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Looks Can Be Deceiving…We Recommend a Double Take!

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At least once a day we get a call from a friend, a friend of a friend, or a friend of a friend of a friend (say that three times over) asking us to review their results and give them our advice. Inevitably, they are overwhelmed, frightened and often confused. “FS something, I’m not sure” and “mobility of sperm okay but appearance abnormal.” After we sort out some of the details, we are ready to break it down for them in the most basic of terms. Here are some of our tidbits from girls in the know.

  1. FSH means NOTHING without Estradiol. FSH and Estradiol are like Bert and Ernie or Bonnie and Clyde. You can’t test one without the other; they don’t make sense when analyzed alone. FSH is a hormone made in the brain (pituitary gland) that signals the ovaries to ovulate (and make estrogen measured as estradiol in your blood).  When FSH is measured early in your cycle, if elevated, it may indicate a decline in ovarian function (meaning your egg quality is declining, making pregnancy more difficult).
  2. FSH is falsely lowered by a high estradiol. A normal FSH level with a high estradiol level means that the FSH is NOT normal. Estrogen from the ovaries sends a signal back to the brain to make less FSH in the brain. When estrogen levels in the body are high, the brain makes less FSH. While abnormal levels don’t mean you’re down for the count in terms of baby making, it does make us question whether your ovaries are the cause of your fertility struggles.
  3. FSH and Estradiol MUST be sent to the lab on days 2-4 of your cycle. They are not accurate (in all cases except for women with very long, irregular cycles) if sent at other times. Don’t have the blood work done on the wrong day just to check it off your list; you will be re-writing it on your To Do list for the next month.
  4. The ranges on the lab report are not always right. Yes, we know that this may sound confusing and totally contradictory but levels need to be interpreted by a physician. Make sure that if you get your levels you speak to a licensed professional before shedding too many tears.  Don’t go straight to Dr. Google with your FSH level until you understand what it means for you specifically!
  5. The “dye test” (or the HSG, as we call it) must be done in the early part of your cycle. It cannot be done after you ovulate (you could be pregnant!)
  6. An HSG is not meant to be torture. While it can hurt, in most cases it’s pretty tolerable. Take some Ibuprofen before…You should be fine!
  7. A “luteal progesterone” test is not equivalent to a day 21 progesterone test. Luteal means “post-ovulation.”  Physicians often test a progesterone (blood test) on “day 21” to confirm an elevation, indicating ovulation.  A day 21 progesterone test is only appropriate for women who have (approximately) 28 day menstrual cycles. If your periods are 35 days, your progesterone on day 21 may be negative (low indicating no ovulation), but that doesn’t mean you won’t ovulate or didn’t JUST ovulate. It just means that it is  (approximately) 7 days too early to check the levels. Make sure to share how long your cycles are with your doctor before diving into the blood work.  If you have longer cycles, then going in after day 21 may be better to confirm whether or not you are ovulating.
  8. Not all fibroids are created equal. Fibroids can be a big deal. They can cause pretty bad bleeding, pretty significant pain and pretty real infertility. However, the caveat to the infertility issue is location, location, location. Whether or not a fibroid causes infertility depends on the location of the fibroid. Fibroids located within the uterine cavity are WAY more likely to cause infertility than those in the muscle. Make sure you have a road map of where your fibroid is before you undergo surgery.
  9. Motility (a.k.a. mobility in the words of many patients!) is how sperm swim. It is reported as a percentage (% of sperm moving in the sample). Old school normal was 50%. Now that number has been knocked down to 40% (and only 32% need to be moving forward). While no one wants to fail at anything, take it easy on your guy if his “mobility” is off—chances are if you use the newer guidelines things won’t be too bad.
  10. Sperm shape has really taken center stage recently. It has become one of the most debatable, doubtable and don’t-know-what-to-do-about-it issues. While it is still unclear as to what abnormal morphology means (impaired fertilization potential currently tops the list), the level of normal to abnormal has been reduced significantly. The new normal is 4% or above. Make sure that you are aware of the new numbers and are aware of what the information means before you start any treatment (some centers are still using the old reference values and therefore are calling anything <14% abnormal rather than <4%). Additionally, while low morphology does mean your partner needs more testing, it does not mean that he needs IVF (in vitro fertilization)!

There are a lot of myths circulating out there. Make sure to ask a reliable source before counting yourself out. While we may not be a friend of a friend of a friend, we are certainly your professional pals!

Metformin Madness…Will It Make Me a Momma?

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Any medication that promises to make you pregnant (or at least markedly increase your chances) and make you lose weight seems too good to be true. Wait, so I can eat ice cream and French fries while losing weight and getting pregnant? Count me in! But like most things that sound too good to be true, so is the hype surrounding metformin.

Metformin is a medication that is traditionally used to treat diabetes. It lowers sugar and insulin levels: hence, why it is used for diabetes. For women with PCOS, in whom insulin levels are high, metformin can not only improve the abnormal glucose/insulin situation but also improve ovulation rates. When metformin was released as an ovulatory agent, it became all the rage for women with ovulatory dysfunction. It was handed out like candy to anyone who had even the slightest ovulatory issues. However, while it was in the medicine cabinets of thousands of women, it didn’t stand up to all the hype. It didn’t turn ovaries of stone into sand—many ovaries still stood their ground.

Turns out, metformin is not a magic potion. A large randomized control trial (randomized control trials are the gold standards of medical research) did not show that metformin was even in the same ballpark as Clomid. Women who took Clomid ovulated and got pregnant at a much higher rate (about three-fold higher) than women who took metformin. Additionally, the metformin-Clomid combination was no better than Clomid alone. The only group of women in whom metformin was semi-magical was overweight/obese women with metabolic disturbances (elevated sugar and triglyceride levels, abnormal liver function, and high cholesterol). In these women, metformin combined with diet and exercise could be quite helpful in kicking the ovaries into gear. Additionally, this dynamic duo can significantly improve your overall health, wellness, and longevity.

With the pluses come the minuses. Metformin can make your stomach feel a little funky; be sure to talk to your doctor if you experience GI side effects (bloating, diarrhea, etc.). It is also important to have your kidney and liver functions measured while taking metformin, as it can do some not-fun things to your kidneys and your liver. While there are certainly occasions and cases where metformin is the magic ingredient, it’s not the “butter” in the ovulation concoction. It may help with the flavor, but it isn’t the force behind what gets the ovaries going.
Don’t fool yourself into thinking that metformin is magic. You still need to eat right, exercise, and maybe even take some Clomid. We will find some cocktail that makes your ovaries shake!

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

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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!

Keep on Climbing: The Clomid Stair Step Protocol

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When you have gone through about 40 of those ovulation predictor kits without ever seeing a smiley face, a dark line, or even a hint of a peak reading, you are likely experiencing ovulatory dysfunction. And when you don’t ovulate, you don’t release an egg. If you don’t release an egg, you can’t get pregnant. No matter how wide open your tubes are, no matter how fast your partner’s sperm can swim, and no matter how welcoming your uterus is, no egg = no embryo. However, the good news is that, in most cases of ovulatory dysfunction, if you can achieve ovulation, you have a pretty good chance of getting pregnant. The only trick is finding something to trick your ovaries into ovulating. Don’t worry; we have a lot of tricks up our sleeves!

It’s pretty unlikely that if you are a female between the ages of 20 and 50 that you have not heard of Clomid. The “C” word is often batted around in ladies’ locker rooms, girls’ dinners, or women’s outings. You have almost certainly have had a friend, a coworker, or even a sister who have taken it.  It is one of the most commonly prescribed oral fertility medications and therefore is no stranger to anyone experiencing fertility problems. In fact, Clomid is most commonly used to induce ovulation in women who don’t ovulate (or ovulate as frequently as airplanes land on time at LaGuardia airport!). It can also be used to achieve “super” ovulation (a.k.a. ovulating more than one egg) in women who ovulate regularly but are not getting pregnant. Although Clomid is “super,” it isn’t a slam-dunk. Some women don’t ovulate in response to Clomid and ultimately may require multiple rounds (a.k.a. dosing cycles) of Clomid before an egg is ovulated.

Clomid belongs to a family of medications called SERMs (selective estrogen receptor modulators). And like most families, they don’t agree on everything (or anything)! In some areas of the body, they bind to receptors and exert a pro-estrogen response, while in other areas of the body, they bind to receptors and exert an anti-estrogen response. In women who don’t ovulate, Clomid will bind to estrogen receptors in the brain and alter the release of the hormones responsible for sounding the alarm clock to the ovaries—wake up, it’s time to ovulate! Here are some important bullet points to remember when considering the big C:

Clomid is typically given for five days (five days = 1 round of Clomid); in most cases, it is started on day 2 to day 5 of the menstrual cycle. We can practically hear your next question: nope, it does not matter which day you start! The goal is to start when the ovaries are at their baseline (a.k.a. bottom of the stairs) so that we are most effective in getting a follicle to respond.

Clomid comes in 50 mg tablets. So, simple math: when your doctor prescribes 100mg, you need to take two pills a day; 150mg, you need to take three pills a day; and so on and so forth…. However, like most medications, our goal is to find the lowest effective dose. Although the line in the sand with Clomid can vary based on the physician, most fertility doctors won’t give more than 200mg per day. The reason for the red light at this dose is that, above this dose, you will pretty much only get side effects without much success.

Clomid doesn’t always work (achieve ovulation) on the first attempt (or the first dose). And here are the stats to prove it!

  • 52% of women will ovulate on 50mg.
  • An additional 22% of women will ovulate on 100mg.
  • An additional 12% of women will ovulate on 150mg.
  • An additional 7% will ovulate on 200mg.
  • An additional 5% will ovulate on 250mg.

Those who ovulate at lower doses are much more likely to get pregnant than those who require higher doses to achieve ovulation. When one dose doesn’t work (that is, you come back to your doctor with no signs of a follicle growing or ovulation), don’t despair. You can simply “stair-step” up to the higher dose without missing a step. In these cases, a period brought on by Provera is like a pause. Sometimes, you need them, but oftentimes, you don’t (who doesn’t like a good run-on sentence; let’s face it, punctuation and deep breaths can be way overrated)! While there are certainly clear indications for Provera, it is no longer required between Clomid and/or Letrozole (another oral ovulation induction medication) cycles.

When a specific dosage of either oral ovulation induction agent is not doing the trick (a.k.a. inducing ovulation), you can simply step up the dose. For example, if your doctor prescribes 50 mg (one tablet of Clomid/day for five days), and your ovaries are hanging out in the pelvis saying, “That’s all you got?” you can immediately start a five-day course of Clomid 100mg. And if that doesn’t do the trick, you can proceed directly to Clomid 150mg without passing go. Clomid can be affected by obesity. Simply stated, women who have a higher BMI are more likely to fall into the group of women who either do not ovulate or do not ovulate but don’t get pregnant. Bottom line, Clomid works better in concordance with a good diet and exercise plan.  

Clomid can make you feel like crap. Although most women tolerate the medication without so much of a peep to their doctor, side effects are fairly common. The most frequently reported include mood swings, hot flashes, and bloating. While more serious side effects do exist (visual changes), they are pretty rare. Clomid cannot be given indefinitely. If you are going to see the double line on the EPT stick after taking Clomid, it is most likely to come in the first 3–6 cycles. If it doesn’t happen during this time, it’s probably best to move on to a different type of treatment. Clomid can cause you to have twins. As much as double strollers, double diaper duty, and double feedings seem fun, our goal is one healthy baby at a time. Although the likelihood is fairly low (about 8% of Clomid cycles result in multiple gestations, with the majority being twins), it is important to discuss this with your doctor and vocalize your concerns about multiples early.

Although the stair “master” was designed with Clomid in mind, the same applies to Letrozole (common alternative to Clomid). You can stair step from Letrozole 2.5 to 5 to 7.5 in the same way you do Clomid 50 to 100 to 150. In fact, recent data suggest that Letrozole may in fact be more efficacious than Clomid in getting women to ovulate. Additionally, the side effects with Letrozole are a bit more tolerable, and the risk of twins is lower. So if Clomid doesn’t work for you or your ovaries, there is another staircase that should get you to the same destination!

Who doesn’t love to skip a few stairs on the way up to the top? However, in this “flight,” it’s better to take each step at a time. While the top is ovulation, how far you have to climb to reach it will vary—some may peak with a mere 50mg of Clomid, while others will take it to the top with 150. If you “jump,” you may over respond to the higher dose (#twins). And although it may seem that two is better than one (it would be nice to only have to be pregnant once!), multiples introduce much more risk. Just make sure you are holding on to the banister, walking in a single-file line, and keeping your head up. If you follow these instructions, we can get you to the summit safely!  

Can I Break up with My Birth Control?

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The 40s are often deemed the decade of freedom. Careers are stable, and relationships are solid (for the most part). You are done with babies or opted to not go this route (and for those still on the baby journey keep this advice for later!). You are a seasoned player on almost all fronts. But just because your brain thinks pregnancy is a thing of the past doesn’t mean that your ovaries are in agreement. Despite a decrease in egg quality and quantity, you can get pregnant in your 40s, so much to your chagrin, you can’t throw your birth control out when you hit 43, 45, or even 48. As long as you are still ovulating, you can get pregnant, no matter how old you are!

The reality is that, although your body is changing, your birth control options are not much different as you move throughout the decades. No matter what age you are, the name of the game for hormonal contraception is preventing ovulation, fertilization, and implantation. While certain options might work better at certain points in your life, they will all work in preventing pregnancy. For example, we are big fans of the hormonal IUDs (Mirena, Skyla, Liletta) for women in their 40s. They not only prevent pregnancies but also do so with little systemic exposure to hormones (a.k.a. the hormones stay in the uterus rather than in other areas of the body). This reduces the risk of negative side effects from hormones. It also reduces the risk of select cancers such as uterine cancer, a malignancy that affects women as they age.

On the flip side, while oral contraceptives may have been your go to in your 20s, they may not be right for you in your 40s. Women above the age of 35 are more likely to suffer the negative side effects from oral contraceptive pills. This is because age plus issues like high blood pressure, obesity, diabetes, and high cholesterol/triglyceride levels (disease processes that are more likely to be present as we age) equal a greater chance of bad things (stroke, blood clot, etc.) happening while on oral contraceptive pills. So while oral contraceptive pills are not totally out, a good history and physical exam are required before starting them.

The bottom line is that you can’t just assume that your baby-making days have passed you by, even if you used fertility treatments to conceive or if everyone around you is using fertility treatments to get pregnant. While age is a risk factor for infertility, not every woman in her 40s is infertile. Until your periods bid you adieu, you can’t break up with your birth control. This is one relationship you can’t seem to get rid of! While your ovaries may be running on empty, they still have some gas left in the tank. And although we all love surprises, this surprise may be one that will make you do a whole lot more than scream!

Getting Your Timing Back: Preparing for Pregnancy

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Nowadays, many of us prepare for getting pregnant in the same way we would train for a race or prepare for a big meeting at work. We carefully map out when we will stop our contraception, how we will tackle the trying thing, and how long we will let things go “naturally” before seeking out fertility advice. Infertility has gotten a lot of press (one in six couples will experience infertility), and therefore, many couples are thinking about what could go wrong before the process has even begun. But let us mitigate some of the madness about becoming a momma with a few morsels of advice about the “pre” period.

Most women who are not trying to conceive have a better idea about when their Amazon Prime package will arrive rather than when to expect their period. Tracking often applies only to packages, not periods! And the situation is even more confusing for women who are on the pill, the patch, or the ring or have an IUD. These forms of contraception can turn the system off all together (which is not a bad thing, we promise!), which makes knowing what’s up with your periods pretty problematic.

And while we certainly don’t recommend that you stop your hormonal contraception to focus on Aunt Flo’s arrival, we do suggest that you say goodbye to hormonal contraception a couple of months before you are ready to give things a go. During this time, you can get a good idea about the regularity (or irregularity) of your cycle—this information will be helpful when you are trying to track your ovulation and time intercourse. To protect yourself from pregnancy while you are getting your timing back, we suggest using a non-hormonal form of contraception (a.k.a. condom)—barrier methods only block pregnancy in that moment. They won’t have any impact on your menstrual cycle/ovulation.

Second, while we don’t want to turn the process into a science project from the start, we do suggest that you visit your OB before you get the pregnancy party started. During this visit, they will not only offer you good advice about timing/trying but also will make sure you have a clean bill of health. Medical problems that predate pregnancy can get worse with a baby on board; therefore, it’s important to make sure your body is prepared for what’s to come. A thorough medical history and physical exam can reveal a lot.

Additionally, during the pre-conception visit, most OBs will perform a genetic screening panel—this blood test is basically taking a magnifying glass to your genes to see what’s normal and what’s abnormal. And although we don’t have the ability to look at all 25,000 protein coding genes, we can look at a good number of them. In cases where you come up as a carrier for a genetic disorder, we will want you to chat with a genetics counselor and test your partner. Couples who are both carriers for the same genetic condition may elect to do PGD to screen embryos.

For anyone who has ever played tennis, golf, baseball, or squash, you know how important timing is. It can take a good number of practice sessions before you are making good contact with the ball. The same can be said for your menstrual cycle. Taking a few swings before game day can help. But remember, not everyone needs so much time on the practice field. Although infertility will affect many couples, you may not be one of them. Don’t let fear force you to start trying before you are ready for a baby. You will get your timing back, and if it doesn’t happen on your own, we can coach you through it!