Question 9).

Routine testing of the male partner of an infertile couple includes a basic semen analysis evaluating the volume of semen, the concentration of sperm (sperm count), the percentage of moving sperm (sperm motility), and the percentage of normally shaped sperm (sperm morphology). (See Table 2.) Although some clinics perform additional sperm function tests, such as the acrosome reaction and hypo-osmotic swelling test, the overall benefit of these two tests remains somewhat controversial. Both of these tests attempt to predict the functional ability of the sperm in terms of its ability to fertilize an egg. Ultimately, however, the best evidence of normal sperm function is a recent pregnancy or normal fertilization during a cycle of IVF.

Tests to detect the presence of antisperm antibodies in the blood of the female partner or coating the individual sperm may sometimes be recommended. Female antisperm antibodies may cause infertility that is best treated by IVF. Antisperm antibodies present on the sperm themselves may inhibit normal fertilization. In such cases, collecting a semen sample in media for use in artificial insemination may be considered, but these patients are usually recommended to pursue IVF with intracytoplasmic sperm injection (ICSI).

Kristin comments:

Despite having a diagnosis of PCOS when I was referred to an RE, I still had to go through the regular battery of blood tests, ultrasounds, and an HSG. It was a really scary time because none of my friends had ever gone through any of the tests and I really felt like a pincushion. Besides the physical toll of the tests, it was definitely emotionally draining. I think the initial tests in some ways prepare you for the weeks of daily blood draws and ultrasounds that accompany IUI [intra-uterine insemination] and IVF. Before IVF I was terrified of needles, but within days I was a pro at giving myself shots.

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Question 7: What are typical causes of infertility?

Being a fertility specialist is a bit like being a detective. You gather the evidence and then work on a hypothesis. Once you have the hypothesis, then you can test it out and see if the problem is resolved. Today I saw a new patient that was very frustrated with her situation and the response that she had gotten from her previous physicians. I listened carefully to her story and then explained carefully what I thought explained her particular problem. We now have a plan to test my hypothesis. If I am right then we will all be very happy, but I think that even if I am wrong then at least the couple understood how I approached the problem in a logical fashion.

Ultimately there are not that many fertility issues and common things are common. But every patient has their own story to tell and we need to listen in order to make sound decisions. So what types of problems do we deal with? Good question and the topic of today's Question of the Day from the upcoming 2nd Edition of 100 Questions and Answers about Infertility.


7. What are typical causes of infertility?

The causes of infertility are wide ranging but can be examined in light of the reproductive cycle described in Question 1. (See Table 1.) In general, the causes of infertility can be equally divided between the male and female partners in a couple.

Half of all infertility cases, therefore, involve problems with the sperm of the male partner. Unfortunately, functional tests for sperm competence (the ability of sperm to fertilize an egg) are not available leaving us to rely upon the descriptive components of the semen analysis. A complete semen analysis should include the total number of sperm (concentration), the percentage of those sperm that are moving (motility), and the shape of those sperm (morphology).

Many factors can reduce the female partner’s ability to conceive. For example, a woman may have anatomical problems related to the fallopian tubes, uterus, and peritoneal structures within the pelvis such as adhesions or endometriosis. Problems with ovulation are very common in infertile patients, and women with irregular periods may suffer from a common disorder such as polycystic ovarian syndrome (PCOS). Another major fertility factor is reproductive aging. Peak fertility occurs when a woman is in her twenties, and it declines significantly during her thirties and forties. The rate of decline increases after the age of 35 as is evident in decreased IVF pregnancy rates and decreased embryo implantation rates in this age group.

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Question 6: How do I choose a fertility clinic?

Well Washingtonian magazine has published its annual "Top Docs" issue and I was pleased to report to my parents that I made the cut again (as did Dr. DiMattina). Yet, several excellent Ob Gyn physicians that I know were not on the list this year. Did they suddenly become terrible doctors? No. However, probably they will lose some patients because of the fact that they were not voted in this year.

Popularity contests are probably not the ideal way to choose a physician. Neither is the internet. So how should a patient make such an important decision.? I would go with whatever clinic has the best candy at the front desk...but seriously, this is an important question to consider. So important that it is the Question of the Day for this rainy Monday in March.

6. How do I choose a fertility clinic?

Choosing a fertility doctor for your care may be the single most important factor that leads to a successful pregnancy, so choose carefully.

Many patients are referred to us by their OB/GYN, friends, relatives, former patients, news articles, or through the Internet. But the one common denominator we have routinely observed with the sophisticated patient is that she is well prepared before coming for her initial office visit or she quickly becomes informed and knowledgeable before we begin any treatments. Patients often say to us, “I checked you out before making this appointment.” Of course, we are always flattered by such comments, and we anticipate that this patient will ask all of the important questions and make an intelligent decision regarding her treatment options. She will also probably experience less stress during the evaluation and treatment process, as she has developed a better knowledge base and understanding of what to expect.

All fertility clinics come with a unique flavor of their own. Some are run by a solo practitioner, others by 2 to 6 member groups, while others are clinics with over 15 doctors. Regardless of the size of the group, be sure you are getting the attention and treatments you desire and deserve. You should never feel like a number with a revolving door of doctors.

Of course, patients are not doctors and will not have the knowledge or experience of a reproductive endocrinologist, but a caring doctor will always welcome any and all questions and will take the time to answer them in a way that you can understand. We view patients as our partners, and once we understand what they are willing or not willing to do, we can devise a treatment plan that offers hope without subjecting them to any unnecessary additional stress.

Other things to consider.
Statistics, statistics, statistics: You want a baby, so choose a fertility clinic with good success rates. However, a wise man once said: “There are lies, damn lies, and statistics.” So, how does one determine what to make of these statistics? In truth, there is no easy answer. Clinics that are more selective can inflate their success rates, while those that have a different philosophy may suffer the consequences even though they have an excellent program. For example, clinics that encourage elective single embryo transfer (eSET) or that offer unstimulated or Natural Cycle IVF may demonstrate lower clinical pregnancy rates as fewer embryos are transferred. Yet, in fact, such clinics that routinely transfer one or two embryos may have the best IVF programs. When considering a clinic, it is important to know what your specific chances for success will be within that clinic.

If there is one yardstick with which to compare clinics, then we recommend examining the pregnancy rate using donor eggs. In this patient population, the pregnancy rates should be very high. A low donor egg pregnancy rate may be concerning. All clinics should have a good pool of young egg donors and a recipient population that is fairly similar allowing for better comparison of clinics.

Advertising may be misleading. Obviously, a practice with 10 to 20 doctors will produce more total babies than a medical practice with only 2 to 6 fertility doctors, but the pregnancy rates may be equivalent (as can be seen in Figure 37 of Appendix B). Individuals should evaluate the clinic statistics and obtain a good understanding and feel for what their specific chances for pregnancy will be per treatment. Patients may also evaluate the clinic success by reviewing IVF statistics at the Centers for Disease Control and Prevention (www.cdc.gov/ART/index.htm/).

Experience: Experience of the clinic, in our opinion, may be one of the most important factors when deciding which doctor and which clinic to seek for fertility care. One should ask how long the doctors have been performing various treatment procedures. It is also important to know whether or not cutting edge procedures are either being offered or are being developed in the practice.

Subspecialty board certification: Most doctors practicing in the field of in vitro fertilization and infertility are subspecialty board certified in reproductive endocrinology and infertility. Evidence of this certification can be found by going to the Society for Reproductive Endocrinology’s Web site, which lists doctors who are subspecialty certified in reproductive endocrinology and infertility. Additionally, patients may find it beneficial to check if their doctor has a faculty position at one of the local medical universities or actively participates in the teaching of the medical students and residents in their locality.

Availability and accessibility of doctors: It is important that you have access to your doctor in order to have your questions answered and needs addressed. Evaluate whether or not the availability and accessibility of the doctor is an easy process or a difficult one when making decisions as to where to seek care. The friendliness and helpfulness of the staff will also give you a feel for the character of the practice.

Cost: It is always important to get the total cost. Factor in extra expenses such as the fertility drugs, which can cost thousands of dollars; intracytoplasmic sperm injection (ICSI); assisted embryo hatching; embryo cryopreservation; and preimplantation genetic diagnosis (PDD). These drugs and procedures can quickly increase the overall cost for treatment.

A word of caution: In general, Internet chat rooms may be a dangerous place for seeking advice regarding finding an infertility doctor. Be careful what you hear online, as it always represents just one half of the story. It is far better for you to do your own homework and research than to rely on information provided from others, which may be based on misleading impressions or experiences. Patients reporting on their experience with a given clinic or doctor may represent both extremes of the spectrum.

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Question 5: Who should evaluate the infertile couple?

I was never sure if I had all my shots as a child. With a father who was a general surgeon all of my camp forms were filled out at home. My Dad would pretty much just make up dates that seemed reasonable. I bet that many of these forms had me getting shots on major holidays and weekends but no one ever seemed to care.

When my Mother was 40 years old she stopped getting her period and felt pretty awful....tired, sick, nauseated etc. She asked my Dad what his diagnosis was and he replied "menopause." He snorted when she suggested that she might me pregnant. I arrived 7 months later! So my suggestion is to avoid getting fertility advice from general surgeons. Ob/Gyns are another story and in many cases the fertility evaluation can be initiated without a specialist. However, for patients over 35 yrs old and those with prolonged infertility or a recognized issue, it may make more sense to start with an RE.

So here is part 1 of the weekend edition of 100 Q&A about Infertility:

5. Who should evaluate the infertile couple? Do I need to see a Reproductive Endocrinologist?


In many cases, the routine fertility evaluation can be conducted by an obstetrician/gynecologist, or a family practitioner. Certain tests can easily be ordered and interpreted by physicians in the first two specialties, but a reproductive endocrinologist (RE) may be required to interpret advanced testing and provide the most accurate counseling. Women who are more than 34 years old may elect to immediately consult with a reproductive endocrinologist.

Although all physicians trained in obstetrics and gynecology are exposed to the specialty of reproductive endocrinology and infertility, this training may by cursory at best. On the other hand, a reproductive endocrinologist (RE) is a physician who specializes in the treatment of reproductive disorders and infertility. A physician specializing in reproductive endocrinology undergoes 4 years of training in general obstetrics and gynecology following his or her completion of medical school. At the end of these 4 years internship and residency (which includes exposure to normal and high-risk obstetrics, gynecology, gynecologic oncology, and reproductive endocrinology and infertility) a physician may then apply for an additional 3-year fellowship in reproductive endocrinology and infertility. There are usually only 25-35 fellowship positions available each year so competition can be intense. After completing these 7 years of training, the physician takes a series of written and oral examinations to become board certified in this specialty. Although not all practitioners of reproductive endocrinology and infertility have undergone formal fellowship-level training, the majority have, and this training includes both clinical and basic science experience.

There are several professional organizations for physicians who are interested in the treatment of the infertile couple, including the American Society of Reproductive Medicine (ASRM) and the Society for Reproductive Endocrinology and Infertility (SREI). Any physician who is interested in infertility may join ASRM, but members of SREI must be board eligible or board certified in reproductive endocrinology and infertility. Both of these organizations maintain websites that allow patients to identify local specialists (www.asrm.org; www.socrei.org).


Carol comments:

I began discussions with my gynecologist at age 34 regarding my lack of success at getting pregnant. He put me on a plan that seemed to represent a pretty standard process of elimination. First, I did the basal body temperature charting for 3 months to determine if I was ovulating; then, I spent 3 months on Clomid with no success. Looking back on it now, I question his resistance to send me directly to an RE for further evaluation given my age and what the ovulation charting had revealed. Don’t be afraid to push your doctors. I wish I would have pushed harder to get things moving.

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Question 4: Is Infertility Becoming More Common?

Are you familiar with those ads for "Hair Club for Men?" Well, besides the fact that I am losing my hair (which my kids think is hilarious) I have always liked the line where the owner states I am not just the owner...I am also a customer. In the mid 1940s my parents were told that they could never have children. My mother had a bicornuate uterus with one side that was abnormally small. She later found out she was missing a kidney on that same side which my Grandmother always blamed on my Dad who is/was a general surgeon. "My daughter was perfect until she married your father" she would often tell us. Yup, Nana and Dad did not have a real good relationship.

In any case, while stationed in Italy just after WWII my parents found themselves pregnant again after a number of terrible miscarriages. Instead of following the advice of the doctors, my Dad refused to have them do a D&C on my Mom once she started bleeding a bit. It was the right decision as what was happening was the bleeding was from the abnormal side of the uterus and the pregnancy was actually doing fine on the other side.

The end result was my older brother Mike (see photos of Baby Mike with 2 people who claim to be my parents). With the exception that he is also a general surgeon, he seems to have turned out OK. After 2 more successful pregnancies my parents called it quits with 3 boys.

So whenever I deal with a patient with a uterine anomaly I think of that Hair Club for Men advertisement....I'm not just a fertility doctor...I'm also the product of a couple with fertility issues...

4. Is infertility becoming more common?

A common misperception is that infertility is becoming more common. In fact, the infertility rate has held relatively stable over the years. Instead, two major factors account for the increased utilization of fertility services.

The first of these factors is simply the greater availability of the services themselves. Prior to the 1978 birth of Louise Brown, the world’s first baby conceived through in vitro fertilization (IVF), the options available to treat an infertile couple were limited to tubal microsurgery and ovulation induction with medications such as clomiphene citrate (Clomid). With the development of advanced reproductive technologies (ART), the techniques used to treat the infertile couple have become both much more successful and more accessible. Fertility providers now practice throughout nearly all urban centers in the continental United States, with more than 400 IVF clinics reporting their success rates through the Society for Assisted Reproductive Technologies (SART) and the Centers for Disease Control and Prevention (CDC). Statistics from all reporting IVF clinics are available at http://www.cdc.gov/ART/index.htm.

The second factor accounting for the increased use of fertility services is the trend toward delayed childbearing. Over the last generation, a significant number of women have deferred childbearing while they pursued advanced academic careers or entered the workplace. Unfortunately, female reproductive capacity drops from a peak in the second and third decades of life so that by the age of 40 years there is a marked reduction in fertility and an increased risk of miscarriage.

Finally, the stigma associated with fertility treatments themselves has also eased in recent years, prompting more couples to seek out such help. Previously, couples who were seeking fertility treatments often found themselves beset by a bewildering array of options and knew few other couples with whom they could discuss the range of treatments. Today, more than 100,000 cycles of ART are performed in the United States every year. Given that 1% of all U.S. births are now the result of fertility treatments, most couples probably know someone with a successful outcome from fertility treatments. The current explosion of information available through the Internet and through organizations such as the American Society for Reproductive Medicine (ASRM), RESOLVE, and the American Fertility Association has allowed patients to better understand fertility-related problems and seek appropriate care. A number of states have implemented mandates that guarantee varying levels of insurance coverage for fertility-related procedures, which has had the effect of easing the financial burden for couple who seek out this type of care.

Kristin comments:

When I started discussing my fertility problems with my mother, she opened up about her own struggles to conceive my brother and me. While she did eventually get pregnant on her own, it took her over 2 years to conceive me and about the same amount of time to conceive my brother. She said that nobody really talked about infertility when she was trying to get pregnant and the fertility options were minimal. My mother was an only child because my grandmother could never become pregnant again despite years of trying. I would guess that both my grandmother and my mother had the same infertility diagnosis as I do—PCOS [polycystic ovarian syndrome]—but in their childbearing years it was not commonly diagnosed and treatments were either nonexistent or limited.

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Question 3: How Common is Infertility

One of the unique features of the 100 Q&A series of books is that patients offer their view on several of the topics that are covered. As a physician it is easy sometimes to assume that patients have knowledge that they actually don't possess. We do thousands of sonograms every year and yet to the patient these images often just look like weather maps. It's kind of like that scene in the Matrix when they are all watching a stream of numbers flowing down the screen. To us we just see a flow of characters on the screen and yet to them they are watching Neo and Morpheus slug it out in a training session within the Matrix... Perhaps it is not the smartest idea to share my knowledge of science fiction with potential/existing patients.... On the other hand, I did convince my wife to date, marry and reproduce with me so go figure.

So here is the Question of the Day from the soon to be published 2nd Edition of 100 Questions and Answers about Infertility by Gordon and DiMattina...with a little help from three of our patients....

3. How common is infertility?


Infertility is an extraordinarily common disorder. An estimated 25% of all women will experience an episode of infertility during their lifetime. Infertility currently affects about 6.1 million women and their partners in the United States. The percentage of reproductive-age women who report problems successfully conceiving and maintaining a pregnancy varies with age. In the youngest segment of the population, approximately 10% to 15% are affected by this problem. Among women older than age 35, however, more than one-third report diminished fertility. The rates of pregnancy loss are also related to a woman’s age, with the rate of miscarriage exceeding 50% in women older than age 40.


Kristin comments:


When you’re in the throes of infertility, desperately wanting a child while seemingly everybody around you gets pregnant on their “first try,” you wonder if you’re the only one who can’t get pregnant. My husband and I have been very open about our fertility problems, and once I really started to share our story with friends and acquaintances I discovered I was not alone . . . far from it. I have created amazing friendships with other “infertiles” I have met through Internet communities, reading blogs, and even support groups in my area.

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Question 2: What is Infertility?

So how bad was the snow in Washington, DC? Let me tell you....it was epic! Seriously. I had not seen see snow that deep since the Blizzard of 1978 in Boston when I was only 12 years old (see photo below).

The roads were a complete disaster and just trying to get to work was near impossible. I remember a few years ago when we had a lesser storm that I arrived at the office to find myself the only employee who made it in. There were 18 patients waiting and no nurses, no medical assistants, no front desk. So until the rest of the crew made it in I was checking the patients in, rooming them, drawing the blood and doing the sonograms (my usual role)! So the hotel seemed a good option for this most recent storm (see other photo).

Of course, the bad weather was a perfect time for us to work on revising the book and trying to get it off to the publisher. I am pleased to say that we are doing well in terms of the timetable and I truly hope thatthe book will go to press way before I complete running through all these questions. I think that I need to talk with Jones and Bartlett about an iPad version so I have an excuse to give Steve Jobs more of my money.

2. What is infertility?

Approximately 80% to 85% of couples who are trying to become pregnant will successfully conceive within a year. Thus infertility is commonly defined as the inability to achieve a pregnancy within 12 months of unprotected intercourse. However, certain patients may have recognized factors that preclude normal conception; for them, the 12-month period of waiting makes little sense. Common examples of women with such problems include those who have extremely irregular periods, a history of severe endometriosis, a history of previous tubal pregnancies, or other anatomical factors that would clearly lead to diminished fertility. Since fertility declines significantly as a woman ages, couples are encouraged to seek evaluation for infertility after 6 months of no contraception if the woman is older than age 35.

Another problem related to reproduction is recurrent pregnancy loss. Many women can readily conceive, only to suffer repeated pregnancy losses. These women represent a special subset of those who are unable to successfully reproduce and should be evaluated by a medical professional.

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New Beginnings - Question 1: How does normal reproduction work?

Well hard to believe that the 2nd week of March is here already. What an eventful month we all had in February as Washington DC was paralyzed by Snowmageddon. Dominion Fertility was open in spite of the terrible weather and several of us stayed for many nights with our friends at the Westin Arlington Gateway. The hotel was a Godsend to us...especially once the power failed at our home and we were reduced to living like small animals huddled together in a den.

But now it is time to buckle down and get back to the virtual world and the routine posting of fascinating information on the 100 Questions and Answers Blog! Dr. DiMattina and I have been hard at work revising the 100 Q&A book for a 2nd Edition. We anticipate outstanding sales and a possible movie adaptation staring Brad Pitt and Chris Pine. James Cameron will be directing and the special effects will be provided by ILM. Watch out for updates regarding open casting calls for this summer blockbuster.

Meanwhile back in the real universe I am planning on posting a Question of the Day every other day until we run out of questions. Do the math and that takes us into 2011...

So on with the show....or book....or blog....or whatever.

1. How does normal human reproduction work?

Norman human female reproduction depends on the correct functioning of four components of a woman’s body: the brain, the ovary, the fallopian tube, and the uterus. At the time of her birth, a woman’s ovary contains all of the eggs that she will ever have. These eggs are contained within fluid-filled sacs called follicles.

Every month, the brain sends out a signal from the pituitary gland (a gland located at the base of the brain) stimulating the follicles to grow. Not surprisingly, this hormone is called follicle-stimulating hormone (FSH). Under the influence of FSH, a group of follicles begins to grow, but by the fifth day of the reproductive cycle a single dominant follicle has already been selected. This dominant follicle may be either on the right ovary or the left ovary.

As it grows, the follicle produces an important steroid hormone called estrogen. Estrogen causes the lining of the uterus (endometrium) to thicken in anticipation of the eventual implantation of an embryo.

By mid-cycle, this follicle has grown to a diameter of 20 to 22 mm. At this time the brain releases a second hormone, called luteinizing hormone (LH), from the pituitary gland. LH is the trigger that induces ovulation.

Approximately 36 hours after the LH surge, the follicle releases the egg. It is the job of the fallopian tube to trap the egg. If the fallopian tube fails to catch the egg, then pregnancy cannot occur.

During intercourse, tens of millions of sperm are deposited in the woman’s vagina when her male partner reaches orgasm and ejaculates. While the egg is safely held within the fallopian tube, these sperm swim from the vagina, into the cervix, through the uterus, and up into the fallopian tube, where fertilization occurs. (See Figure 1.) Normally, the growing embryo travels through the fallopian tube for 5 days after fertilization, at which point it reaches the uterus. (An embryo that remains trapped within the fallopian tube is called a tubal pregnancy or ectopic pregnancy, and can be a life-threatening condition.) The embryo divides many times along the way, and by the time it reaches the uterus, it has grown to hundreds of cells and is called a blastocyst.

Once the egg is released from the ovary, the follicle (now called a corpus luteum) continues to produce estrogen and begins to produce a new hormone: progesterone. Progesterone induces changes in the estrogen-primed endometrium, allowing implantation of the embryo and thus permitting pregnancy to occur. In the absence of a pregnancy, the levels of estrogen and progesterone both fall 2 weeks after ovulation and a menstrual period ensues, shedding the lining of the uterus. Menstrual flow lasts approximately 3 to 5 days in most women.

Overall, human beings are not very fertile, with maximum pregnancy rates of only 20% to 25% per cycle during the years of peak fertility (the second and third decades of life).

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