Where Everybody Knows Your Name

While most of you, particularly those above the age of 35, are now picturing a couple of bar stools, Sam, Cliff, Norm, Woody, and Frasier, our minds are far from a local bar in Boston. Our minds are on the waiting room of your local fertility clinic. The place where “everybody should know your name” (but should not scream it loudly for everyone else there to hear!) but never does. The place we are referring to is the waiting room of your fertility clinic.

Contrary to popular belief, the waiting room should not resemble the subway platform during rush hour! Patients are not cattle, and your lady parts are not pieces on a factory assembly line. And while we, too, are fans of a morning sweat session, it should not be achieved by racing your fellow patients to the front of the ultrasound line.  It adds anxiety to an already stressful process. Fertility treatment is not easy. The process of getting there, getting in, and getting out should not make this process even harder. Simply said, if your blood pressure rises several degrees when you walk through the door, it might be time to walk out.

The desire to have a child can be overwhelming. It can drive even the sanest of us to do crazy things. And although we can’t promise that pineapple core, vitamin supplements, and a gluten-free diet will do the trick, we can promise you that they won’t hurt you. However, allowing yourself to be treated as a number and not as a person can be hurtful. In fact, it can compromise the quality of your care and your chances of conceiving; if nobody really “knows your name,” how can they appropriately treat your infertility?

Let’s face it. You don’t need everyone in the fertility office to be your best friend, but the individual doing your ultrasound should know your name, know why you are there, and know what you might be doing next (and should give you more than 30 seconds of their time!). If you are getting the boot out of the door the moment your bottom hits the exam table, it’s probably about time to find yourself another fertility clinic.

Fertility treatment is often a journey. For some, it can take years. The relationship you form with your doctor and your doctor’s office staff should be a good one. And while you may never find yourself in a bar in Boston talking about baseball, it is important that you feel comfortable with those sitting on the stool in front of you. The fertility clinic should be a place “where everybody knows your name.” You owe it to yourself. Cheers!

How to Properly Identify Sperm, Eggs, Embryos, and Everything in Between

“License and registration” can be two of the worst words any driver hears: simply stated, you are so busted! No matter how loud the radio is playing and how good you feel driving on the open road, going 85 in a 60 is not a good thing. After the “Officer, I really wasn’t going any more than 10 miles an hour over the speed limit” and the half-hearted attempt to sweet talk your way out of the ticket without so much as a smile from the highway patrol guy or gal, you pretty much take your ticket and drive away.

And although you may vow to go to court and fight it, most of us pay our fine (ugh) and move on. And while no one likes to waste their hard-earned money, the downside of losing some cash is not so catastrophic (although points on your license can be a real bummer). However, errors in proper identification, particularly in a fertility office, can be disastrous.

In any medical practice, especially a fertility one, you want to be “pulled over” every time you set foot in that medical building. From the staff at the front desk to the chaperones who put you in the exam room to the medical assistants who draw your blood, asking to see identification is a good thing. In fact, the more people who ID you, the better (yes, we are looking at your age☺). When any gametes (eggs, sperms, or embryos) are being used, it should be even more in your face—in the changing room, in the embryo transfer room, and twice prior to the transfer. If you find yourself becoming annoyed, that means we have done our job correctly. While redundant, we want to be more sure than sure that we have who we think we have. Like the cop on I-95, we mean business!

Expect us to ask your name, your date of birth, your Social Security number, and your partner’s name and date of birth (here, we will give you a pass on the SSN). No need to call LifeLock. We’re not trying to commit identity theft; we’re just ensuring that we have the right players in this game of baby making. We ask repeatedly to eliminate the chance that any errors occur. We have systems set up to double check everything not only twice but also by two people. In fact, the most common words you will hear in an embryology lab are “Can I get a check?” No eggs, sperm, or embryos are ever moved without two sets of eyes—always.

When it comes to identification, we don’t mess around. We don’t even joke about it. So, if staff personnel don’t ask you these important questions and you feel uncomfortable, in the words of the NYPD, if you see something, say something. Voicing your concern does not make you annoying; it makes you on top of it. And if things don’t change, then maybe that is not the right fertility practice for you. In general, we are pretty good bouncers and know who should come into the club.

Trust us, even the best fake IDs don’t get past us.

Don’t Break My Heart: The Impact of Fertility Treatment on Heart Disease

Be still, my beating heart: Does fertility treatment increase your risk for heart disease? The latest results from a large Canadian study made everyone’s heart skip a beat with its recent findings. The data showed an increased risk in heart disease in women who required fertility treatment to get pregnant. And while this study got a lot of press, before you have a heart attack, here are five things that you should know:

  1. Even with the increased risk reported in the study, the absolute numbers are very low (a.k.a. the number of women who experienced cardiovascular events was pretty small). While we aren’t turning a blind eye or a deaf ear to the results, we are interpreting them with caution.
  2. IVF in the 1990s and IVF in 2017 are VERY different. The treatment protocols and techniques have changed more than the fashion trends (#bellbottoms). Therefore, it’s nearly impossible to study the aftereffects of treatments given then to the aftereffects of treatments given now. Our medications are different, our stimulation styles are different, and our dosages are different. In fact, it’s hard to find anything that’s the same!
  3. When analyzing any research study, it’s important to distinguish between correlation and causation. Although they may sound the same and start with the same letter, they are very different in what they suggest and what they mean for you. When you think of causation, think of cigarettes and lung cancer: We all know cigarettes cause lung cancer. When you think of correlation, think of cigarettes and infertility. Cigarettes do not specifically cause infertility, but they have been associated with infertility. In this study, fertility treatment has been correlated with heart disease (to a modest effect), but fertility treatment has not been demonstrated to cause heart disease. And although the distinction may seem insignificant, it’s actually pretty important!
  4. Anyone who is going to undergo fertility treatment should be in good shape. While you don’t need to join us for regular 5:30AM workouts, you do need to be in good health. Pregnancy is no walk in the park; you want your body to be prepared for those nine months and the many months that follow!
  5. The primary outcome studied was “adverse cardiovascular events.” The authors lumped stroke, TIA (think of it as a temporary stroke), MI (a.k.a. heart attack), and heart failure altogether. And while they all may affect your heart and your brain, they are not all the same. By opening up the floodgates (or adding more diseases to the primary endpoint), you will almost certainly capture more women who fall into the “I got that disease” category. So, while more women who took fertility medications may have gotten the primary outcome, the primary outcome was pretty expansive.

Your heart is as important as your ovaries, your uterus, and your fallopian tubes to us fertility doctors. While we may seem to have a one-track mind (#makingbabies), we are not only focused on your fertility but also your future health. Therefore, we will keep following the latest scientific breakthroughs and bring them to you hot off the press. We cross our hearts!

Going Long: When the Finish Line May Be Further Than You Think

For all of you runners, swimmers, and cyclists, you know what it takes to prepare for that long-distance jaunt. Aside from what you should eat (#carbLOAD) and what you should wear, how far your legs or arms need to take you is pretty important. Preparation, both physical and mental, is key to crossing that finish line.

The same can be said for individuals and couples going through fertility treatment. Knowing how many rounds or cycles it will take you to reach the finish line (#baby) will help you prepare for the journey. And while this is no straight-up calculation or predetermined training plan, information such as age, ovarian reserve, and fertility history can definitely help us estimate. Here’s how far you might need to go…

There are about 180,000 IVF cycles performed in the US each year. And from these cycles, about 65,000 babies are born. Over the years, the numbers have added up, and nowadays, nearly 2% of babies born each year are a result of IVF. Simply stated, more and more people are doing IVF, and more and more babies are born after IVF. However, the number that is less clear is how many cycles it took each person to get to her personal finish line (a.k.a. a baby).

And while this statistic may elude us, what is pretty evident is that those who hang in there longer (a.k.a. complete more IVF cycles) are more likely to conceive. In fact, a recent Swedish study demonstrated that women who did three IVF cycles had about a 65% chance of pregnancy. This was higher than women who stopped at one or two. And while we are certainly not advocating endless IVF cycles, we are recommending that you go the distance based on your doctor’s recommendations.

If your doctors think you have the potential to push on (you are still making a good number of eggs, you are having advanced embryos transferred, your embryos are passing the genetic screening test), then we recommend that you keep on keeping on. Just make sure that you know how far they think you should go, and in turn, make sure they know how far you want to go.

Going back to our original metaphor, think of it like this… If someone told you that you had to run five miles and then midway through told you it was actually 10 miles (oops!), you would be pretty peeved. You would probably doubt your ability to go the distance and maybe even decide to bow out before the race was over.

On the contrary, if you planned to do a 10 miler but midway through found out the race was only half that distance, you would feel pretty good. Energized and invigorated, you would kick that race’s butt and sprint to the finish line. Fertility treatment might make you go the distance. While we certainly hope the race is over shortly after it starts, if it goes longer we don’t want to leave you out there on the course without the appropriate gear.

Information, preparation, and participation (a.k.a. a doctor who consults with you after every IVF procedure) will guide you through this often-torturous race. But having a good idea about the course before you start will make each passing mile a bit easier.

Hey, Hey, What Do You Say…What’s the Difference Between These “Ks”

Historically, the final shot, or the “trigger” shot, in an IVF cycle was almost always a fixed amount. While there was variability in what medication was given (hCG/novarel vs. ovidrel), the dosage was pretty standard. Both medications when administered correctly were pretty good at achieving egg maturation. Their differences were in many ways limited to cost and prep time. (hCG must be mixed, and ovidrel is a pre-filled syringe). Who got what was frequently based on insurance coverage and cost. Nothing to shake your pom-poms about! Fast-forward to about 2008, and the game got more interesting with the introduction of a new player, a.k.a. Lupron (leuprolide).

It was discovered around this time that Lupron could not only achieve egg maturation but also eliminate the risk of the dreaded ovarian hyperstimulation syndrome (OHSS). Have we found ourselves both the rookie of the year as well as an MVP in one shot?

Yes and no. While Lupron is really good at avoiding OHSS for almost all, it falls short in achieving egg maturation for some. It requires the endogenous production of good amounts of LH (hormone made in the hypothalamus) to be effective. Without it, it really won’t work. Simply stated, it needs a teammate. Cue hCG or ovidrel. Giving two medications in combination (hCG + Lupron OR ovidrel + Lupron) is like drafting your dream team…dribble, shoot, score! Together, these medications (in the correct “K”) can achieve egg maturity without causing significant OHSS.

The tricky part about hCG, and where some of the confusion comes in (#most common on-call phone call for a fertility doctor!), is when we start to modify the dosage from the traditional 10,000 (a.k.a. 10K) down to 5K and then to 1K. In certain instances, we even modify it more to doses such as 2K or 3K. Why this can become so tricky is the mixing that the various “Ks” require. How you get from a 10K to a 1K dose is all about the water.

If you inject 1cc or mL of water (saline) into the powder and then give yourself a 1cc or mL injection, you have yourself a 10K shot of hCG. Not a problem if you are not cooking several dozen eggs. If you want a LOWER dose of hCG to reduce your risk of OHSS, you would increase the amount of water you inject into the powder to dilute the medication.

It would go something like this: 10 cc or mL of water into the same powder (rather than 1cc). However, you would ONLY give yourself a 1cc or mL injection of the water/powder solution. The more water = the more dilution = the less potent. Ovaries with a ton of potential that are being given Lupron alongside hCG don’t need so much oomph from the hCG. The combo is enough to get their system going without getting them sick.

While ovidrel is no slacker in terms of egg maturity, it is harder to play with the dose. Because the syringe is pre-filled it’s hard to manipulate the dosage. For this reason, many clinics have moved away from using ovidrel in exchange for hCG. It’s VERY important to discuss the trigger medication and what would be best for you and your ovaries before starting the cycle. It can be a huge bummer when you spent your hard-earned cash on a trigger medication that you can’t or don’t want to use. Also, make sure to get the playbook before you leave your doctor’s office on the morning of the planned trigger shot. Getting new instructions only a few hours before the big game can be incredibly overwhelming.

As physicians, we are here to be your cheerleaders and guide you in this “Hey, hey, what do you say?” chant as you throw the final pass. The trigger medication is the grand finale of a whole lot of plays. It’s important to get the medication and the dose right to ensure that your cycle ends on a touchdown and not on a fumble!

Where to Place Your Bet: The Difference Between Egg and Embryo Freezing

Who doesn’t love a good pre-game? Standing in a parking lot with the sun beating down on your back, relaxing with your friends: life couldn’t be better. While you may don a Giants jersey and your friend Eagles green, your pregame rituals are pretty much the same. Good food, good drinks, good times. When you enter the stadium, that’s when things start to change.

The same can be said for the difference between freezing eggs and freezing embryos. The “pre-game” part is pretty much the same—you take injectable gonadotropins (hormones) on a daily (sometimes twice daily) basis. This doesn’t change whether you are freezing eggs or embryos. Additionally, in both cases the medications and the morning visits will most likely start with the start of your period and go on for about 10 days. Therefore, in terms of the stimulation (a.k.a. the pre-game process) the two are pretty much the same. It is not until the eggs are retrieved that you run to opposite sides of the field.

If you’re rooting for team egg freeze, here’s what your game plan will look like once we start to play ball. Shortly after the eggs are retrieved, they will be evaluated for their stage of development (mature versus immature). Those that are mature will be frozen immediately. And this is where the information about your eggs and your fertility ends. You will know nothing more about your frozen friends other than quantity. We cannot tell how many will be “good” (a.k.a. make a baby) and how many will be bad (a.k.a. do nothing). But as most American possessions go, the more, the better. Women who have more eggs frozen will have a better chance of pregnancy from them in the future.

And in the blue corner, we have team embryo freezing! For those that choose to embryo freeze, after the eggs are extracted they will be fertilized with sperm. The resultant embryos will then be watched over the next several days in the laboratory. How they grow, how they divide, and how they develop is very telling for their health. Some, if not several, will drop off along the way—those that can’t hack it in the lab would definitely not hack it in the uterus.

In many ways, the lab is like the ultimate test of survival, or natural selection. At the end of the game, you may only have a few players on the field, but these players are tough, resilient, and really know how to play the game. They have weathered the storm and are your true MVPs.

In many ways, egg freezing is like drafting a player who has demonstrated potential in college but has not yet played in the big leagues. They should be good, but you can’t know for sure. It’s also hard to survey the newbies in spring training and know who and how many superstars you’ll have at the end of the season.

In the same vein, if your ovarian reserve tests are normal and there are no red flags in your medical history, you should have some good potential in your eggs. Embryo freezing is like signing a player who has already won rookie of the year. You know more about the player’s (a.k.a. embryos’) ability to hit it out of the park because they have already been vetted. Take it one step further…if your embryos undergo PGS (also called CCS or TE biopsy—the chromosomal analysis of embryos), we have even more information about their ability to make a baby. You have vetted them in the most aggressive way possible.

For many women, embryo freezing is not even an option. Unless you have a partner or chose to use donor sperm, without a sperm source, you can’t make embryos. The lack of sperm and the ability to make embryos are NOT a bad thing AT ALL! And we definitely don’t recommend using donor sperm just to make embryos and have more information about your egg quality. In these situations, egg freezing is totally the way to go! Additionally, even if you have a partner, egg freezing may be a better option for you. Not to be Debbie Downers, but nearly half of all relationships end in divorce. So be careful about who you mix your gametes with!

If you are even thinking about freezing, be it eggs or embryos, you’re being proactive. You are several steps ahead of the game. It’s like you’re planning your roster months before opening day! Either way you do it, you’re giving yourself options and choice. And that’s really why you did this in the first place. So however you get on the field, you are here to play ball—go, girl, go!

Hop on the Blame Train: Advanced Paternal Age Does Matter!

How many times have you read, been told, or watched someone lecture about what happens to us ladies as we age? Aside from the greying of our hair, the sagging of our bottoms, and the wrinkling of our skin, we can look forward to the withering of our ovaries. Sounds like fun! And while we women are used to shouldering all of the blame, men and advanced paternal age play a pretty sizable role in the fertility equation. Just because guys make sperm almost all of their life doesn’t mean that they should make a baby with this sperm. Here’s why.

Let’s start with a bit of basic biology…the process of sperm production in men is called spermatogenesis. Unlike oogenesis (the production of eggs), which occurs ONLY when you are a fetus inside of your mother’s womb (remember, a girl is born with ALL of the eggs she will ever make), spermatogenesis is like the Energizer Bunny—it keeps on ticking.

However, just like any device that is running on batteries that have seen their better days, over time, things start to go awry. Things stop moving, start sounding funny, and become unable to perform their duties. The situation is really not all that different with sperm. As guys age, their sperm-production battery (a.k.a. spermatogenesis) starts to become more error prone. We see more breaks in DNA (the genetic material that is passed down to your future lineage) and a higher frequency of mutations within the DNA. These mistakes translate into abnormal sperm, which translates into abnormal embryos and infertility. Additionally, as men age, their semen volume decreases, sperm motility decreases, and the percent of normal sperm decreases—D-Day is upon them.

The length of time it takes a couple when the male partner is older to conceive is longer than the time it takes a couple when the male partner is younger. The line in the “age” sand is debatable and usually set anywhere between 45 and 50. The same delay in conception appears to hold true even when doing IVF; older sperm will likely set you back (how much time is not clear).

And while the sperm may be slacking, there are also data to suggest that paternal age has a significant impact on how often a couple with an older partner not only has sex but also on sexual function. Studies show that older men have sex less often due to decreased sexual desire and diminished sexual function. Less sex is going to equal less chance of conceiving, no matter how good the sperm he still has.

Research has also shown us that advanced paternal age (again, think 45 or 50 years old) has an impact on specific genetic and medical conditions. These include autosomal dominant disorders (achondroplasia, Apert’s syndrome, Marfan syndrome, etc.) as well as schizophrenia, autism/autism spectrum disorder, and certain congenital anomalies. How or why these diseases or errors happen is not super clear. So far, scientists think the money is on a reduced amount of antioxidant enzymes hanging around in the semen. Think of these enzymes as the police; they are responsible for cleaning or stopping abnormalities. Just like a city without a good police department, the fewer enzymes, the more potential problems for the sperm and the resultant embryo.

Newer evidence also suggests that children born from older dads may have a SLIGHTLY higher chance of childhood cancers (specifically, leukemia and brain/nervous system tumors). Given these risks, most of us OB/GYNs will recommend chatting with a genetics counselor either before or in the very early stages of pregnancy. They can help break down even the most complex of issues and set the stage for what can happen when the curtain goes up.

Fertility is a two-way street. While we have let the guys off the hook when it comes to age in the past, we now know that paternal age does matter. It can most definitely play a role in infertility and abnormal pregnancies. Sperm, like their egg counterparts, seem also to be on the hunt for the fountain of youth. This is important to remember when looking for the cause of infertility.
And although we joked about it, this process is way stressful, and therefore, there is no need to blame, to point fingers, or to look for fault. While we want to find cause, we don’t want to ascribe blame. That train has left the station. It’s time to move together towards our destination.

The Lingo

We talk fast, sometimes too fast…way too fast! We also move fast and think fast—we can’t help it; we’re New Yorkers! But sometimes we need to slow down, not only how we talk but also how we move, both through our days and through our lives. And while it’s going to take work (#meditation) to slow things down, we can help those whom we frequently talk to (a.k.a. our patients) better understand the shorthand or lingo that we are using for medical terms. Think of the following as the Truly, MD, fertility language translator. We offer you the top 15 most frequently heard acronyms in the halls of a fertility clinic, in alphabetical order.

ART: Who doesn’t like to paint and color? And although we, too, like an adult coloring book (they’re now all over the place!), the ART we are referring to stands for Assisted Reproductive Technologies. Anything where fertilization occurs outside of the body (think IVF, egg donation, or surrogacy) is under the paintbrush of ART.

Azo: Despite the way it’s written, you’re not about to visit the zoo. Azo comes from the Greek word azoos, which means lifeless. In fertility medicine, azoo– is a prefix that, when placed before -spermia describes the lack of sperm found in the ejaculate. It can occur either when sperm is not being produced OR when sperm is being produced but its exit out of the testicles is blocked. In both cases, it requires an evaluation by a urologist.

CCS: Think of a girl named Elizabeth. Elizabeths can be Lizs, Beths, Lizzies, and even Elizas. Sometimes they drop the nickname thing completely and go by Elizabeth. Simply stated, there are many ways to refer to your friend named Elizabeth. Same goes for the names we use to describe the genetic testing of embryos. CCS, or comprehensive chromosomal screening, is a term used to describe the genetic testing procedure that checks to see how many chromosomes an embryo has (remember, 46 is the magic number!).

DOR: Women with low egg count and low egg quality are frequently diagnosed with diminished ovarian reserve. Simply stated, the “fuel tank” in the ovaries is running low. The ovaries have a finite number of eggs. Once we exhaust that supply, there is unfortunately no way to “refuel the tank.” To maximize what is remaining in the ovaries, fertility doctors will often recommend IVF.

hCG: Everyone’s favorite hormone. hCG is the hormone that is secreted by a pregnancy, so when it is positive or present in your blood or urine, it indicates that you’re pregnant. And while it can’t tell us if the pregnancy will be good, it tells us if something is there. On the flip side, it is also a shot we administer to achieve ovulation and egg maturation.

IC: Simply stated, IC = intercourse. Intercourse = sex. We, as fertility doctors, “prescribe” IC frequently. By using tools like your menstrual cycle, your ultrasound, and your blood work, we can predict when you will ovulate and when “having IC” will give you the best chance of “having a baby.”

ICSI: Staying with the egg-meets-sperm concept when ICSI is performed, this meeting takes place in a whole different spot in a whole different way. There is no swimming or mingling, but there is a whole lot of selection. During ICSI (intra-cytoplasmic sperm injection), an embryologist will select individual sperm and physically inject them into the egg to achiever fertilization. In most cases, the highest rates of fertilization are achieved following ICSI.

IUI: In the body, sperm has to swim—from the vagina, to the cervix, to the uterus, and to the tube to finally meet the egg. And while this journey is fairly short and fairly quick (most sperm reach the tube in less than two minutes), it can be taxing. IUI (also known as intrauterine insemination) is sort of like a way to bypass step A and step B, allowing them to get to step C much faster!

IVF: Fertility medicine has come a long way, baby! And while we have seen a lot on both the diagnostic and treatment side, the biggest leaps and bounds have come with in vitro fertilization (#IVF). In the most basic terms, when an egg meets a sperm outside of the body and fertilization occurs in the laboratory, that’s called IVF. The resultant embryo is either transferred back into the uterus three to five days later or frozen for future use.

Oligo: Going back to our Greek roots is where we will find the definition for the frequently used prefix in fertility medicine, oligo-. Simply stated, oligo means few, little, or scanty. We often put it in front of medical terms such as -spermia (a.k.a. sperm) or -menorrhea (a.k.a. period) to describe how many or how frequently something occurs.

OPK: OPKs have become a part of a reproductive age woman’s vernacular! They are so commonplace that we often forget they are somewhat new to the fertility scene. OPK stands for ovulation prediction kits, and they are an OTC (a.k.a. over the counter) means to know if you’re ovulating. While it does require urine, some diligence (you frequently need to take the test several days in a row), and anywhere between $20 and $100, it can provide helpful information regarding when and if you’re releasing an egg.

PGD: Although PGD and PGS are used interchangeably, they are not identical. PGD describes the genetic testing of embryos for single-gene disorders. PGS is looking to make sure that the embryo has the accurate number of chromosomes. To do PGD, you have to be looking for the presence or absence of a specific genetic condition, not for overall chromosome number. Picture this…if you and your partner are both carriers for Cystic Fibrosis, you would do PGD on the embryo to make sure that embryo will not inherit the disease. We can test for hundreds of genetic conditions as long as we know what the specific mutation is.

PGS: In many ways, PGS is the umbrella term for everything that “rains” genetics. Pre-genetic screening involves screening the embryos through a variety of techniques for chromosome number. It is probably the most frequently used term, by both physicians and patients, to describe embryo genetic testing.

TE Biopsy: We are taking you back to “Elizabeth” one last time…just with a bit of a twist. TE biopsy (a.k.a. trophectoderm biopsy) finds itself in the same family of terms used to describe genetic testing. However, TE biopsy actually describes the technique that we use to obtain the cells needed for the genetic testing. The trophectoderm is the part of the embryo that will become the placenta, months down the road. We take cells (biopsy) from the trophectoderm and send it to the genetics lab for analysis.

Although it’s fairly likely that we missed a few frequently used ph-rases (that’s what happens when you move fast!) this list captures most of the big ones. Use it as your cheat sheet when trying to decode the language you hear at a fertility clinic. And while you may never totally speak the same language as your fertility doctor, at least you will come pretty close to being fluent.

Can’t Stop, Won’t Stop: What to Do When Your First IVF Treatment Fails

Can’t stop, won’t stop; it’s not for nothing that this may be one of our favorite sayings. As overplayed as it might be and as trite as it might sound, it’s pretty much how we aim to live our lives, how we chose to tackle our challenges, and how we hope to make it to the end of a marathon. We push each other, we push ourselves, and we push ahead to get to OUR end.

But life is not a race, and there is no set finish line (except for the obvious one that we won’t harp on). How you end your day, how you end your career, and how you end any struggle in many ways is up to you. You set the start line, the halftime, and the finish line. Much can also be said for how many rounds of fertility treatment you decide to do and how long you continue to try for a baby.

Knowing when to call it quits can be nearly impossible. Whether professionally or personally, it’s hard to know when enough is enough. In terms of fertility treatment, specifically IVF cycles, how much is too much? How many is too many? When do you move on to something else?

A recent study from England published in a very prominent medical journal (JAMA) recently addressed this question. It got a whole lot of press and found its way into the New York Times, the Wall Street Journal, and all of the morning talk shows. It basically showed that women who hung in the game were more likely to get pregnant—quitting after a couple of failed IVF cycles was not the right move. Although they didn’t find a magic cutoff number after which patients should be told to exit stage left, they did find that nearly 70% of women under the age of 40 got pregnant after six IVF cycles. While about 30% of women got pregnant on the first cycle, many took longer to cross their finish line.

The results were less promising for women older than 40; while they also got pregnant at a higher rate after more IVF cycles, the total number did not exceed 30%. Bottom line, even though this study got as much press as a Kardashian wedding, it’s important not to misanalyze the data.

This study is NOT giving the green light to endless IVF and fertility treatments. This study is NOT saying that multiple IVF cycles are always the way to go. This study is NOT saying everyone who does multiple IVF cycles will get pregnant. This study is simply saying that, if you can emotionally, physically, and financially (unfortunately, finances come into play big time) swallow the treatment AND your doctor believes you are a good candidate, it’s okay to keep on keeping on.

Knowing when to bow out is nearly impossible. Unfortunately, there is no magic number. But here’s the CliffsNotes version from girls in the know… For starters, we use age, pregnancy history, and ovarian reserve testing to decide when enough is enough; these initial parameters can shed a lot of light about what’s to come.

Additionally, we use IVF response as a gauge of how much gas you have left in the tank—are you responding to medications, are you producing follicles, is your estrogen level rising?

Last, we use embryo development and, if available, embryo genetic testing results (PGS/CCS/TE biopsy, which tests for aneuploidy) to help patients decide whether further treatment is a go. For example, if patients have done several IVF cycles without any viable or normal embryos, we are hard pressed to recommend continued fertility treatments with your own eggs. And while no, history doesn’t always repeat itself, in these cases, it comes pretty close.

We are not dictators, czars, fortune tellers, or goddesses (although we wish we were)—and we are not afraid to admit that. We can’t tell you that more will be better; it may just cost more money, cause more physical discomfort, and evoke more emotional anguish. But quitting too early can be a real shame.

Just like in sports (from two women that love to pound the pavement!), there should always be a day for rest, always a moment to breathe, and always a time to stop. Without a break, you get injured. Without a day to sleep in, you get fatigued, and without days off from work, you get frustrated. In cases where there is no definable finish line for you or your partner, you may need your doctor to help you set it. When you collectively find that line in the sand, be careful not to step over it. Things will start to sink quickly on the other side.

The Art and Science of IVF

As first-year medical students sitting in the back of the Mount Sinai School of Medicine lecture hall, we had no idea what to expect from the Art and Science of Medicine course. We all thought of ourselves as scientists (I mean, this was medical school!). Art was far from most of our minds. Questions like “What will this class be like?,” “Will it be lecture-based or textbook-based?,” and “Will the exams be graded or simply marked Pass or Fail?” flooded our minds. In typical Jaime and Sheeva fashion, poised with pens in our hands (we were both ferocious note takers!), we were ready to transcribe every word uttered by the lecturer to soak up and eventually memorize every piece of data shared. However, what followed surprised us: we would not be note taking, we would not be studying, and we would not be test taking.

We would learn about the art of medicine.

Art and medicine may strike some of you as odd. It did us! Medicine is a practice rooted in science and data, not color or design. The people you knew who became doctors did it because they liked facts, not pictures. However, in reality, how we diagnose a disease, how we treat a problem, and how we formulate a plan are really an art. The many available imaging modalities, medications, and surgical procedures are our colors. How we blend them to get the best outcome for you, the patient, is our art.

For fertility doctors, ovarian stimulation in particular (a.k.a. how you get the ovaries to produce multiple eggs) is our art. What protocol we select for a patient, when we increase and decrease medications, and how to obtain the highest percentage of mature, good-quality eggs is our art (not to be confused with ART= assisted reproductive technology!). Sure, we have scientific data to guide us in our decisions, but what can make one IVF cycle more successful than the other has a lot to do with the art of ovarian stimulation. And we bring you back day after day for blood draw after blood draw and ultrasound after ultrasound not because we like to torture you but because it helps us customize your design, your art.

Don’t get us wrong. There is a lot of science in what we do. The laboratory is our science. The embryologists, the culture system, and the genetic testing are science. And without the science, our art is just some strokes on a blank canvas. It takes both, the art and the science, to treat a patient and to achieve success in all areas of medicine.

So, if you ever wonder why we do what do and how we decide on treatment protocols, they are our art. And when they are combined with science, it can make a beautiful picture!