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frequently asked questions

General Questions

The simplest protocol is Clomiphene 50-100mg 3-7 (or5-9) of the cycle. With the addition of vaginal ultrasound monitoring on the day of the LH surge or by day 14 if no LH surge, you may be given a HCG injection and IUI performed 36 hours later. Adjustments in the ovulation induction protocol can be made in subsequent cycles depending upon your response.

Just don’t overdo it. Air travel is fine as long as the pressure is maintained, which it generally is in commercial aircraft.

Swimming and any other low impact exercise that doesn’t over exert you are fine. It’s best to avoid things like jogging and high impact aerobics. Avoid picking up anything too heavy during the waiting period (greater than 15 lbs.).

Many early pregnancy failures are due to genetic abnormalities, mainly “trisomies” where an extra chromosome is present in what should be a pair. The earlier the failure occurs after implantation, the more likely it is to be genetic. You can also have implantation problems that would cause chemical pregnancies such as hypercoagulation, failure to from the needed blood vessels, or autoimmune issues. It is important to remember that, chemical pregnancies are early miscarriages, not abnormal hormones as the name may imply.

You can get somewhat of an idea from the size of the egg and the estradiol level at midcycle. But other factors arise as you get further into your 30s. you really can’t diagnose egg quality until you get the eggs out of the follicles, put them under the microscope, and see how they behave. There are some less invasive screenings for ovarian reserve/egg quality such as the Clomiphene challenge test, FSH, and Inhibin B, but they are also not as accurate as looking at the egg directly.

Menstruation only requires development and shedding of the endometrium in response to alternating levels of estrogen than progesterone in the bloodstream. These hormones can be produced by the ovary even when an egg does not mature or release.

There is not complete agreement on this. You might consider “too early” to be cycle day 10 and “too late” to be day 20. There are two problems with late ovulation. The first point is that you obviously you have fewer chances over a given time period. Second is the fact that late ovulation you may be releasing eggs that have not been matured properly. It is also possible that the other parts of the reproductive system are not in sync with the egg. That is not a say you cannot conceive if you ovulate late- it happens all the time. It is just that your chances are somewhat reduced.

Yes, it is normal for menses to be light, heavy, or simply different, due to the hormone levels being different. Also, progesterone supplements can delay the onset of menses. Most women don’t start their periods until the progesterone levels drops to somewhere between 2-4, which may take a few extra days.

You are probably feeling the effects of the hormones you are taking. It’s really too early to be feeling anything as a result of a pregnancy. Implantation normally takes place about 5-10 dpo, but even after that it takes a couple of days for the hCG to build up in the blood stream. The presence of these symptoms does not indicate pregnancy, and the absence of them does not indicate a failed cycle.

It does not mean you are pregnant. Nevertheless, it is a good indicator. If you have good progesterone levels, that means that a pregnancy that is trying to implant will have a better chance of finding a good receptive environment.

First, if you are concerned about the possibility of OHSS you should call your clinic as soon as reasonably possible. OHSS (Ovarian Hyperstimulation Syndrome) is when you have an unusually large number of mature follicles that release. When these follicles release, there is an unusually high concentration of estrogen-rich fluid in the peritoneal cavity, and the ovaries are generally enlarged far beyond their usual plum size. In milder cases, women experience bloating and some pain from the oversized ovaries The treatment then is just a matter of rest and staying well hydrated. In more severe cases, the estrogen in the peritoneal cavity causes fluid to leak out of the circulatory system into the peritoneal cavity. This can cause marked discomfort and bloating, and can cause difficulty breathing due to pressure on the diaphragm. In the most severe cases, the leaking of the fluid will lead to hypovelmic shock and organ damage because of a lack of perfusion. Generally you do not see severe OHSS until the Estradiol gets into the 5000+ range. As long as your doc keeps a close eye on your dosage and development, the chances of anything other than mild discomfort are minimal.

The number of eggs retrieved is largely a function of age, responsiveness and the stimulation protocol, good monitoring, and a bit of luck. If there are too many eggs, there may be a possibility of you developing ovarian hyperstimulation, and your doctor will counsel you for the same. Sometimes, the doctor may also advise cancellation of the current cycle, if the risk is very high. If there are too few eggs, there maybe another stimulation, which may be needed and your doctor will advise the same. Or, she may ask for certain additional tests to find out the cause of this unexpected result to prevent its recurrence in the next cycle.

No, each cycle is independent. Your per-cycle chances do not increase.

No. there is no evidence that shows a statistically significant increase in the ovarian cancer risk. Many studies have shown that there is no direct relation with cancer, however, there is a limit on the use of Clomiphene for more than 12 months during the patients life-time and hence the doctor may stop Clomiphene and switch over to using injectable gonadotropins for ovarian stimulation.

The idea of coasting is either to get a too-high level of Estradiol to drop a bit or to slow down development- generally eggs are of better quality if the patient has at least 7-8 days of stimulation. In addition, they may possibly want to slow down some of the lead follicles and get some of the smaller follicles to catch up a little, several studies have shown that coasting does not reduce success rates for a cycle, and it can also reduce the risk of ovarian hyperstimulation syndrome (OHSS).

Most patients on progesterone during the luteal phase automatically. The underlying concept is that if you wait and find out if the progesterone is low, even at seven days past ovulation , it can be too late because the lining may not be receptive to implantation. Low progesterone can cause implantation failure, because its role is to vascularize and maintain the uterine lining, which is where implantation takes place. Some women require more progesterone support in the luteal phase than others and this depends on your baseline hormone levels. However, all patients undergoing an IVF cycle will be given progesterone in the luteal phase. This can be either as injectables, or tablets. . There are four different common methods of progesterone supplementation: progesterone in oil shots , progesterone suppositories or vaginal capsules, vaginal gel, and oral progesterone. Discuss the best medication method and dosage with your doctor.

Many infertility specialists are using this as part of their protocol, especially for patients with histories of miscarriage and lining problems. This decision will depend on your individual case history and the ovarian response to the stimulation drugs.

There are several variations on the IVF protocol. This description is of a standard long “down regulation” protocol. When the patient is under 35 and has a history of good response to stimulation. In the long down regulation protocol, you start the cycle before your stimulation and retrieval cycle. On D3 of that cycle, your FSH level is measured. On D21, you do a progesterone test to see if you have ovulated. Starts the GnRH shots once a day. The dosage varies from doctor to doctor to some extent. Your period should arrive close to its due date. On D1 or 2, you are tested to ensure that medication has shut down your own hormone system. If you are adequately suppressed and an ovarian scan shows no cysts, you will usually start injectables on D2 or so. Your medication dosage depends on your diagnosis, age, and response history if you have taken injectables before. After three days of ovulatory stimulants, your follicles and Estradiol levels will be checked. E2 levels above 100. If needed, your medications will be adjusted. You will go in a few days later for a second round of blood work and an ultrasound follicle check. After that, you might report to your clinic daily for blood work and ultrasounds. Once your follicles have reached an appropriate size and your E2 levels are good, you stop the stimulation and GnRH, and are given the hCG shot, in the presence of good blood flow. The eggs are retrieved using an ultrasound probe that has a needle at the end of it. They put the needle through the vaginal wall and aspirate the follicles. You will generally start progesterone immediately following the retrieval. Sometimes, your doctor may change this protocol to a “short protocol”, This decision is done during the planning of your cycle, and depends on the indication and other factors involved in individual case.

In most cases, doctors who do two IUIs do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective. However, some recent research suggests that higher pregnancy rates may be achieved by doing two IUIs, one at 12 hours past the hCG shot and one at 34 hours. However, your doctor will decide depending on your current stimulation cycle.

For most men, a 1-3 day break is ideal. That gives the “sample” an opportunity to regenerate. Too “old” of a sample raises the risk of poor motility, white cells, and other problems.

Mixing injectables and Clomiphene is an attempt to get some of the stimulant, cervical mucous, and lining benefits of injectables without spending as much money as would be required by doing only injectables. This will be helpful in patients who do not respond with clomiphene and need more drugs for stimulation

In theory, days 3-7 of Clomiphene lead to more follicles and fewer side effects on the lining and the mucus. It seems to make a difference for some women and does not make any difference in others. What is important is that it should be used for a maximum of 6 cycles continuously and not more than 12 months in all.

Once a patient has had 3-6 IUI cycles with injectables, they might consider moving to IVF as the chance of a successful IUI cycle is reduced.

The vast majority of Clomiphene pregnancies occur during the first 4-5 ovulatory cycles. If after the first 3 attempts at a reasonably high dosage, there is no response, you might consider moving on to Injectables earlier. The average number of cycles on Clomiphene before moving on is three to six.

I have leftover cysts on my ovaries. My doctor wants me to sit out this cycle. a) What causes these cysts? A corpus luteum, or functional cyst, is simply a leftover follicle that has outstayed its normal lifespan. Sometimes, they continue to produce progesterone and estrogen, which may delay the arrival of the next period. b) Will they go away? Functional cysts almost always go away with time. Birth Control Pills are sometimes prescribed for a month or two, to hasten their resolution. They never need any other intervention. If not, relieved by medication, they may not be functional cysts and need further evaluation. c) How big do they need to be to reduce chances of pregnancy? Research has shown that any cyst 10 mm or larger is associated with a lower chance of getting pregnant. Those that had a 10 mm cyst at the beginning of a cycle had half the pregnancy rate of those who had no cysts. It does not eliminate your chances of pregnancy, but it does sharply decrease them, through two mechanisms. First, physically, they can crowd out the development of new follicles. Also, if the cyst is secreting hormones at the wrong time of the cycle, it interferes with the chemical balance required for good quality ovulation and drastically reduces the chances of pregnancy. It is normal to have small cysts, which may be very small leftover follicles or follicles that are preparing for the next cycle. Anything under 10 mm shouldn’t be cause for concern as long as your baseline hormone levels are in range.

I am concerned about the size of my follicles, and the timing of my HCG shot. How big should my lead follicle be before I take my HCG shot? How much do follicles grow each day? A lead follicle should be at least 16-17 mm when the patient is on urinary gonadotropins for ovulation induction, it should beat least 18 mm on a recombinant FSH , and should be about 22 mm on Clomiphene citrate therapy. Other measurements such as E2 and progesterone should be used to indicate maturity. Follicles grow 1 to 2 mm a day both while taking ovulatory stimulants and after the HCG shot.

How do we know if the sperm count is adequate for IUI? Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If this functional sperm count exceeds 1 million, chances for pregnancy with well-timed IUI are excellent.

If these bloods were drawn on day three of a cycle, the results would imply decreased ovarian reserve or eggs available. FSH is more of an indirect measurement of ovarian reserve. This is specially true if you are above 37 years of age, or you have had previous cycles which were not as expected in the ovarian stimulation. Your doctor will also advise you for the same if she suspects any hormonal imbalance or PCOS or if you have irregular cycles

D1 is the first day you see a red flow, not just intermittent spotting. There is no universal rule for the cutoff time for that date. But most often D1 is considered the first day of full flow that begins before mid-afternoon.( some doctors believe in 8pm as the cutoff time and some will take it as the noon. However, this helps in giving some flexibility in starting treatment especially in women with irregular cycles.

The earliest that a sensitive blood test can pick up any HCG at all is 5-7 days after ovulation. Your quantitative serum beta test can be reliable about 10-12 days after ovulation, if you have not taken a HCG booster. If you have taken a HCG booster, then you may have a reliable test at 14 days past ovulation. The serum beta HCG is the most reliable test. Your HCG level has to be above 50 units in the blood to get a positive result for urine pregnancy tests.

Fertilization occurs within 24 hours after ovulation.

Eggs are able to be fertilized for about 12-24 hours after ovulation. The older the woman, the shorter this time becomes.

Normal, healthy sperm live approximately 48-72 hours. We do know that washed sperm can survive in the IVF incubator for up to 72 hours. That would be considered the upper practical limit.

Ovulation occurs 36-40 hours after the HCG injection. Eggs will release in this time frame if they have not been retrieved. This is adequate time for planning any form of treatment. Frequently, the ovulation is associated with mild discomfort felt in the lower abdomen and is confirmed by doing a serial ultrasound follicular monitoring by the doctor.

A reproductive endocrinologist or an infertility specialist, specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem than an OB/Gyn. It can be a tremendous waste of time, and money that you could put toward treatment with a specialist who can get to the root of your problem.

Infertility is the inability to conceive after a year of regular, unprotected intercourse. Couples who have known barriers to fertility, such as Endometriosis, Polycystic Ovarian Syndrome(PCOS), male factor infertility, irregular cycles, etc., do not need to sit out the traditional “waiting period “for one year to seek expert care for infertility.

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