I Am Ready to Race Again; Is It Too Soon? Pregnancy Interval

For any of you who have competed in a long-distance competition (be it a run, a swim, a hike, or a bike), you know what it feels like to cross that finish line. Total euphoria—combined with a fair amount of exhaustion, pain, and lots of blisters! The first thought that runs through your head, after the “I can’t believe I actually made it” moment is either “When can I do it again?” or “I am NEVER doing that again!”

The first group is already planning their next race, mapping out their training schedule, and thinking about how they could have done it better. While the “Okay, I can check that off my bucket list group” is looking for the nearest bar, a bath, and a bed. In many ways, pregnancy, labor, and having a newborn is very similar to the training and racing of a long-distance competition.

While the “Yes, let’s do it again” and the “No, I am so out” camps in pregnancy and parenthood are more fluid than the participants in long-distance competitions, (hard-core Group B members may move into Group A), people usually have a pretty set idea about how many times they want to be pregnant, how many times they want to give birth, and how many children they want.

Most of us even have a pretty good idea about how close together we want our kids to be (medically termed birth spacing). Whether you want them back-to-back or you prefer to space them apart is a personal decision. But how soon you can hop back on the baby machine is dependent on more than just your feeling ready. It also depends on factors out of your control such as if you had a C-Section or a vaginal delivery, if issues like high blood pressure or diabetes complicated your pregnancy, and if you required any additional procedures post-delivery. These all can hold you up even if your heart is ready to race again.

Regardless of what went down during your pregnancy, the time between delivery and a pregnancy should be AT LEAST 18 months. Any shorter inter-pregnancy interval can increase the chance of preterm delivery, premature placental separation (placental abruption), pre-eclampsia (high blood pressure in pregnancy), placenta previa (particularly after a C-Section), low birth-weight babies, and autism.

While the definitive reason behind why these events occur more frequently is debatable, fingers seem to point towards the “maternal depletion hypothesis.” Pregnancy and the stressors of a newborn takes a lot out of you, and your body needs time to re-fuel and re-energize before it starts the race again. Stressing the system before it is ready to function can interfere with its ability to do its job well.

Among the organs in the body that need a break, the uterus is at the top of that list, especially after a C-Section. The uterus is a muscle, and a muscle that is injured (particularly cut and sewn back together) needs to heal. Without adequate time to heal, there is a higher chance that it will open (a.k.a. rupture which is life threatening to  you and the baby) in the subsequent delivery. Furthermore, women who had a C-Section and want to try for a vaginal delivery in their next pregnancy (vaginal birth after cesarean section=VBAC) need extra-extra time to rest their uterus before it is pushed to push.

You don’t have to decide which group you are going to side with moments after crossing the pregnancy finish line (#delivery). Labor can be long and exhausting. Give it some time before you wave the “Yes, I want another baby” or “No way; I am done” flags. Even if you are raring to go moments after the race is over, give it time before you line up at the next start line. Hydrate, stretch, rest—do whatever it takes to get you ready to go again. The time off will do you good—and your next pregnancy.

How Old Is Too Old? The Age Limit for Pregnancy

We have all heard the stories, seen the headlines, and talked about it over the water cooler on Monday morning: “66-year-old woman delivers twins,” “65-year-old woman delivers quadruplets,” and most recently, “72-year-old woman delivers baby” (that last one really made us stop in our tracks)! It gets us talking and gets us thinking: How old is too old for a woman to have a baby? Is pregnancy in your 60s really healthy? Is it fair for a child to be born to parents who are 60?

The questions are endless. And although we are not advocating for Congress to raise the age for Social Security or cut Medicare benefits, we do believe (as does the American Society of Reproductive Medicine) that at some point we all must throw in our reproductive towel. Here’s why.

Let’s start by shedding light on how we women in our 50s and beyond (as well as most women in their late 40s) conceive. In nearly all cases, the pregnancies have been achieved with donated eggs. By the time we hit our mid-40s, our egg supply has pretty much gone kaput. And the ones that are still hanging around often lack the ability to make a healthy embryo.

But while the ovaries have waved goodbye to most things fertility, the uterus is still hanging on. It is like that friend you had growing up who could be dared to do anything (you know the kind we’re talking about… “Dare you to eat a worm…”). The uterus is sort of a pushover for anything with estrogen and progesterone. However, like your middle school friend, just because it will do it doesn’t mean it should do it.

There are guidelines released by the American Society of Reproductive Medicine (they’re sort of like the fertility FBI) suggesting at what age people should and should not be pregnant (no matter how willing their uterus is!). This is what they have to say:

“Physicians should obtain a complete medical evaluation before deciding to attempt transfer of embryos to any woman over age 50. Embryo transfer should be strongly discouraged or denied to any woman over age 50 with underlying issues that could increase or further obstetrical risks and discouraged in women over age 55 without any issues.” (ASRM Ethics Committee)

Let us translate. What they are really saying is that it’s okay to attempt pregnancy in women over the age of 50 as long as they have really, really clean bills of health. It is not okay to transfer embryos, no matter how clean their bill of health, if they are over the age of 55. And while they don’t have your phones wired and your Internet tapped, even if you as the doctor or the patient don’t get “caught” doing this, if you violate the rules, you could get hurt.

Pregnancy complications increase markedly as women age. It can be a pretty dangerous nine months for both mother and baby. In medicine, when the risks start to approach the benefits, you have to seriously stop and consider what you are doing. Donor egg pregnancies in women who are above the age of 55 are one of those times. There is an increased risk of pre-eclampsia (pregnancy-induced high blood pressure), gestational diabetes, low fetal birth weight and, in some studies, fetal mortality. Additionally, nearly three quarters of the babies born to woman above the age of 50 are delivered via C-Section—and while we all think of a C-Section as nothing, it is a major surgical procedure.

Pregnancy is somewhat of a conundrum for us doctors. It is the first time and the only time that you have two patients AT ONCE (in the same body!). It is not only difficult medically but also ethically. Donor egg pregnancies in women who are older than 50 bring up the “fair-to-child” debate. This topic is more controversial than who you voted for this election season.

Let’s just say it’s a good thing there are curtains at the polling places and in doctor’s offices—privacy is key! And while medical ethicists could debate this topic for hours (similar to MSNBC and Fox re: presidential candidates) citing studies and data points on both ends, the bottom line is that no one really knows the answer.

There are those who say that it is not uncommon for grandparents to raise grandchildren, to provide economic support to the family/children, and to serve as the parents in a family unit, so what’s the big deal with women getting pregnant in their 50s? Is it sexist to limit a woman’s ability to have a child while allowing older men to keep on keeping on, no matter how old they are? Shouldn’t women be given the same opportunity as men?

On the flip side, there are those who argue that older parents can’t meet the physical and emotional demands of raising a child. And furthermore, there is a fairly good chance that the child will lose one or both parents at a young age—how can losing a parent or parent (s) before adulthood be fair to a child?

It’s a pretty intense debate. And while all the speaking points may get muddled in your head and you don’t really know whose side you are on, what is important to remember is the following: our jobs as MDs is to keep you informed and healthy. If we think something could hurt you, no matter how badly you want a baby, we must hold up a big flashing STOP sign. While we want to make you a parent and help you build a family, our primary duty is to keep you healthy.

When we say no, it is not because we are being ageists, it’s because we are being “aware-ists.” We are aware of what could go wrong and don’t want to see this happen to you. We won’t play truth or dare with your health. Trust us, no dare is worth it.

The Retrieval: The “Eggs” Are Cooked!

After multiple days and nights of shots, several early morning ultrasounds, and endless blood draws, D Day has arrived: it’s time for the retrieval! Your doctor has used the information from these early AM get-togethers to time the procedure perfectly. While the goal is to obtain the highest number of mature eggs (remember, only mature eggs can be fertilized!), we don’t want to risk quality. Therefore, while the shots could go on and on (don’t look so excited!), we stop them when we feel we have hit the sweet spot—the highest number of mature high-quality eggs.

The retrieval (a.k.a. the egg extraction) will occur approximately 35 hours after the trigger/final shot (hCG, ovidrel). The finale of shots and the retrieval are timed so that the eggs have reached their “finale” in maturation when they make their curtain call in the embryology lab!

In nearly all cases, the egg retrieval will take place in an operating room adjacent to the embryology lab. And while it may be cold in there (brrrr, blankets please!), there will be many people ready to make the experience less frigid and less frightening. In addition to the physician, the nursing staff, and the operating room staff, there will most likely be an anesthesiologist present who will administer pain medication to you during the procedure. This will alleviate almost all of the discomfort and erase most of your memory of the procedure. However, because anesthesia will be given, we ask you not to eat or drink anything after midnight on the night of the procedure (a small price to pay for a pain-free experience!).

The egg retrieval is a vaginal procedure; with the help of a vaginal ultrasound, physicians watch themselves as they pass a needle through the vagina into the ovary and ultimately into the follicle. The needle is attached to a suction system which, when activated via a foot pedal, allows the follicular fluid and egg to drain into a tube.

The tube filled with follicular fluid and hopefully an egg is walked from the operating room into the IVF laboratory; an embryologist will be anxiously awaiting its arrival (let the egg hunt begin!). In most cases, the retrieval is pretty short and straightforward and takes no longer than 20 minutes (timing can vary based on how many follicles you have to drain). You will wake up in the recovery room with little memory of the event, asking us when it is going to start!

In many ways, although the egg retrieval feels like the finish line, your journey is only just beginning. And while the stomach/thigh shots will come to a halt as well as the early AM rendezvous, the waiting game has just begun. Much of the real information about egg, sperm, and embryo quality will come over the next several days.

Although the waiting game is the worst, a lot of information will be gleaned during this time period. One word of advice: be aware of the dropoff that will inevitably occur over the course of the next few days. Follicle number does not equal egg number, egg number does not equal embryo number, and embryo number does not equal baby. (LINK: 5 + 5 = 2? The Difference between Follicle Count and Embryo Number) If you are prepared for this dropoff, the loss will be easier. Remember—don’t count your chickens before they hatch!

I Am in the Mood for a Chocolate Chip Cookie…Follicles and Ovarian Reserve.

Who doesn’t like a good gooey, moist, chocolate-filled chocolate chip cookie? The more chips the better, says every part of your body but your tush! The same can be said for the follicles (and eggs) in your ovaries. The more, the better—at least most of the time!

A big part of the fertility assessment is ovarian reserve. You probably hear your fertility doctor throw this term around like it’s candy (or cookies! ): “Your ovarian reserve looks good!” “Your ovarian reserve is not so good.” You may be nodding and thinking, “What in the world are they talking about?”

Ovarian reserve is the medical way of saying how many eggs you have and what their quality is. While most of our assessment comes from hormones and blood work (cue FSH and AMH), a big “bite of the cookie” comes from our ultrasound. This ingredient is as basic as sugar and flour to making a finger-licking calorie worth its cookie.

An ultrasound performed in the early part of your menstrual cycle (a.k.a. the follicular phase) can tell us a lot about what your ovaries have left to give. Is your bag of chips half full, or are you running dangerously low on supply? By measuring the follicles (a.k.a. “chocolate chips”), we can get a good idea about the egg quantity (a.k.a. ovarian reserve). We call this measurement of follicles your antral follicle count (nicknamed AFC).

An AFC is ideally done on day 2–5 of the menstrual cycle. By doing it early, we can catch you at what we like to call baseline. “Home base” is when we can get the best idea about what is going on in those ovaries because no follicles have yet to start running the bases.

Eggs are invisible (to the naked human eye). It doesn’t matter how high we crank the ultrasound waves, we will never be able to see those eggs unless we bust out our microscopes and speed-dial our embryologist friends. Eggs live in follicles. (Picture a dozen eggs that you would buy in a grocery store—the shells cover the eggs. Unless you crack them, you won’t see them.) We need to count follicles to find out about egg number. Although it is an indirect measure of ovarian reserve, it is pretty on point.

We do a lot of ultrasounds. We can look at the screen and pretty quickly size up those ovaries. But a little baker’s secret for all of you laypeople—the little black circles in the ovaries are the follicles. (Anything fluid filled on an ultrasound will be black). The ovaries are usually grayish/white. So put that together, and what do you get? Bibbidi bobbidi CHEW! You probably get the visual at this point…the more follicles (number of chocolate chips) in the ovaries, the chewier they look. The chewier they are, the more eggs you have!

On the flip side (or the less tasty side), the fewer the follicles and the more white/gray ovary, the lower the antral follicle count. The lower the antral follicle counts, the fewer the eggs. It’s a simple as your most basic recipe!

Surprisingly there are some times when cookies can be just too sweet. You know when you take that first bite, and you think, hmm, I can’t go much further? Well, the same goes for ovaries. There are some with too many chips. Polycystic ovaries can have too many follicles or structures that look like follicles. There is a plethora (think many, many bags) of these small follicles/cysts that can impact the regularity with which you ovulate and your ability to make a baby on your own. It can also lead to elevated testosterone levels and cause all of those unfavorable side effects (think hair and pimples).

Back in the day, women with “PCO ovaries” were routinely taken to the operating room to remove a piece of their ovary to cut down on these small follicles/cysts and all the negative things that they bring.

Just like chocolate chip cookies, we all have brands we prefer. Some of us swear by Duncan Hines, while others of us go for the Nestle Tollhouse. And there are those that are out there and like to make them themselves (go, girl, go!). Whatever your sweet tooth desires, there is something to get it going. Ovaries are the same way. Some of us may have chocolate chips galore while others of us are more like a sugar cookie.

While antral follicle count tells us a lot about what your egg number may be, it does not mean that just because your bag needs to be refilled, you won’t have a baby. It just helps us pick the right ingredients (fertility meds) in the right amount to make your cookie!

Why We Say that IVF (In Vitro Fertilization) Is Therapeutic and Diagnostic…

What on earth are those ladies talking about? Have they lost their minds? How can treatment tell you more about what the problem is than the diagnostic tests themselves? Isn’t the treatment supposed to treat the problem, not tell you what’s wrong? Yes and no and everything in between. Hold your questions for a moment, because we have answers.

A good chunk of couples today suffer from unexplained infertility. While much of that infertility is thought to be related to egg quality, often times unexplained infertility dodges our current diagnostic capabilities (the tests in our arsenal). No matter what tests we perform on you and your partner, we find nothing. Blood work, physical exams, ultrasounds, sperm checks, and the tube test: they all come back normal. This can be beyond frustrating, for both you and us! We want to give you answers just as much as you want answers. Unfortunately, despite our endless years of schooling, training, and post-training, we can’t.

In many cases, we can’t tell you about your reason for infertility until you go through treatment (a.k.a. IVF) and we take a magnifying glass to your gametes  and embryos.

Yes, ovarian reserve testing (FSH, AMH, AFC) tells us a whole lot. While these tests often help us diagnose the problem (diminished ovarian reserve-low egg quantity) and give us a good idea about how to treat the problem (and how much medication to treat it with), they don’t always tell the whole story. There are many women who have tons of follicles/eggs but have very poor egg quality. However, when their eggs come out and the resultant embryos don’t divide well, degenerate, and don’t make babies, we by the transitive property (woo-hoo, algebra) know a lot about the embryo quality. Furthermore, if such embryos make it to PGS (pre-implantation genetic screening = genetic testing for abnormal chromosome number), the abnormal-to-normal ratio can surprise us and provide even more answers to a previously unanswerable problem.

One of the most interesting parts of our job is to spend time in the IVF laboratory. Watching our skilled colleagues (embryologists) as they manipulate eggs, sperms, and embryos is fascinating. Through our time in their presence, we have learned a lot about infertility, fertility, and the grey in between. Eggs that degenerate, sperm that is abnormally shaped, and embryos that arrest, fragment, and break down provide us with a lot of answers (#diagnosis). If you get pregnant, then it is also treatment.

In many ways, we find answers in the smallest or tiniest members of our crew. It is for this reason that we say, nearly three times a day, that “IVF is both diagnostic and therapeutic.”

IVF is certainly not always the answer, for either diagnosis or treatment. It doesn’t always work and doesn’t always succeed in getting women pregnant. Even when the embryo quality is an A++++ in embryology labs that are not giving triple-A ratings just to get in good standings, IVF can fail over and over again.

We do not have tunnel vision, and we are not afraid to change directions or ask for directions. We want to do what’s best, and if that does not mean IVF or Western medicine or traditional treatments, we are open to trying new things. But just remember, when you hear “IVF” and think, “I will never do that,” and your doctor says, “IVF is not only diagnostic but also therapeutic,” that person has not lost his or her mind! The lab lets us in on a whole lot and in many cases leaves you pregnant!

Check Your Gas Tank Meter…It Might Be Time to Refuel: The Thyroid

In many ways, the thyroid is like the man behind the curtain. You have never seen him and are not really sure what he does, but you know he’s there. You’ve heard about him, blamed him for your weight gain and for sleeping through your alarm clock, and considered that errors in his way are keeping you from getting pregnant. But how he is masterminding all of this remains unclear.

While the intricacies of the thyroid are more delicate than a lace shirt, the basics come down to a simple Goldilocks type of situation: the thyroid is working too fast, too slow, or just right. When it’s really off, you usually feel really off. Simply stated, when your thyroid is running on empty or very close to it (think flashing red light telling you to pull over ASAP), you will feel like a car without gas, putt putt puttering through your day, being tired, cold, and constipated, with dry skin and hair loss, to name a few.

On the flip side when your tank has been topped off just a bit too much, you feel like you had one too many shots of espresso. You experience insomnia, diarrhea, palpitations, hot flashes/sweating, anxiety…

However, sometimes the deviations are subtle, and your thyroid is just slightly off (medically termed subclinical). But you may not know it unless a doctor checks. While the subclinical part will usually not cause you any noticeable symptoms, it can increase your risk of miscarriage and infertility and lead to negative pregnancy outcomes. Bottom line: if your thyroid is off, it’s not only your bottom line that will suffer but also your plus one.

As a result, fertility MDs are somewhat fixated on hitting the thyroid hormone level sweet spot! We check it on nearly all of our patients pre-pregnancy and then again during pregnancy. We are somewhat OCD in getting it to the perfect point and will labor over when to start some additional medication, when to increase or decrease it, and when to stop it.

What and where is this elusive “gas producer”? The thyroid is a small butterfly-shaped gland that sits at the base of the neck. In most women who are free from thyroid disease, the thyroid is small and cannot be felt. The thyroid produces thyroid hormones (T4 and T3); these hormones travel through the blood throughout the body to target organs. Almost all of your vital organs are target organs in desperate need of a little thyroid juice! The ovaries and the uterus are also quite “thirsty.”

Thyroid hormone plays a role in regular ovulation, pregnancy implantation, and miscarriage. Additionally, babies don’t start to produce their own thyroid hormone until about 13 weeks of age (in utero). Therefore, for the first trimester of pregnancy, babies rely exclusively on their mothers. If you are borderline low making thyroid hormone, they will be super low. And given that thyroid hormone is essential for brain development, this is not an area you want to be lacking in! It is for this reason that doctors will frequently start a thyroid supplement early before the situation hits rock bottom.

While your thyroid may not be to blame for all of your problems, it’s under (termed hypothyroidism) or over production (hyperthyroidisim) may be the cause of some serious ailments. And like most autoimmune conditions (where the body basically attacks itself), women are about six times more likely to be diagnosed with thyroid disease; most of those diagnoses will be made in the reproductive years (30s and 40s).

Not only is the thyroid important for pregnancy and fertility, but the start of it’s decline often occurs during the reproductive years.  So while your tank may be running on empty because you’re burning the candle at both ends, it is always a good idea to have your thyroid level checked, particularly when contemplating pregnancy. Who knows? You may just need a little refueling to help put an end to those annoying symptoms!

Who Doesn’t Want Half and Half in Their Coffee? IVF Stimulation Medications

Calories, shmalories… We like our half and half! In fact, the lighter the better (sweet is good, too!). Half and half gives coffee that creamy taste that is not replicated by any amount of whole or skim milk. The same can be said for ovarian stimulation medications—the ovaries of most women like half FSH and half LH. In many cases without this combo, the response is bland and lackluster.

But before we go any further, let’s take it back to the “beans” (a.k.a. the basics). While FSH and LH are hormonal medications used in IVF, they are also hormones produced naturally in the brain. It is the steady production of FSH and LH throughout the menstrual cycle that results in egg production and ovulation.

Because in a natural cycle you never see FSH without LH, many fertility doctors prefer to keep this dynamic duo intact when selecting IVF stimulation medications. As a result, combined protocols (as we call them in fertility medicine) are definitely leading in the fertility polls. Most of us have seen better ovarian response, better egg quality, and hence, better embryo development when the two are mixed. But taking it back to the beans (a.k.a. the basics), FSH and LH are two hormones that are normally made in the brain.

Great, now they want me to take two shots? Unfortunately, yes, we do. And while we would love to minimize the number of times you have to stick yourself, doubling up will likely do your ovaries wonders. When we stimulate ovaries for IVF, as unnatural as it feels, we are trying to mimic a natural cycle as much as possible. Nature happens for a reason! By giving both FSH and LH together, we are coming closer to what happens when we are not there. These two were paired together before we got there—it seems silly to separate them!

Yes, there are certain women who do better with straight whole or skim milk or even black coffee. For example, women who suffer from hypothalamic amenorrhea (no periods due to low hormones from the brain) need LH. Their ovaries will sit on the runway all day without a blast of LH. On the flip side, women with the real deal PCOS do better with minimal LH in their stimulation. Their ovaries see LH all the time (been there, done that), so it’s better not to put fire on an already flammable situation.

The debate over whether to use FSH alone or FSH + LH has gone on longer than the Coke vs. Pepsi debate. There is evidence on both sides to support combo protocols vs. straight FSH or LH. While doctors may have a preference for one (and can certainly find evidence to support it), most large reviews have demonstrated that (like us) two are better than one. When sitting down with your doctor, before you start the shots, ask them what you are getting, why they are giving it to you, and why they like this for you. Asking questions will quell some of the confusion and anxiety that those bags of needles and boxes of medicines bring upon their arrival.

Your choice of cocktails is very personal. Trust us, we get it. While some of us are vodka soda fans, others like to mix with cranberry juice. And then we have the more elaborate amongst us who go for Cosmos, Long Island Iced Teas, and Mojitos. (Watch out the next day: sugar hangovers are the worst!) Whatever you like to mix with your alcohol, you probably have a reason for it. Same goes for your ovaries and us. Everything we do has a purpose. The difference is, we’re helping make babies, not Bellinis. Here’s to your success, your health, and your fertility. Cheers!

Cervical Mucus: A Marker for Ovulation and a Must for Pregnancy?

For many of us, there is nothing more off-putting than the thought of tracking your cervical mucus day after day, month after month. It’s not easy knowing what you are looking at, why you are staring at your underwear, how long this exercise needs to go on, and what you will do with this information.

Egg white versus watery, creamy versus sticky. Are we baking a cake or making a baby? While in many ways, it’s sort of a little bit of both, tracking your cervical mucus is not a prerequisite for detecting ovulation or having a baby. The changes that occur over the course of those approximately 26 to 36 days can provide helpful hints on both if and when you are ovulating. However, while it is important and does serve as a reservoir for sperm, it is much lower on the fertility pecking order.

The cervix is the lower part of the uterus (a.k.a. the womb); it is the conduit between the uterus and the vagina. When not pregnant, the cervix measures about 2 to 3 cm. During pregnancy and particularly as its end is near, the cervix begins to shorten, thin out, and ultimately dilate. Think of the cervical mucus as the pond at the base of this conduit. It serves as a reservoir for sperm by providing it with nutrients and safety for several days (up to five, to be exact!). While the majority of sperm is in the tubes minutes after ejaculation, the pond holds on to the stragglers. Over the course of about three to five days, sperm is released into the uterus and the tubes, hoping to meet its mate and make an embryo.

Much like the variability in the uterine lining during the approximately one-month-long menstrual cycle, the cervix and its mucus also go through a host of changes. After bleeding has stopped, the cervical mucus is usually scant, cloudy, and sticky. This lasts for about 3–5 days. What comes next is the stuff that you are taught to look for.

In the three to four days leading up to and after ovulation, the mucus changes to clear, stretchy, and fairly abundant. Following ovulation, the cervix becomes somewhat quiet, and cervical discharge remains scant. The “stage hands” behind the curtain setting the scene for the changes observed in cervical mucus are estrogen and progesterone production. Altering levels of estrogen and progesterone results in major modifications in mucus content and production.

If the cervix falls short on producing and maintaining its reservoir (a.k.a. mucus), problems can arise. However, while cervical factor infertility used to be considered a serious and real problem, today the cervix and cervical mucus production are hardly ever the cause of infertility (only about 3% of infertility cases are due to the cervix). Because of this, tests to evaluate the cervix/mucus are no longer needed.

Traditionally, a postcoital test (nicknamed the PCT) was performed to seek out cervical dysfunction. Now, picture this: fertility doctors used to obtain a sample of cervical mucus before ovulation and after intercourse and check it out under the microscope. They were looking for the presence (or absence) of moving sperm. Although this is sometimes used in couples that cannot have a formal sperm check, it is otherwise one for the ages. The subjectivity, poor reproducibility, and very inconvenient aspect of it have eighty-sixed the PCT in the land of fertility medicine.

In cases where the cervix has been previously cut, burned, or frozen, a narrowing of the cervical canal can arise (medically called cervical stenosis). Cervical stenosis can make procedures that require access to the uterus difficult (picture trying to pass something through a really narrow hole—it doesn’t fit!). Therefore, prior to undergoing any fertility treatment, a cervical dilation (that is, a widening of the cervix) may be required. This allows your doctor to then put sperm or embryos back into the uterus.

However, while the narrowing can make infertility procedures somewhat more challenging, the width is not what’s causing the entire problem. Cervices that have been exposed to trauma like surgery can have difficulty producing mucus. No mucus equals not much of a place for the sperm to hang out (cue IUI or IVF).

While the cervix may not be playing the feature role in the fertility play, it does serve as an important role. In addition to providing a respite to sperm, it also helps maintain a pregnancy to term. When a cervix shortens or dilates before time’s up, it can lead to a snowball of negative events: preterm labor and preterm delivery, to name a few. Bottom line, it’s not only a reservoir but also a roadblock. Until that nine-month mark has passed, it should not let anything out that front door!

Think about your cervix and cervical mucus but don’t drive yourself nuts. Yes it is a way to confirm ovulation but no it’s not the only way. While we are advocates of knowing your body and being aware of what’s going on with your cycle, obsessing over what’s going on won’t change what’s coming out. We have ways to get the sperm to meet the egg even if the cervix isn’t cooperating!

5 + 5 = 2? The Difference between Follicle Count and Embryo Number

Numbers are no strangers to fertility medicine; success rates, dosages, and egg/embryo counts are all things we count. And despite our tenuous personal relationship with math, over time, we have become quite comfortable with statistics, percentages, and probabilities (disclaimer—as they relate to IVF only)!

However, the number that often eludes us, and the question on so many patients’ minds, is the following: What is the follicle to egg to embryo to viable (able to make a baby) embryo conversion rate? Simply stated, if I have 10 follicles will I have 10 eggs, and if I have 10 eggs will I have 10 good embryos? The short answer, without any derivatives, formulas, or equations is no…You will very likely not. And here’s why.

Human reproduction is an incredibly inefficient process; think the DMV on a bad day! While we start with over a million eggs, a very small percentage of them actually have the potential of making a baby. So while a woman may ovulate every month, many of these months the egg that is released won’t put you on the path to pregnancy. Now, while in most natural un-medicated cycles only one egg is released per month, there are actually a group of eggs that are vying for the ovulation “trophy.”

Think of egg /ovulation selection as a horse race. At the beginning of the month, several horses (a.k.a. eggs) are racing to become the egg that will be ovulated. Ultimately, one breaks free, garners enough receptors to capitalize on the available hormones, and wins the ovulation race. When we are young, there may be 30 or 40 “horses” that enter this race. Although there will still only be one winner at the finish line, the race is more robust. As a result, there is a much higher chance that your winner will be fast, strong, and able to get the job done.

As we age, the number of “horses” lining up at the gate declines until we are left with only a few weaker, slower, scrawnier participants. There will still be a winner, but you may not get very many calls from interested breeders!

Let’s stay with the horse-racing metaphor for a moment. One of the primary goals of an IVF cycle is to ensure that all of the horses that start the race finish it; in this race, we don’t want a winner. As fertility doctors, we give hormones to ensure that there is enough juice to get every follicle/egg to go the distance and cross the finish line. We want all of the eggs in that month’s cohort to grow and develop at the same rate and ultimately achieve maturity.

However, even with the strongest of cocktails we are limited by the number of entrants. If five horses enter the race, we can have no more than five horses finish it. Think of the first ultrasound in an IVF cycle as the race check-in. If the doctor sees five follicles (remember, eggs are microscopic so we count follicles that hold the eggs) there are likely to be no more than five eggs extracted at the time of the retrieval.

Unfortunately, IVF is not as simple as horse racing, and the follicle number seen at the start does not always translate into the egg number you have at the end. There is a very large attrition rate as you move throughout an IVF cycle. The race is longer than a couple of laps around the track, and therefore, the numbers drop off quickly.

And the situation only becomes more complex as women age. As the years rise, the baseline follicle count falls, and you lose your cushion. With a diminished starting follicle count at the outset comes a decline in egg number at the conclusion. Fewer eggs equal fewer embryos. Fewer embryos mean fewer viable embryos.

No matter how young or old you are, there will always be a noticeable decline in the follicle to embryo equation. It is a function of human reproduction. However, if you are going to fall, you hope that there is a cushion below you to break that fall.

What Endo Can Do to Your Eggs, Your Tubes, and Everything in Between: Endometriosis and Infertility

Endometriosis (a.k.a. endo) does not mess around when it comes to infertility. It can have some pretty serious consequences on almost every organ in your reproductive tract and beyond (ovaries, tubes, plus). That’s why it’s no stranger to any fertility MD or any fertility clinic. We are always on high alert looking for the “enemy” lurking in our midst. Many, if not most, cases of unexplained infertility are likely due to endometriosis, but it can play a pretty good game of hide and seek. Unless we go undercover in the operating room, we often won’t find that endometriosis, no matter how hard we look. While making endo’s official acquaintance may be difficult, we can speculate with pretty good certainty about its presence. Symptoms such as painful periods, chronic pelvic pain, pain with intercourse, and certain cysts serve as the “bread crumbs” (think Hansel and Gretel) for us fertility doctors who are looking for endometriosis.

Nearly quarter to a third of couples suffer from unexplained infertility (all points on the fertility list have been checked, but nothing seems to be wrong).  About 40% of these couples are battling the big bad E. Why and how endo causes infertility is about as controversial as the 2016 presidential election, and like it, we don’t recommend mentioning this topic at dinner with your future in-laws! Some think that the stage of disease (a.k.a. how aggressive it is) has an impact on how it does its dirty work.

For example, women with mild/minimal endo (stage I or II; after-surgery endometriosis can be “staged” or classified by an endometriosis grading system) may be battling infertility because there are a lot of negative vibes (say, prostaglandins, cytokines, and chemokines) lurking in the corners of the pelvis. These substances are hormones you hope to meet on only very few occasions: they are not kind to the body. They can cause pain, inflammation, and tissue damage. They are released by endometriotic tissue, and their presence in sacred places (ovaries, tubes) can throw things off. The ovaries, tubes, and even the endometrium are not happy with these guys around. Follicular development, fertilization, and implantation can be impacted (and not in a positive way!).

On the flip or the more severe side, when severe (stage III or IV) disease is present, it’s not only hormones that you have to worry about fighting. Picture a Sunday-night Game of Thrones episode—you have the Starks, the Lanisters, the Baratheons, and the Targaryens (not to mention the White Walkers and the Wildlings). In the “game of fertility,” severe endo not only causes inflammatory soup, which is thick and unappealing, but also adhesions and structural abnormalities. Scar tissue in the pelvis can impact the release of eggs, block a sperm’s ability to get from the uterus to the egg, and/or prevent the tube from picking the egg up if and when it is released. Furthermore, endo eats away at your egg count. Less eggs = less chance at a good embryo = less chance at having a baby.

In many ways, it is easier to get Congress to pass a bill on immigration then to get a group of fertility specialists to agree on how best to treat endometriosis. Bottom line, there will be a lot of filibustering on both the surgery and the medicine (clomid, letrozole, IUI, IVF) side. Back in the day, we did surgery (a diagnostic laparoscopy) on anyone who walked through our doors with infertility. It was a part of the evaluation just like a sperm check or tube check. Long gone are the days of diagnostic surgery. If you doctor suggests one, you should skedaddle your way out of that office! However, if the symptoms are there and enough red flags are flashing “endo,” you may consider going to the operating room to see what’s up. There are definitely medical data out there that show that, if endometriosis is removed, your fertility can get a boost, particularly when the disease is more mild/moderate AND in the approximately six-month window immediately following surgery. Watch for doctors who are having you double dip. You really want to avoid multiple trips to the operating room. This is where you are more likely to get complications, more likely to compromise your egg count, and less likely to get anything beneficial out of the surgery.

Think about when a congressman or woman is up there trying to sway voters. They will use a lot of reference and data points (some more accurate than others) to push the needle their way. The same can be said as to why your doctor thinks surgery gets a green or a red light. Some things that put you on the STOP or DO NOT ENTER THE OR list include previous surgery, advanced maternal age (greater than 35 years old), other fertility factors that would warrant IUI or IVF (low sperm count, blocked tubes), and a history of previous fertility treatment. Such factors usually warrant more aggressive fertility treatment (a.k.a. IVF) anyway, and therefore, going through surgery before would likely not be beneficial. Of course, there are always exceptions. We cannot stress how important it is to hash these points out before you take to the podium. You want all the information before you cast your vote.

If you do opt to give surgery a go, make sure it is with someone who specializes in endo surgery. Many doctors like to operate, but endo is not their area of expertise, even though they might say it is. Make sure they have been well vetted before you decide to go with them. If you do take the plunge and go to the operating room, depending on your level of disease, your age, and your other factors, you may be able to give the good ol’ old-fashioned “timed intercourse” a shot in the three to six-month window after surgery. There is some evidence to show that mild/minimal disease treated surgically in women less than 35 years old increases their fertility in the three to six months after surgery, but we cannot stress enough that the benefit of surgery does not last forever. The time window is limited!

While we would not recommend holding back on fertility treatment forever, a brief hiatus to give timed intercourse a go is acceptable. In women with more advanced endometriosis, fertility treatment is usually started right after surgery—there is not much time to waste. The additive effect of surgery plus fertility treatment can be just what the doctor ordered for pregnancy. While the fertility treatment can range from oral medications (think clomid or letrozole) + insemination, injectable medications (think Gonal F and Follistim and Menopur) + insemination or IVF, we usually want to optimize this endo-free or endo-reduced period to its greatest extent. It may take some time to reach a consensus on surgery vs. fertility medications/IVF, but there is one that is a total no brainer—medical therapy for those who are trying to get pregnant. Hormone therapy (oral contraceptive pills), Lupron, and anything that turns your system off is not going to allow you to get pregnant. Therefore, during these trying times, it’s a no go.

Another no-go or not-necessarily-go is removing those unattractive blood-filled inflammatory-laden cysts (i.e., endometriomas) just because you want to have a baby or just because you are doing IVF. Their presence is only problematic if you have pain or we suspect an ovarian cancer might be lingering within, not because you want to have a baby. The exception to this rule in the land of fertility treatment is if the endometrioma’s position could impair your doctor’s ability to do an egg retrieval. Otherwise, while yes, you may want or need some antibiotics at the time of the egg extraction, (these cysts can become infected at the time of retrieval), they should not get in yours our way too much and can stay the course!

You can’t just flip the channel here and decide not to watch CNN until your trusted lawmakers finally make up their mind. With endo, you have to decide which route to go sooner rather than later. Otherwise, you could be waiting a very long time for a baby and dealing with a lot of pain—filibustering will not fly. Because endo has a real-deal impact on your fertility, we often need to pull the big guns out to get things going and to get endo out of your pelvis! Don’t get bullied into a treatment plan that you are not comfortable with; there are options. Stand your ground—your voice and your vote matter when it comes to endo and infertility. You need to like the view from your side of the aisle!