Question 22. Why are my menstrual cycles irregular?

We often have residents from the Ob Gyn residency program at Georgetown rotating through our office. When they sit in on my consultations they get very familiar with my little song and dance about the normal menstrual cycle. Let's face it....if you don't understand normal reproduction then how can you figure out how to order appropriate tests on your patients to determine the problem. Yet, sometimes in spite of our attempts at education, they still can't figure it out. So here is your chance, dear reader, to become smarter than an Ob Gyn resident! Read on and ask questions as needed....

Here is today's Question of the Day from the upcoming 2nd Edition of 100 Questions and Answers about Infertility!

22. Why are my menstrual cycles irregular?

In a typical reproductive cycle a single follicle (containing a single egg) reaches maturity after 2 weeks culminating with the release of that egg a process called ovulation. Once ovulation has occurred menstrual flow will appear 12-14 days later unless pregnancy supervenes. Thus, most women cycle every 28 days (14 days to grow the egg and 14 days after ovulation until period returns).

Understandably, if a woman has irregular and unpredictable cycles, then logic suggests that she is probably not ovulating normally. Ovulatory problems are usually divided into two main categories: problems with the ovary and problems with the signals from the brain to the ovary. If the irregular cycles result from a lack of follicles within her ovary, then the failure of the ovary to respond will cause the pituitary gland to secrete increased amounts of follicle-stimulating hormone (FSH). Women with elevated levels of FSH are described as having diminished ovarian reserve; if their periods cease entirely, then they are described as having premature ovarian failure (POF). Different laboratories may vary as to how they define an “elevated” level of FSH, so a discussion with your physician is crucial to correctly assess the results of this test. In most cases, however, an FSH level of more than 15 IU/L is evidence of diminished ovarian reserve; FSH levels exceeding 30 IU/L usually signify POF.

If a woman has a normal complement of follicles but still does not have normal cycles, then the problem must lie elsewhere. Most such women suffer from a communication mismatch between the brain and ovary, disrupting the carefully coordinated hormone signals that induce the growth of ovarian follicles. The causes of this disruption can be further classified, with most patients being found to have polycystic ovarian syndrome (see Question 22) as opposed to other hormonal imbalances.

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Question 21. Will my insurance pay for my fertility treatments?

Obviously healthcare reform has been a hot topic here inside the beltway this past year. No doubt that trying to navigate the insurance coverage jungle is confusing to say the least. Most plans cover diagnostic testing for infertility. Some plans cover treatment for infertility. Some plans only cover certain treatments and dictate a specific order to those treatments. Some plans cover a certain dollar amount and couldn't care less what treatments you do....and on and on and on.

Sometimes patients ask us to code visits using non-infertility codes. In other words, a patient is sent to me by her Ob Gyn for infertility and we spend 35 minutes discussing only infertility. Then she asks me to code the visit as endometriosis because her sister has endometriosis and so perhaps maybe she also has endometriosis and that is what is causing her infertility. There is a term for this request....insurance fraud. As much as I love my patients (especially those that read this blog....both of them), I am not prepared to go to the "big house" on their behalf. Sorry but no. I am not prepared to spend a few years behind bars. It may have done wonders for Martha Stewart's career but I have no interest in that type of life experience.

So here is today's Question of the Day:
21. Will my insurance pay for my fertility treatments?

Insurance coverage for infertility varies widely across the United States. Several states, including Massachusetts, Illinois, and Maryland, have passed legislative mandates for infertility coverage. In these states, access to fertility treatment is guaranteed through the patient’s employer. In the vast majority of states, however, fertility coverage is inconsistent. Some companies may offer extensive fertility benefits, while others offer no coverage at all to their employees.

It is important that you understand your specific benefits before you seek out any kind of fertility treatment. Insurance plans may provide a specific dollar amount to spend on fertility treatments or cover a certain number of cycles of either IUI or IVF. You should work with your fertility provider’s billing staff to determine which benefits are available to you before launching into a treatment plan. Given that some insurance plans may cover infertility more extensively than others, it is always appropriate to examine your insurance options during periods of open enrollment for health benefits. Many insurance companies will not cover fertility treatments in patients who have been voluntarily sterilized (e.g., vasectomy, tubal ligation). Plans may also have specific requirements in terms of duration of fertility and exclusion criteria for IVF concerning ovarian reserve testing or age.

Rebecca comments:
One of the biggest mistakes I made in my family building journey was making ‘assumptions’ about my husband’s and my insurance plans. These assumptions, NOT FACTS, guided some of our initial decision making processes regarding treatment. Those errors in judgment wasted precious time, and most likely were financially costly. As a wiser and more seasoned patient, I would advise that one take as much precaution and care in learning about her/his insurance coverage, as one does with obtaining information about her/his treatment options. Work with the fertility provider’s billing staff regarding your plan and benefits as soon as you begin consulting with your RE.

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Question 20. How expensive are infertility treatments?

Children are not cheap. Unfortunately, those patients with infertility are having to invest in a bit more than dinner and a movie in order to have the privilege of spending thousands of dollars to house, feed and entertain the little monsters. But seriously, when contemplating the array of treatment options one must consider the economic aspects when making a plan. Unfortunately, the fertility treatments that work the best tend to be the most expensive and most invasive options. So let's look at the options available and a range of what these treatments cost in most clinics. Your experiences may vary from clinic to clinic and these are typical not recommended prices....

Also, many clinics offer IVF Guarantee Programs which refund a portion or all of the cost if a couple fails to deliver a baby. Many patients really embrace this concept and I certainly understand the attraction but I still recommend that you read the fine print and make sure that you fully understand what specific costs are included in such arrangements.

Good luck to all and have a great weekend as you peruse today's Question of the Day:


20. How expensive are infertility treatments?

Some insurance plans may cover the cost of a fertility evaluation but not cover any fertility treatments per se. Other plans may stipulate a certain lifetime benefit for fertility case and still other plans may provide a specific number of treatment cycles.

In those patients without insurance coverage, the cost of fertility treatments varies widely depending on the specific treatment utilized. For example, a cycle of ultrasound monitoring without the use of fertility medications, culminating with intrauterine insemination (IUI), may cost $1300 to $1500 in many clinics. Compare this with the cost of IVF with intracytoplasmic sperm injection, freezing of extra embryos, and assisted embryo hatching, for which the price tag can total $14,000 to $16,000 (not including the cost of injectable fertility medications ($2000 to $4000)). The use of donor-egg IVF, although extremely successful, is also very expensive, because the donor must be reimbursed for her time and effort as part of the treatment and also because of the extreme screening tests mandated by the FDA. The price for donor-egg IVF typically ranges between $25,000 and $30,000, depending on the clinic. Unstimulated or Natural Cycle IVF may represent an economically attractive option since it may cost a fraction of stimulated cycle IVF (e.g. $4400 per cycle in our clinic).

In most patients, the more expensive, more invasive fertility treatments usually result in the highest pregnancy rates. Couples are advised to carefully consider the proposed course of treatment and the costs that may be involved.

Many IVF centers in the United States offer “money back” (refund) programs. A couple accepted into such a program pays a premium that covers several fresh IVF cycles as well as frozen embryo transfers (FET). If they fail to conceive or are deemed to no longer be appropriate candidates for treatment, then all or a percentage of their initial payment is refunded. These programs have remained somewhat controversial but can allow couples to pursue other options if IVF proves unsuccessful.

According to the ASRM Ethics Committee Statement of June 2006, the controversy surrounding such programs relates in part to the concern that such arrangements appear to violate long-standing ethical prohibitions against paying contingency fees in medicine. This concern is based on Opinion 6.01 of the AMA Code of Medical Ethics, which states, “a physician’s fee should not be made contingent on the successful outcome of a medical treatment.”

Furthermore, the 2006 Committee Statement (which can be found on the ASRM website at http://www.asrm.org/Media/Ethics/ethicsmain.html) concludes, “the risk-sharing form of payment for IVF is an option that might be ethically offered to patients without health insurance coverage for IVF if certain conditions that protect patient interests are met. These conditions are that the criterion of success is clearly specified, that patients are fully informed of the financial costs and advantages and disadvantages of such programs, that informed consent materials clearly inform patients of their chances of success if found eligible for the risk-sharing program, and that the program is not guaranteeing pregnancy and delivery. It should also be clear to patients that they will be paying a higher cost for IVF if they in fact succeed on the first or second cycle than if they had not chosen the risk-sharing program, and that, in any event, the costs of screening and drugs are not included.

“The Committee was especially concerned about the incentives that risk-sharing programs create for providers to take actions that might harm patients in order to achieve success and avoid a refund. For risk-sharing programs to be ethical, it is imperative that patients be aware of this potential conflict of interest, and that risk-sharing programs not overstimulate patients to obtain a large supply of eggs or transfer more embryos than is safe for the patient, fetus, and prospective offspring. Patients should be fully informed of the risks of multifetal gestation for mother and fetus, and have had ample time to discuss and consider them prior to egg retrieval.”

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Question 19. What are Natural Cycle fertility treatments and am I a candidate for them?

Given the interest in organic food, environmentally friendly energy and "green" buildings, I guess it was only a matter of time until Natural Cycle fertility treatments became more attractive to all of us. Remember those Promise margarine commercials that would end with "It's not nice to fool Mother Nature!" Well, sometimes Mother Nature may in fact know best and that is the idea behind Natural Cycle fertility treatments.

I think that one has to be creative when considering the infertile couple and using Natural Cycles for fertility treatment may make a great deal of sense for a variety of patients. So without further delay, here is the Question of the Day for the upcoming 2nd Edition of 100 Questions and Answers about Infertility:


19. What are Natural Cycle fertility treatments and am I a candidate for them?

Natural Cycle Fertility treatments are based entirely on a woman’s normal natural menstrual cycle. In other words, no ovarian stimulating drugs are used. Rather, the doctor attempts to produce pregnancy using the woman’s naturally produced egg and/or hormones. In order to use any form of Natural Fertility treatment, the patient must have fairly regular menstrual cycles. Highly irregular cycles do not allow the use of natural fertility treatment. Three different types of Natural Fertility treatments currently exist and they are Natural Cycle IUI, Natural Cycle IVF, and Natural Cycle FET.


Natural Cycle IUI

Natural Cycle IUI is an extremely simple infertility treatment. Generally speaking, the patient is monitored during a menstrual cycle to determine the timing of ovulation using either urine LH, blood estradiol and progesterone or sonography. Once the egg has been determined to be mature ovulation can be induced by a single injection of human chorionic gonadotropin (hCG) followed by a well timed artificial insemination(IUI). Sometimes IUI is performed without the use of hCG if it appears that an LH surge has already begun based upon hormone testing. See Question xxx for more information about IUI.

Natural Cycle IVF (NC-IVF)

Natural Cycle IVF (NC-IVF) also requires that the patient have fairly regular normal menstrual cycles. NC-IVF is a very simple, patient friendly form of IVF. No ovarian stimulating drugs are used in NC-IVF. Instead , the patient’s naturally produced follicle and egg are monitored using estradiol, progesterone and ultrasound measurements. Once the egg is judged to be mature, a single injection of hCG is given and the egg easily collected in the office under transvaginal ultrasound using minimal or no sedation. It literally takes only a few minutes to collect the egg, similar to a simple in office blood draw. The egg is then fertilized usually by ICSI (as only one egg is obtained) and a single embryo is transferred 3 or 5 days later. Couples with proven previous fertility may use IVF without ICSI in many cases.

NC-IVF is extensively performed around the world in over 50 countries and the world’s very first successful IVF baby in 1978 was produced using NC-IVF. At that time, our knowledge and technology was rudimentary compared with today’s standards, so fertility drugs were used to obtain more eggs and embryos to improve the very low IVF pregnancy rates. With improved understanding and technology, many eggs and embryos are simply not necessary to produce a successful pregnancy for many couples using IVF. Also the costs for NC-IVF are about 20-25% of the cost of a single stimulated IVF cycle and NC-IVF avoids the risks associated with the use of ovarian stimulating hormones. Thus, patients who are planning on a single embryo transfer or who wish to avoid using fertility drugs often prefer NC-IVF. Other patients who fail stimulated IVF or who wish to try NC-IVF with their own egg prior to considering ova donor IVF may be candidates for NC-IVF.

Problems with NC-IVF include: premature LH surge, which occurs in 10-15% of patients, and less commonly failure to obtain an egg at the time of the follicle aspiration,. Occasionally fertilization may not occur (even with the use of ICSI) or embryo growth may suboptimal with failure of an embryo to develop to an appropriate stage prior to planned embryo transfer. When compared with stimulated IVF utilizing single embryo transfer, the pregnancy rates should be equivalent between NC-IVF and stimulated IVF. Studies comparing these 2 types of IVF are needed but our personal experience supports this notion.

Natural Cycle Frozen Embryo Transfer (NC-FET)

At Dominion Fertility, we only perform NC-FET in patients who have regular menstrual cycles. NC-FET is less expensive, simpler for the patient and the pregnancy rates are equal to medicated FET. In NC-FET, the menstrual cycle is monitored in the same fashion as described above. A single injection (hCG) is given to the patient for the entire treatment cycle. Seven days later, embryo transfer is performed. It’s just that simple! The entire treatment takes one menstrual cycle or about 4 weeks to complete.

We have been performing NC-FET for several years now and our data shows equal pregnancy rates in with NC-FET or medicated FET. In our opinion, the only draw back to NC-FET is that it requires the IVF center and patient to be flexible with respect to scheduling of the embryo transfer as this date can only be estimated. With a medicated FET, the exact date and time of the embryo transfer can be programmed before beginning the treatment.

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Question 18. How will my reproductive endocrinologist determine a plan of therapy?

Here in Washington we are surrounded by planners. People are available to plan your party. People are available to plan your finances. People are available to plan for your kid applying to college (or secondary school or even kindergarten). People are available to plan your attempt to lose weight and get in shape (personally I am doing the Special K diet...gotta look good for my college reunion at the end of May). So it is not surprising that patients look to their RE to plan their fertility evaluation and treatment. I am not a "me doctor - you patient" type of guy, but there is a point where I step up and say here are my recommendations. These may be negotiable but I really try to give my perspective. And yet, it doesn't matter how wonderful the plan seems to me.....if it is unacceptable to the patient then it is back to the drawing board.

Cookie cutter medicine is dangerous. One size does not fit all. I really hope that the physicians of tomorrow will still try to individualize care rather than relying upon only guidelines. My mother was diagnosed with breast cancer back in 1993. She had a very poor prognosis at that time with a <5% five year survival rate. One oncologist told my Dad that if it was his wife that he would "take her to Florida and make her ready for the end." Well, my Dad refused to take that advice and she underwent surgery, chemo and radiation therapy. Now 17 years later she has, knock on wood, never had a recurrence of her cancer. Fertility treatment can be nearly as stressful but the spontaneous cure rate is much better than with cancer. One of the best aspects of offering Natural Cycle IVF has been to allow patients with a poor prognosis to still try their hand at IVF. For some of these patients it is enough to have tried and then they can either give up or pursue donor egg IVF or adoption. For the ones that have a baby after being told that they were a hopeless case, Natural Cycle IVF seems nothing short of a miracle.

So here is today's Question of the Day.


18. How will my reproductive endocrinologist determine a plan of therapy?


In general, reproductive endocrinologists recommend a particular course of treatment only after performing a complete fertility evaluation which usually include a pelvic ultrasound, an assessment of tubal patency (hysterosalpingogram or laparoscopy), a semen analysis, and a variety of hormonal blood tests.

The therapeutic plan for any couple is unique to them. If testing has demonstrated a clear problem, such as blocked fallopian tubes or a markedly abnormal sperm count, then in vitro fertilization (IVF) may be recommended as the only reasonable alternative. However, most couples are not sterile but merely subfertile, so they may be offered a range of therapeutic options—from expectant management, to the use of insemination with or without fertility drugs, to IVF with or without intracytoplasmic sperm injection (ICSI). Furthermore, IVF can be performed using the patient’s own eggs, donor eggs, or donor sperm.

A couple’s particular therapeutic plan will be developed with their specific needs in mind. For those patients in whom IVF is not an option, whether because of religious, financial, or philosophical reasons, the physician should provide counseling about alternative treatments available to them. Not all couples are prepared to undergo extensive fertility treatments, so physicians need to consider a couple’s particular situation when proposing a course of action. Given that infertile couples can sometimes achieve spontaneous pregnancies, the desire of a couple to proceed with therapy needs to be weighed against the likelihood of success for that therapy and the cost involved. These costs may include financial, physical, and emotional considerations. We strongly urge our patients to consider ll options when dealing with infertility including alternative pathways to parenting ranging from adoption to the use of donor sperm, donor egg, donor embryo and gestational surrogacy.

Carol comments:
I feel that finding an RE who will work with you and listen to you is one of the most important factors in achieving a positive outcome. Each individual who is faced with infertility deals with the varying costs (financial, physical, and emotional) differently. For some, the financial aspect limits the number or attempts they can make. For others, the physical and emotional aspects take such a toll that they are only willing to go through a set number of attempts. Based on my discussions with other women who have faced fertility challenges, I believe that each person has a unique threshold for these costs. If you are dealing with a doctor who strictly adheres to a “one size fits all” policy and won’t take your personal situation into consideration, it will only add more stress to an already stressful situation.

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Question 17. Can I choose the sex of my baby?

Years ago I saw a patient that had 3 girls and wanted a boy. Their solution was to take fertility shots and have timed intercourse with the logic that even if they had a multiple pregnancy, one should be a boy. I tried to explain that their logic was not very sound and that they could end up with a real surprise. They were not to be dissuaded and went to another clinic. They followed through with that plan and ended up with triplets....all girls. Six girls under 6 years of age is hard for me to contemplate. Wow. That is a lot of squealing under one roof.

So although we are sympathetic to those who are hoping for family balancing, there still has to be consideration given to the wisdom of certain solutions to this question. As we head into a glorious weekend of weather here in DC, I leave you with the following Question of the Day:


17. Can I choose the sex of my baby?


Gender is determined at the moment of fertilization, when a sperm bearing either an X or Y chromosome penetrates the egg, resulting in formation of either a female or male embryo, respectively. The event is random, and the sex ratio of females to males conceived is fairly even.

Several techniques exist that can enhance the likelihood that a couple will conceive a child with the desired gender. The Ericsson method is a simple, noninvasive method that separates X-bearing sperm from Y-bearing sperm using centrifugation techniques. The sperm are placed on the top of a column of either albumin or Sephadex, and the specimen is centrifuged to isolate the desired gender-selected sperm. This sperm sample is then used for either intrauterine insemination or IVF. The success rates reported with this method vary from no benefit to as high as 75% for the desired gender. The Ericsson method is not associated with any known risk to either baby or mother.

Microsort is a newer experimental technique that involves the labeling of the DNA of the sperm, followed by passage of the sample through a cell-sorting machine. This process yields a smaller sperm sample than the Ericsson method, and IVF with ICSI may be required for pregnancy. Nevertheless, the results appear encouraging in terms of gender selection.

The gender of a child can also be selected using IVF and preimplantation genetic diagnosis (PGD). This technique is expensive and much more complex than the Ericsson method, but success rates for the selected gender routinely exceed 90%. Couples who elect to pursue IVF and PGD for gender selection often do so to prevent genetically inheritable medical diseases, such as Duchenne muscular dystrophy, from occurring in their children.

Many medical authorities consider gender selection to be unethical except in a few circumstances, such as when the couple runs a high risk of having a child with an inheritable medical disease. Others support the use of gender selection when a couple has at least one child but want to limit their family size and desire a child of the opposite gender.

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Question 16. My friend keeps asking whether I had an endometrial biopsy or a postcoital test. Do I need these tests?

As we work our way through the 2nd Edition of 100 Q&A about Infertility, I suppose it is inevitable that some blog posts may end up getting recycled. When discussing the post coital test I always think of the story that I initially related in one of my first blog posts. It may not be the most politically correct story but here it goes....

Here is a true RE urban legend. Many years ago a very trustworthy and honest infertility specialist (not yours truly although I would hope to be described in this fashion) arrived at the office for his usual consultations. He was informed that Mrs. Jones (not her real name) was waiting for Dr. James (not his real name) in the exam room. She was scheduled for a postcoital test.

Dr. James went into the room, said hello and then sat down to perform the postcoital. As he was placing the speculum he asked Mrs. Jones the usual questions: “What cycle day are you?” “Day 14 ,”she replied. “Did you have an LH surge?” “Yes, last night,” she promptly informed the doctor. “OK, so how many hours ago did you have sex?” No answer. Dr. James asked again. The patient hesitated and then blurted out, “But Dr. James I am here for a postcoital test!” “Yes, I know, so when did you and your husband have relations?” She hesitated and then clarified her misunderstanding. “Oh my gawd, Dr. Jones, I thought I was supposed to have sex with you!” Dr. James removed the speculum. Stood up. Walked out of the room with his face blazing in embarrassment.This story was related to me by Dr. James, at a conference one year, so I have no reason to doubt its veracity. Of course, this became a huge inside joke at Dr. James’ practice as Dr. James was routinely asked after that exactly how much time he needed to perform any scheduled postcoital test!

We all want to help our patients and in the process we form some very close relationships, but clearly there are some limits that should never be crossed…even as part of the diagnostic evaluation. So here is today's Question of the Day.


16. My friend keeps asking whether I had an endometrial biopsy or a postcoital test. Do I need these tests?


In the past, the endometrial biopsy was a routine part of the fertility evaluation, but current practice has been to limit performance of this test to a minority of fertility patients. An endometrial biopsy is a simple office-based procedure that is performed just before the onset of a woman’s menses. It is usually performed without any anesthesia and is well-tolerated by most patients with the majority reporting uterine cramping that quickly resolves.

An endometrial biopsy can yield information about the hormonal status of the lining and can rule out chronic infection/inflammation in the uterus. The problem with the endometrial biopsy in terms of its usefulness as a fertility test is that abnormal biopsies are obtained in more than one-third of women with proven fertility. Therefore, the finding of an abnormal endometrial biopsy in fertility patients is of uncertain benefit. Most reproductive endocrinologists prefer simply to have their patients take extra progesterone, essentially obviating the need for the endometrial biopsy in most patients. At the present time, the endometrial biopsy is most reliable as a means to rule out endometrial cancer in those patients who are at increased risk of this disease. Patients at increased risk for endometrial cancer include those who have polycystic ovarian syndrome and infrequent, heavy periods but who do not receive the protective benefit of oral contraceptives or other progesterone-containing medications.

In patients who have experienced repeated IVF failures in spite of the transfer of good quality embryos, it is reasonable to perform an endometrial biopsy to ensure that the lining demonstrates the appropriate hormonal response, the absence of infection/inflammation or the correct expression of cell surface proteins. There is a class of cell surface proteins call integrins that play a putative role in implantation. Some physicians will perform an endometrial biopsy to ensure the proper expression of integrins on the surface of the endometrium. Abnormal integrin expression has been demonstrated in a range of clinical situations including the presence of a fluid filled fallopian tube or hydrosalpinx, but most experts consider testing for integrins to be investigational and limited to special circumstances.

The postcoital test was initially proposed as a means to evaluate the interaction of the male partner’s sperm and the female partner’s cervical mucus. This test is performed approximately 8 to 24 hours after intercourse at midcycle (around days 12 to 14 of the menstrual cycle). During a speculum exam, the physician collects a sample of cervical mucus. This sample is then placed on a slide and examined under a microscope for the presence of motile sperm. In addition to the presence or absence of sperm, the physician records the quality, quantity, and appearance of the mucus. Unfortunately, the postcoital test has very poor reproducibility and limited utility in the evaluation of infertile couples. For example, couples for whom no motile sperm were observed during the postcoital test have conceived. Although the spontaneous pregnancy rates are higher in those patients with a normal postcoital test, the information gathered in this way seldom provides any useful insight when developing a therapeutic plan.

Postcoital tests may prove more valuable in couples in whom, for social or religious reasons, the male partner is unable to provide a specimen for semen analysis. In these cases, a postcoital test reassures all parties that sperm are actually deposited in the vagina during the act of intercourse.

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Question 15. After we have sex, I think that everything comes out. Is this why I am not getting pregnant?

A few years ago I had a high school student spend the day with me in the office since he was considering a career in medicine. He went with me to Fairfax Hospital where I gave a lecture to the medical students and residents. He went with me to Reston to see some consultations. He went with me back to Arlington to watch some procedures including an embryo transfer (he was in the lab not in the room with the patient). I thought that he would be impressed by the depth and breadth of what I do all day long.....

At the end of the day I asked him what he thought of being a Reproductive Endocrinologist. He paused for a minute then blurted out "So basically you talk about sex and tell people when to do it." Oh well. So much for impressing him with the depth and breadth of my medical specialty. He wanted to be a heart surgeon anyway.....

But he was correct that we do have to talk about sex with our patients and that leads us to the Question of the Day just in time for the weekend! Hope all of you have a Happy Easter. He is risen indeed.



15. After we have sex, I think that everything comes out. Is this why I am not getting pregnant?


Honestly, this question is one of the most frequently asked questions that we get during new patient consultations. At the time of male orgasm, the ejaculate is composed of proteins, enzymes, and water from the seminal vesicles. The sperm represent only one to three drops of the total ejaculate volume of 1.5 to 5 mL. Following ejaculation in the vagina sperm rapidly move from the vagina into the cervical mucus, where they can live for 5 to 7 days. The cervical mucus serves as a reservoir for the sperm, from which they can subsequently travel to the upper reproductive tract and meet the egg in the fallopian tube.

It is normal for much of the ejaculate to spill out of the vagina following coitus. For most couples, this does not decrease their chances for pregnancy. Rarely, a woman may suffer from vaginal or uterine prolapse. The altered anatomic relationship may not hold enough of the ejaculate in close proximity to the cervix following coitus. Such conditions usually occur only after several previous vaginal deliveries.

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Question 14. Can infertility be unexplained?

Well I am back from Spring Break in beautiful Quincy, Massachusetts where it rained constantly and there was flooding on a Biblical scale....The ride back was tough but all of us survived the New Jersey Turnpike without incident. To help pass the time, my wife and I listened to an audiobook while the kids watched DVD after DVD. We listened to "The Thirteenth Tale" which is really an amazingly good Gothic-type ghost story. Early on in the book the reclusive author Ms. Vida Winter is confronted by a young man who demands that she "tell him the truth." The truth finally comes out 12 hours into the audiobook but it does make for a great listen!

Sometimes I feel that patients are confronting me in a similar way...tell us the truth. Will we ever get pregnant? Will we have success with IUI or with IVF? Can his sperm fertilize my egg? Will the Red Sox win the American League Pennant race? (well only a few special patients ask that last one...)

The truth is that sometimes we really don't understand why a couple is infertile. But that doesn't mean we can't try to treat infertile couples with unexplained infertility....and that is the topic of today's Question of the Day.


14. Can infertility be unexplained?

The etiology (underlying cause) of infertility in many couples can be determined by various tests as previously described. Yet, there still remains a sizable percentage of couples in whom no obvious cause of infertility can be identified. Some studies estimate that approximately 10% to 20% of patients fall into this category. However, “unexplained infertility” is not necessarily equivalent to “untreatable infertility.” If a couple has prolonged, unexplained infertility with no previous pregnancies, then a number of etiologies are possible.

If a woman is having normal, regular menstrual cycles, it is likely that each month a follicle is growing and that an egg is being released in an appropriate fashion. If pregnancy has never occurred, however, we cannot be sure that the woman’s fallopian tubes are able to trap the egg or that her partner’s sperm are able to swim through the cervix and uterus and find/fertilize the egg in the fallopian tube. In the absence of a previous pregnancy, the question arises as to whether fertilization can, in fact, occur. The scope of this problem is made clear when we look at the fertilization results for patients who undergo IVF with a diagnosis of unexplained infertility. Typically the rate of failed fertilization with IVF is approximately 2%, but this rate increases dramatically—to approximately 20%—in couples who have prolonged unexplained infertility with no previous pregnancies. Ultimately, failed fertilization may result from problems with either sperm or egg, or both. In such cases of prolonged unexplained infertility, the use of intracytoplasmic sperm injection (ICSI) can markedly reduce the rate of IVF fertilization failure since ICSI involves the direct injection of a single sperm in to a mature egg. If a woman produces a sufficient number of eggs, then one option that we frequently employ is to split the eggs into two groups – ICSI and regular IVF. This split provides a control group but if fertilization is poor without ICSI then IVF may ultimately prove to have been of diagnostic benefit.

One of the most significant developments in the treatment of infertile couples has been the move away from extensive diagnostic testing and toward a more rapid recommendation to undergo IVF. We often recommend that patients with prolonged unexplained infertility consider IVF with ICSI, as this combination has both diagnostic and therapeutic benefits.

Carol comments:
We were never able to diagnose the exact reason that I couldn’t become pregnant. This can be frustrating and scary because there is no clear-cut path to fixing a problem that you can’t define. I remember talking to other women who had more defined issues such as male factor or PCOS and thinking that those would be easier diagnoses to deal with. Luckily, we were able to benefit from the movement to more rapidly recommend undergoing IVF for patients whose infertility is unexplained.

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