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The 10 Questions Everyone Should Ask When a Fertility Cycle Fails

A negative pregnancy test can be hard for anyone to bear, particularly individuals and couples who are going through fertility treatment. It’s like studying for weeks and weeks for an exam, thinking you know the material, and then getting an F. “Disappointing” doesn’t even begin to describe how you feel. And while the first place you usually go is your significant other’s shoulders for a good cry (and for a glass of wine and a bite of unpasteurized cheese), the second should be to your fertility doctor to break down why this cycle didn’t = baby.

Here are our suggestions on what should be on your list:

  1. Why didn’t it work?

Hands down, this is the most frequently asked question when a fertility cycle is not successful. And while it is a good place to start, in order to get concrete answers, it’s better to break it down into little pieces (a.k.a. your reproductive parts). When you chat with your doctor, make sure to be specific in your line of questioning; the narrower the question, the more useful the answer. And bring a pen and paper!

  1. Did I make a bad egg?

While we are never fans of finger pointing, in many cases the culprit is an abnormal egg, which resulted in an abnormal embryo, which = no pregnancy (especially if this was an IVF cycle where the embryo did not undergo genetic screening). Unfortunately, barring genetic testing of the embryo, there is not much that we can do to predict if the egg you ovulated or we extracted was normal. While we use hormonal assays (think FSH and AMH) and female age to help guide our treatment plans and analysis of the outcome, they are limited in their abilities to predict the future. This is why we are huge advocates of embryo screening. While it can’t tell us if the extra chromosomes came from the egg or the sperm, it gives us a lot of data about where the “damage” may have started. And while it is nearly impossible to change egg quality, by analyzing the embryos that are produced by those eggs, we can find the good egg (s).

  1. Was my partner’s sperm only so so?

Although men are often sperm-making machines for years longer than we are egg-making machines, as time ticks away, so does sperm quality and quantity. Furthermore, certain medical conditions or recreational habits can hamper your other half’s sperm production. Make sure that your partner has had a semen analysis, and if the results were only so so, your fertility doctor should refer your partner to a urologist. There are procedures, techniques, and medications that can help improve sperm quantity and quality.

  1. Are things not flowing freely through my tubes?

Think of the tubes like any major New York City tunnel—they can get blocked up anytime and for any reason. And while there are certain things in one’s medical and gynecologic history that would predict a tubal closure (a.k.a. a history of pelvic inflammatory disease or multiple abdominal surgeries), in many cases they are just closed for no clear reason. Therefore, before any fertility treatment is initiated, it’s a good idea to have your “tunnels” checked. If there is a problem, you will need to take an alternate route to achieve a pregnancy—and learning this before you set out on your fertility journey will save you a lot of time!

  1. Was my uterus not ready for a guest?

Although the uterus is infrequently the primary or solo cause of infertility or a failed fertility cycle, it should be looked at from a few angles. Routine ultrasounds depict the uterus in two dimensions. And while it can look good in this mirror, it’s important to have a 3D study or a test (HSG or hysteroscopy) that shows the inside of the uterus. Unwanted guests (e.g., fibroids, polyps, or scar tissue) that can interfere with implantation can be lurking!

  1. Should I repeat the same treatment, and if I do, what is the chance it will work?

Yes and no and maybe. (Well, that was helpful advice!) But all kidding aside, the reality is that most fertility treatments doesn’t work the first time you try them. You often must try a few attempts before you see success. However, you should 1,000% speak with your doctor between every attempt and ensure he or she breaks down what happened and how he or she can make things happen next time. Additionally, make sure you have an end point. While this road can be long, it shouldn’t be endless. Make sure there is a stop and you know where and when that will be.

  1. When is it time to move on to the next step?

Unfortunately, this one doesn’t have an easy answer. However, we added it to the list to make sure you ask it. And to ensure that you know that there are options, both in what you do and where you do it. You aren’t tied to one type of treatment or one treatment center. Ask, look, and listen. There are many good resources out there with lots of information (#trulyMD).

  1. Do you have paper and pen?

Write things down! Whether it be the questions you want to ask or the questions that you had answered, remembering everything can be hard. Jotting down what you want to say and what has been said will serve you well in the future.

  1. Can I have my records?

You are your best advocate (and your best record keeper). Asking for your records and speaking up on your behalf does not make you annoying. It makes you smart. And while you don’t need to become a bookkeeper, keep track of what goes into and out of your body. It can ensure that you stay balanced!

  1. What’s next?

We love plans. Just check out our calendars! But we especially love plans when it comes to our patients. Knowing what you are going to do if your day 1, that is, your period, comes can make dealing with D day somewhat easier. Simply stated, plan for the worst (#period), but hope for the best. That way, you won’t waste any time.

Getting pregnant and having a baby are not easy. Contrary to what we thought in college, you don’t get pregnant every time you have sex! Although people use the word “fails” liberally, remember that you are so not a failure. Doing fertility treatment is hard: emotionally, physically, and financially. Staying in the game when things get hard makes you a success—no matter what that pregnancy test shows.

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.

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.

Double Duty…Why Two Is Not Always Better Than One

It would be nearly impossible to count the number of times patients tell us the following regarding how many embryos to put back into the uterus: “I want two…it’s like two for the price of one!” “I want to be one and done!” “It’s like getting a twofer!”

And while we understand the desire for two (trust us, the thought of minimizing the number of times one is pregnant does sound appealing), twins are not just double strollers, matching onesies, and names that start with the same first letter. Twins and triplets-plus can be complicated, not only for the babies but also for the mother. Therefore, serious thought needs to be put into how many embryos are put back into the uterus.

Old-school fertility doctors routinely transferred several embryos into the uterus at one time; twins, triplets, and even quadruplets were sort of the “cost of doing business.” Back in the day, our IVF techniques weren’t so great. The procedures were new, and there were a lot of unknowns. To increase a patient’s chance of getting pregnant, multiple embryos were put in. Although even then, “the more the merrier” wasn’t our motto, (women are not meant to carry litters!), we were limited in our ability to identify which embryos had the best chance of making a healthy baby.

Fast-forward 20-plus years, and we are actually really, really good at this stuff. Not only do we know exactly what a three-day-old embryo needs to grow in versus a five-day-old embryo (can you believe it they are already picky eaters at this age!) but we also actually have the ability to check them and make sure they have the right number of chromosomes!

Now, while we can’t tell if they will look like you or your partner or go to Harvard or Yale, we can take a few cells and check to make sure they have the correct number of chromosomes. (The magic number is 46!) When this technique is done and a healthy embryo is found, we almost routinely only put one back in because even this guy or gal more than half the time makes a baby.

If you are considering an IVF cycle or are maybe even in the midst of one, make sure to have a long and serious discussion with your doctor about the number of embryos to transfer back in. Nowadays, not every IVF center is the same; many have the ability to grow embryos in the laboratory to day 5, rather than the traditional day 3. Although two days may seem inconsequential when it comes to most things in life, for an embryo, it’s a big deal. Just these 48 hours gives the embryo time to develop and the embryologist who is watching the embryo develop more information to pick the one that has the best chance of making a baby!

If you are lucky enough to have several A-plus embryos and your doctor only recommends putting one back in, the others can be frozen. Yup, we said frozen. Don’t worry; frozen embryos are not like frozen chicken! Embryo freezing has come a long way, and now in many centers, frozen embryo transfers have a better chance at making a baby than a fresh one. Simply stated, you won’t lose anything from freezing the extra embryos and putting only one embryo back in at a time. Sticking with the “one and done concept,” many couples get all the embryos they will ever need in one fresh cycle, thanks to good freezing techniques!

It’s sometimes hard to imagine that anything can go wrong in twin pregnancies. Nowadays, our schools and parks are teeming with twins; it really has become all the rage! But take it from us, not every twin pregnancy ends in a cute Anne Geddes photo. Twins have a higher chance of almost all risky pregnancy complications. On the fetal side, these include stillbirth, preterm delivery, and the serious problems that can come along with having a preterm baby: neurologic, cardiac, pulmonary, gastrointestinal, and serious developmental issues. Additionally, a high percentage of twins will experience some delay (motor and verbal skills) in the first two years of their life that requires treatment.

On the maternal side, women carrying twins or more have a much higher chance of serious medical complications. These include diabetes, high blood pressure (preeclampsia), heavy bleeding, hyperemesis (significant nausea and vomiting), Cesarean Section, and post-partum depression. Although most twins and most moms of twins will be running (actually, probably sprinting) and laughing in no time, there are a number of twins that will suffer permanent consequences from prematurity. The risks are real and should not be ignored.

And partners of those who have twins don’t get off easily, either. Sure, they don’t have to endure the insane stretch marks, the prominent varicose veins, and crazy swelling that multiple babies in one uterus at one time can bring, but let’s face it, double the work comes with added stress on the relationship. Studies have shown that divorce/separation rates are higher in families of multiples. Having a baby is not easy, sleepless nights and long days can be beyond difficult; imagine multiplying that by two!

We live in America too, and trust us, we get it. Other than pounds, for most of us, more or bigger always seems to be better. Why have one of something when you can have two? While we are not going all one-child-policy on you, we are advocating having one child at a time. It will be healthier for you and healthier for your unborn children. While twins are adorable and the bond they share is unlike any other sibling relationship, we are big fans of taking it one step at a time if possible.

When building a family, slow and steady is the best and safest way to get to the finish line.

When Is Enough, Enough? Does Fertility Treatment Have an End?

Some things are really hard to hear. Whether it is as simple as how your hair looks or how you look in that dress to how to treat an aggressive medical condition, the truth can really hurt. And oftentimes, accepting the truth can be nearly impossible. However, there are only so many times that you can hold your hands to your ears and play deaf. There are only so many times that you can ignore the flashing red lights in front of you. Ultimately, if you don’t change lanes you will find yourself at a roadblock that you can’t overcome or pass. However, knowing when it’s time to get out of the lane can be the hardest part. That’s what we are here for.   

As fertility doctors, our job is to guide you, to support you, to educate you, and ultimately to help you achieve your dreams of becoming a parent. We take the information provided to us by blood tests, ultrasounds, medical history, semen analyses, and family histories and with it try to see what is off, which pieces in this puzzle are not fitting together and how can we put the pieces back together.  

However, our job goes way beyond diagnosis. We are also there to implement and design treatment plans. Some plans you may like, and others, you may not. Some may seem too aggressive; others, too lax. Some may seem too involved, and others, too casual. Whatever it may be, you have to take the information and options presented to you, process them, and then proceed.  

But we cannot simply stand on the sidelines and watch you run into a 320-pound linebacker without a helmet. While your fertility doctor should be frank with you throughout your entire treatment course, this is particularly true when deciding on the best treatment strategy.   

At some point, the seesaw of pros versus cons is no longer even close to even. The American Society of Reproductive Medicine defines this tipping point as futile treatment (≤1% chance of achieving a live birth) and very poor prognosis treatment (>1% to ≤ 5% per cycle). Allowing a patient to continue to try when the odds are so incredibly low and not sharing such information is, in our opinion, criminal. Honesty is imperative in any doctor-patient relationship, but it is especially essential in fertility medicine.  

While we want to help you achieve your dream, we must be honest with you about the likelihood of achieving these dreams. Sometimes, dreams must be modified (donor eggs rather than your own eggs, a gestational carrier rather than your own uterus) in order to end happily.  

Closing the chapter on any stage of life can be difficult. It is wrought with confusion and anxiety. We are here to help you through this process, to help you move through the pages, and to reach the ending that will make you feel the most complete and the most content. Telling you what you want to hear may make you feel better, but it will likely not make you a baby. And although hearing what we have to say may sting, it may be the bite that leads you to parenthood. And in our line of work, parenthood is paramount. 

What Goes up Must Come Down: What to Expect AFTER an Egg Retrieval

To all you cyclists, runners, rock-climbers, and challenge-takers, the hill can be a real beast on the way up. Pushing towards that summit can be exhausting and physically painful. However, once you peak and start the descent it’s a feeling like no other. You did it. Now, enjoy the reward of the downhill. Much the same can be said of the post-retrieval bloat, discomfort, and weight gain. After you reach the peak, it is smooth sailing.

Women are often shocked at how much worse they feel after the retrieval than before. While the swelling, heaviness, and blah feeling are definitely there before the retrieval, they’re about 10 times worse after! When we tell patients this, they’re often shocked. How can that be? You’re taking the eggs out; shouldn’t the symptoms get better? No, in fact, they get worse!

Let’s do a little Bio 101. Eggs are housed in fluid-filled follicles, and follicles live in the ovaries. Many follicles = big ovaries. Seems simple. During the egg retrieval, we drain the follicles of their fluid, and within that fluid comes the eggs. However, after the follicles are drained of fluid they fill with blood. They become corpus lutea (plural for corpus luteum—you learn something new every day!). The CLs (everyone needs a nickname) make a lot of hormones that can make you feel not so hot (#progesterone). Additionally, they often fill with blood. As a result, the ovary stays enlarged, and your belly stays big. This hormone soup keeps the ovaries large, the belly filled with fluid, and you feeling like a balloon at the Macy’s Thanksgiving Day Parade!

Okay, so I am going to feel awful…how long will this go on? The length of the post-retrieval to menses (a.k.a. period) varies based on the trigger shot you were given. Women that get straight HCG or ovidrel will feel the bloat for about 12–14 days. The HCG hormone in both of these formulations is like gas for the ovaries—they keep the ovaries charged and the hormones pumping. And although the symptoms will improve significantly after about seven days, you won’t be back in your skinny jeans until you get a period about 14 days later.

If you were given a Lupron or Lupron +HCG trigger, your period of pain will be protracted (that’s why we give it!). Most women will start to feel better about three to four days after the retrieval and get their period about seven days later. For the majority of women, the blah-blech feeling will steadily increase post-retrieval until you hit the peak about three-ish days later; the summit will be higher and the climb further if your trigger medication was straight-up HCG with no Lupron chaser.

When embryos are transferred back into the uterus during the stimulation cycle and you get pregnant, it’s like you are racing the Tour De France rather than your local 10-miler. The pregnancy will make HCG, and the HCG will make that hill way longer. You won’t recover for several weeks into the pregnancy. It is for this reason, along with new data on the OB benefits of fresh cycles, that we push you to press pause and freeze the embryos. Trust us. Your body, your ovaries, and your brain will thank us.

They say life is about the journey and not the destination. And we mostly agree with that. However, in terms of ovarian stimulation and the aftereffects it’s all about the destination. The climb up will likely not be fun. Keep your eye on the top, and take one step at a time. We’re right there beside you, cheering you on!

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!

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!

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.