I am 41 and my tubes are blocked. I had to go out ofstate to do a Fallopian Tube surgery with a tubal surgery specialist. I was told it had a 70% chance of being successful, but it failed. I am sad the doctor was unable to unblock my tubes. What can I do now?
Minerva from Walterville OR

You’re correct. Yours is a sad story indeed. A woman with blocked tubes is faced with three choices: Try and get the tubes unblocked through surgery, have a baby using IVF or abandon the pursuit of any future children. While each of these first two strategies has its pros and cons, in most cases, IVF is the better way to go. There are several reasons for this.
When making a decision of which method to consider, you might take three main factors into account :PRICE, CHANCE OF SUCCESS and INVASIVENESS. When comparing price, you can research what is available in your area, but in general, you might find tubal reversal procedures running about $5000 to $11000 and IVF procedures running $10000-$15000, so it would appear that tubal reversal holds the edge here. If the prices you find differ from these ranges, then of course you would adjust your strategy accordingly.

Comparing success rates gets tricky because IVF is intended to result in an instant one-time pregnancy from a one-time procedure, while tubal reversal (if successful) is intended to give multiple low-chance attempts over the course of a woman’s remaining reproductive lifetime. I did many tubal-reversal procedures earlier on in my career, but I have not done a single one in over six years. So while you may keep this bias in mind, I still feel there is a very good reason for this bias. It’s because in almost all cases of patients coming to see me to discuss these two options, it turns out that IVF is as good an option or better than tubal surgery. Over the years, the success of IVF has gone up with technological advances in embryo culturing technique in the lab, so much so as to make invasive surgery less practical an approach in comparison.

In a good case scenario (33-year-old with tubal ligation), the chance of a baby can be over 60%, depending on the program and on depending on many factors having to do with the patient herself. In a bad case scenario (40-year-old with endometriosis), the odds could be closer to 15%. Compare this to tubal surgery, which requires two areas of success. First, there is the success or failure of the surgery. If the surgery fails to reconnect the tubes, then the whole project is shot. Even if the tubes DO successfully get reconnected, then comes the monthly attempt of getting pregnant which might be as high as 20% chance PER MONTH chance in the better-case scenarios and lower than 1% chance PER MONTH of getting pregnant in the less favorable scenarios.
With regards to invasiveness, the edge goes to IVF. An egg retrieval is a very easy procedure using just a needle. The patient is comfortably under anesthesia and the procedure is over in less than 20 minutes. A tubal reversal will at the very least involve laparoscopy, which involves three very small surgical incisions, one below the umbilicus and two in the lower abdomen. In comes cases, the procedure involves a large surgical incision. A tubal reversal surgery will take over an hour and sometimes up to three hours. One disadvantage of IVF is the ovarian stimulation which accompanies it, which at best is a little uncomfortable and at worst can result in serious ovarian hyperstimulation.
I’ve had many patients come for IVF after having failed a tubal reversal and get pregnant with the IVF. I try my best to track my patients, but I realize the tracking is not 100% perfect. Still, I have yet to encounter a patient who has failed IVF and then gone on to have a pregnancy with a tubal reversal. I do have one patient who failed IVF at age 38, then went on to have tubal reversal done. It was successful in opening up the blockage, but she never got pregnant. She then came back to see me in her early 40’s and did IVF again, this time successfully.
Minerva, in your specific situation, given your age, I think most RE’s and even most tubal surgeons would agree that IVF is the better way to go for you. Your case was especially sad, because the tubes did not get reconnected. But honestly, even if the surgery had been successful, you would still have a challenge ahead in trying to get pregnant month to month. At this point, I would strongly frown upon any attempts to do another tubal surgery, especially having failed one already. IVF is not a fantastic option, but still is the best one left for you. Your RE can give you a better estimate of your chances of success after evaluating your ovarian age. Good luck!

Hi Dr.
On CD 3 during my ultrasound they noticed left over follicles from Cycle #1. Just when I thought I was going two steps forward I feel as though I took two huge steps backwards.
My follistim injectables were 300 iu for 5 days and then they lowered it to 225 iu for 2 days and then I triggered with Ovidrel so I guess the RE really wanted to stimulate those ovaries. Guess what? It worked! When they did my Progesterone levels it showed I ovulated. So not sure what went wrong there.
E2 levels were so out of whack (263). Just a side note, I started taking Estrodial as the prescribed protocol as we were heading toward doing IVF if the IUI didn’t work. I’m 42 years of age and will be turing 43 in Aug. DH for our IUIs had 14 mill. sperm and 12 million sperm. Not exactly sure if that was a problem or not. However, after the IUI didn’t work and AF came early we decided to stay on course with another IUI cycle #2. Also, came off of the Estrodial. So my point here is that I am not sure if my body overloaded on the estrogen and this was a side effect resulting from it. Anyway, the RE recommended I force ovulation and trigger with Ovidrel and come back on March 27th for bloodwork to make sure I ovualted again. With ovulation, I am guessing you get another menstrual cycle and then DH and I will start another IUI cycle hopefully in early -mid April. Keeping our fingers crossed that by having 2 menstrual cycles back to back that all my hormone levels retreat back to normal and all the bad stuff in my body leaves and we can start the process again.
However, after extensive reasearch on the internet and your site, it seems that I now have Polycystic ovarian syndrome. I do have all the sign and symptons of it especially the weight gain around the middrift area.
Do you think I should request a check for insulin resistance to see if I should take metformin and start a excercise & diet plan? I notice the success rate is a bit higher once a good diagnosis has been established for PCOS. Maybe I am wrong it was just what I was reading.
Thanks a million for reading and looking forward to your advice or questions I should be asking my RE about here in NJ so I can be successful in having a beautiful baby.
Becca from NJ.

Dear Becca,
Thanks for sharing your story. Based on what you’ve described, the biggest obstacle, as you probably already know, is the degree of age-related DNA damage in your remaining eggs. In addition, it’s well known that PCOS hinders fertility even if you do ovulate. Now you mention that you “have all the sign and symptons”. Other than truncal weight gain, you didn’t go into detail on what those clues are for you having PCOS. But giving you the benefit of a doubt, I suggest you have your RE test your insulin resistance or alternatively, if they are agreeable to it, they can just empirically try you out on metformin for 2-3 weeks. For example, if you report losing 5 pounds in 3 weeks and noticing a huge boost in energy, it would likely be a good reason to stay on it.

You also asked if you should start an exercise and diet plan. You would have to ask yourself, even if you didn’t have PCOS, what’s stopping you from adopting a healthy exercise and diet plan anyway. Right? You seem to already have many of the answers to your own questions.

Best wishes and by all means, have that talk with your RE!

Journal club is one of those things that I don’t look forward to, but which afterward, I’m glad I went. About once a month, I carpool all the way from Orange County near Disneyland, to a restaurant just a block from the UCLA campus. A fellow RE, an embryologist and I battle the LA traffic and usually get there a bit late. Last night was no exception. We arrived to join a debate already in progress. In attendance, seated in a huge circle was an audience of 25 people, consisting mostly of RE’s, RE fellows, urologists and acupuncturists.

The first article concerned using new ultrasound technology to measure volumes of follicles instead of the way we do it now, which is to measure the diameters. There was a consensus lack of enthusiasm for this technology, although some postulated that follicle measurements could be automated and done by a tech or machine. We then debated the efficiency of letting techs do our ultrasounds despite the facts that the patients love it when the doctor does it. Should we go for efficiency or go for bedside manner?

Today’s second article concerned the proper obtainment of consent from egg donors regarding the potential use of their gametes in stem-cell research. When an egg donor agrees to donate, she is under the belief that her eggs will be used to generate embryos that will be transferred into another woman in the hopes of bearing babies. However, after the couples are successful, they sometimes end up with twins or are just happy to have one baby. So they then have excess embryos frozen for future disposition. If they are sure they have all the babies they want, they can opt that the remaining frozen embryos be adopted out or be used for research. The main debate was this: If we decide to do stem-cell research with the frozen embryos because they were donated by the couple, is it enough to get the couples permission? Or is it necessary to also track down the egg donor and tell her “Hey you remember those eggs you donated four years ago? We have some extra embryos leftover from them and want to use them for stem cell research. Is that OK with you?”

It can be fun to get a bunch of us opinionated doctors in a room and see how many different viewpoints there are. Some people believed that you should give informed consent encompassing not only all the known technology but on future technology as well. So, for example, someday if cloning is perfected, and you wanted to use the egg donors’ embryos to do cloning research, you would have to track her down and re-consent her. From the other extreme were people who pointed out that for years and years, sperm donors were never given a say in what is done with their sperm after they donated. This then evolved into a discussion of the future of our field. One person predicted the cost of IVF would drastically come down and down as we get more efficient. Another person made a bold prediction that I liked. She advanced that perhaps someday it would be routine for all women in their 20’s to go for an annual pap smear and be asked if she wanted a needle biopsy of her ovary to get some tissue to freeze and preserve for her future fertility. There was some anti-lawyer sentiment about how we aren’t even allowed to consent egg donors without paying a lawyer to represent her. We then moved on to the third paper.

The third paper concerned prepubescent boys diagnosed with cancer and undergoing chemotherapy. It’s common knowledge that adults who are about to undergo chemotherapy should be offered the option of freezing sperm beforehand in case the chemo drugs destroy their testicles. But what do you do if this occurs before boys can ejaculate. A children’s hospital in Pennsylvania did a project where prepubescent boys with cancer who were undergoing surgery anyway were given a choice to have a testicular biopsy done at the time of their main surgery. The big issue was that there’s no evidence that this testicular tissue will be of any use in the future, because right now we still wouldn’t be able to extract usable sperm out of frozen testicular tissue. As often happens, this evolved into an ethical discussion about whether 6-year-old boys could give consent to having their testicles biopsied or not. We then argued who should pay for this and whether or not it would turn commercial, comparing it to the way that companies which advertise cord-blood banking try to convince (scare?) parents into pay money to freeze the umbilical cord blood from newborns even though it is very unlikely to ever be of any use. I’m not sure how the conversation migrated, but we then started talking about different ethnicities and their obsession with fertility. Some of the West LA doctors recounted stories of Persian Jewish families who would insist on not marrying their daughter off until the future son-in-law had a documented normal semen analysis.

The final paper concerned endometrial receptivity and preovulatory progesterone levels. The paper was done by a very well-respected RE out of Nevada. Anyone who has been to a lot of journal clubs knows that with any experimental paper, the first thing journal club attendees do is to pick it apart and criticize the materials and methods, many times justifiably so. This time was no exception. Some of us were really critical of the paper author’s practice of altering someone’s IVF cycle if her preovulatory progesterone was over 1.0 ng/ml and then freezing all the embryos in preparation for transfer in a subsequent month on the theory that the prematurely luteinized lining was bad for implantation.

I worked 70 hours this week and spending time relaxing, learning and debating over dinner and wine is a nice break.

1. Fifth-Party Reproduction: Utilize a sperm donor. Utilize an egg donor. Utilize a surrogate to carry the baby.
2. Fourth-Party Reproduction: Utilize two out of the three (egg donor, sperm donor, surrogate)
3. A) Third-Party Reproduction: Utilize either one of a sperm donor, egg donor or surrogate
   B) In-Vitro-Fertilization with PGD: Take the wife’s own eggs and the husband’s own sperm and fertilize together. Analyze the embryos and transfer only those which are likely to produce the healthiest children.
4. In-Vitro-Fertilization with ICSI: Take the wife’s own eggs and the husband’s own sperm and inject the sperm directly into the eggs. Transfer the “best looking” embryos.
5. Standard In-Vitro-Fertilization: Take the wife’s own eggs and “sprinkle” the husband’s sperm over them, allowing them to competitively battle to fertilize the egg without assistance.
6. Intrauterine Insemination: Wash and concentrate the husband’s sperm, separating out the best swimmers. Then, physically transport the sperm exponentially closer to the target destination where the eggs are hoped to be waiting, usually done in conjunction with drugs to boost egg quantity and quality.
7. Ovulation assistance: Administration of medication to increase the number and/or the quality (probability of healthy conception) of the eggs, while allowing the couple have sex naturally.
8. Restoration of hormonal imbalances: Give medications to correct hormonal defects, such as an underactive thyroid or excess insulin production.
9. Counseling: Pointing out to the couple ways they can change their lifestyle habits and sexual practices to boost their chances of conceiving naturally.

When patients come to us, we seek the balance between starting low on the list and moving up as high as necessary and as high as the patient wishes to go in order to have a baby. The sequence is not a pure progression as there is overlap between some of them. For example, 3A and 3B are listed in parallel because they are different branches of increased severity, but not necessarily mutually exclusive, meaning you could do PGD AND do IVF with ICSI AND utilize an egg donor.

I use this list to help patients see the overall “big picture” of what their options are.

If you’re like me, the two most common reactions you see from people when politics comes up in casual conversation are negative ones. Either you get an avoidant rolling of the eyes, “Ugh. Not politics again, please” or an angry “I hate those _____ (insert name of party or special interest group)”. Never do you see the giddy passion that people display when discussing exotic desserts, the Super Bowl, James Cameron movies or girly vampire books.

One of the reasons for this is that you have instinctively learned to associate politics and government with a general yukky feeling of dread within the pit of your stomach. Why is this? Isn’t government just another business that we patronize. After all, when we deal with government, how is it different from when we deal with a regular free-market non-government business? In both instances, we pay a price in exchange for something. In the case of government, that price is money (via taxes) and loss of freedom (via regulations). What we get back is a whole other matter and subject to a whole other discussion. For today, let’s dissect the reasons how government interactions differ from other transactions and we’ll better understand why we love shopping but why we hate politics.

You may or may not agree with me on this at first, but I sense that in the end, your gut feeling will be one of agreement. There are two important things that shape whether or not a particular business entity will make us happy. The first is the presence of COMPETITION or from the consumer’s viewpoint, the presence of choices. The second, which helps keep the competition honest, is ACCOUNTABILITY.

Allow me to expand on this, OK? Let’s begin with the concept of COMPETITION. If you think back to some of your best experiences as a customer, what were they? Was it a 5-star restaurant or some luxury resort hotel? Was it that clothing store in the mall with the great deals or that friendly-service mom-and-pop grocery store? Now contrast this with some of your most frustrating experiences. You all have your own. Was it the DMV or the traffic court system? Was it that doctor’s office that you are forced to go to because of your HMO?

Let’s analyze the differences between the good experiences and the bad. Is there a correlation between how good something is and the degree of competition that they face? You bet! And why? Well, it’s just natural that a business can’t afford to be bad and have unsatisfied customers if it is to survive in the face of nearby competition. When disgruntled clients can easily walk away and take their business elsewhere, you can bet that the business will bust their butt trying to be the best it can be. However, if there is no competition and it’s the “only game in town”, or if people are forced to spend their money at that business no matter what, then of course, there’s little drive for the entity to excel.

When it comes to politics, there’s really zero healthy competition to give us options. Sure, there’s this illusion that we can choose between the Democratic and Republican candidates. But really, what kind of choice is that? Pardon the bluntness, but it’s like telling a slave that they should be grateful for having a choice of slavemaster for the next four years. I know that this is a little different because we have the option to leaving this country, but is that really a valid excuse? We, the people, own this country. It’s not the handful of people called politicians who own it or who own us. Our economic and social freedoms are increasingly being squeezed away by both parties in this alternating back and force dance where one side gains power and saps our economic freedom and then power switches to the other side who then suck away our social freedoms without returning a single inch of what the other side stole. Deep down inside, what most of us want is individual liberty and the chance to thrive as a free community. So if that’s the case, then why doesn’t a candidate run on the platform of reducing government and increasing freedom? Well, that’s what they often do, but once they get into office, they are no longer bound to deliver what they promised. And as for the honest candidates who will abide by their promises, well, THEY never make it onto the ballot. The barrier to entry is too great. In order to even make it onto the ballot, you would have to have played the politics game and survived for quite a while. And by that time, you’re already bought-and-paid-for by special interest groups with their fat political contribution checks.

That’s where the second factor, ACCOUNTABILITY, comes into play. If you walk into a free-market store and they treat you rudely, you have the absolutely liberating choice to smile and walk out. If you’re so inclined, you can even eliminate the smile and add a rude gesture back. If you have a bad experience in a restaurant, then you have the option of making that the very last time you ever bring your dollars to that particular establishment, and even leaving a bad review on Yelp to warn others. How does this differ in politics? Like night and day. Once a politician is elected, he is set for the entire term, usually four years. If politicians renege on their promises, it matters little to them because accountability is now out the window. By the way, it’s certainly not just our current president who is egregiously guilty of breaking promises. The one before him who asked you to “read my lips, no new taxes” was every bit as bad. I won’t go into the technicalities and semantics of “new” taxes vs just raising preexisting ones, but clearly, the spirit of the promise was broken without regard. Another thing that reduces accountability is the great distance between the controller (the politicians) and the controlees (we the people). If it’s our mayor or our neighborhood association president who does something we hate, we can let our voices be heard. But if it’s some politician 2000 miles away, you can just give it up because in that case, our voice is heard as strongly as a whisper at a rock concert. Our current system of a representative democracy where a few out-of-touch people control the lives of a great majority, is horribly flawed and clearly not the best way to live.

I’m not alone in being intrigued by yesterday’s turn of events in Massachusetts, what is rightfully being hailed as the political “Upset of the Century”. It stunned me and has given me a glimmer of hope for this country. Why? Because, it could well be interpreted as a sign that the Star of Accountability is trying to shine again in politics. Hooray! Recall that in November 2008, a new president was elected on promises of hope and change by a nation sick and disgusted by the corruption and oppressive practices of the former president. However, once the new guy gets into office, he proceeds to unleash a surprisingly bold set of unpopular policies to further destroy our country’s freedom and economy. It got to the point where this new president and his ruling party got so arrogant as to try and shove down the people’s throats a massive government takeover of the enormous sector known as healthcare. Then, with no remorse, when the people voiced that they didn’t want this, the politicians proceeded to resort to every last bit of political trickery to bribe a vote here and there, just to pass something that the people don’t want. In the past, the collective passive mind of the American people would have been tricked into going along complacently. But thanks to the power and transparency of the internet and our gradual liberation from a biased media, last night’s shocking results give some hope that people are actually getting smart enough to say “enough is enough” and caring enough to do something effective. Wow!

One more thing. It’s certainly tempting to give in to the adversarial two-party game of politics, with half the country cheering raucously at yesterday’s Massachusetts results, and taunting the other side, just as that other side cheered and taunted when Obama was elected, reminiscent of when UCLA beats USC in football or vice versa in basketball. But the wiser approach is to realize that we’re all in it together and cheer it as a minor victory of the people vs the corrupt oppressive big government.

Now before all of us freedom-loving people can rest and celebrate, we have to be wary. What if the Republican party continues this trend of regaining power, but then does nothing to offer tax relief, nothing to lessen oppressive regulations and nothing to reduce runaway government spending? It has happened before and might happen again. Stay tuned and stay alert. But for now, we can focus on the positive, that maybe there is some hope that political accountability is slowly emerging.

In any case, as unpalatable as it can be, we can’t afford to ignore politics, because it’s not merely a remote scorecard of who is in office and which side has more. It’s a matter of what you can eat, whom you can marry, what your children are taught and what you are allowed to do in your life. It’s a matter of how much money is stolen from you every month and how much killing and bombing is being done with that money. So let’s all discuss, read, learn, debate, reason and question as if our lives depended on it, because, as you all know, it really does!

Dear Doctor,
Hello, I would be very grateful if you could help me. I ahve GP in the Uk, that unfortunately only gives you 10 mins for a meeting. He told me that my test results were noraml but does not go into anymore detail.
I reaaly need an insight into what the hormone levels mean in terms of fertility.
my plasma FSH is 9.8 iul/L,?LH 4.51?serum testosterone 1.9 nmol/L?serum presterone 1nmol/ L
serum oestradiol 83pmol/L
apart from the FSH, I do not understand what thes figures mean, could you please give me some indication and direct me some websites whereby I can learn More . Thank you

Daniella

Dear Daniella
Thanks for the question. I’m sorry to hear that you were only given 10 minutes with your doctor on a complex issue such as infertility. I understand that you have government-run healthcare over there in the UK, but do you have any option to choose another doctor? The thought of being given 10 minutes with zero choice of choosing a different doctor would scare a lot of the people here in the US as we try to fight off our own government’s attempts to take over this vital part of our lives.
In any case, with respect to your question above, what you have shared are test results regarding your hormones. The FSH and LH are made by your pituitary and are involved in your body’s way of modulating your ovaries to make eggs. The next three ( testosterone, progesterone and estradiol ) are the products of your ovaries.
Depending on your age, you could have a less than average chance of conceiving or an average one. Based on those tests, you probably wouldn’t expect to have a higher-than-average chance of conceiving. As for what you should do, it depends on your age, how strongly you want to have a baby, how long you have been wanting one and what treatments you have already tried in the past. The value of doing those tests is not that great unless one of them comes back as off the charts and grossly abnormal. That’s about the best answer that I can give you without knowing your history and goals. Good luck!

I just went to the Re office for my 3 day fsh level to start ivf last month it was 10.5 and e2 was 69 this month i wanted to start and now my fsh is 15.5 and e2 is 89 my follicle count was 9 no other problems is it possible i need egg donor they told me I have to wait till it goes down what would my options be at 37

Tracey

Dear Tracey,
At 37, your options would be to go ahead and attempt a stimulation and then see how many follicles your body produces or to not take a chance, but go directly to donor eggs. Without knowing the rest of your history, I can try and assume that you have never done IVF before. Depending on how much it would cost you if you were to have a cancelled cycle and how much value it is to you to try with your own eggs, you would balance these two factors out and make a choice that is best for you. Best of luck!

hello
in 2007 I had a fsh of 6.9 in 2008 I had a successful ivf resulting in my little girl.?from that ivf I got 9 eggs out of 13 follicles.with low drugs
we have been considering ivf no2 in the hope for a sibling
my fsh is now 10.2 ( which is the higher end of normal ) and my AMH is 8 not sure is that is normal ???
I am 27 and ivf is the only way for me as have no tubes ( 3 ectopics )
so my question is with my fsh on the rise should I be having ivf sooner rather than later ? are my levels abnormal for my age ?
any advice would be much appreciated
natalie

Dear Natalie,
Yes, assuming that your FSH was drawn near day #3 of your cycle, then the value is considered less favorable than what would be expected in the average 27-year-old. As for going after your second baby sooner than later, in general, you know that conceiving at a younger age results in higher odds of success, lower risk of miscarriage and lower risk of birth defects. So if you mentally and financially ready and are really sure that you want more children, then what’s the reason for waiting? Right? Good luck!

Hi Dr. Lee,
I have followed your blog for several months now. It has been so helpful, and I thank you for that. My husband I have been trying to conceive for 3 years now, and under the care of an RE since October of ‘08. We’ve had 5 IUI’s and 2 IVF’s. Long story short, the first IVF resutled in OHSS and the 4 embryos were frozen. The second IVF only resulted in 2 embryos surviving to day 5 and they were both transferred, but I was hospitalized with the flu AND we got a negative on a pregnancy test. We had a FET this past summer and transferred 2 of the embryos. (Many details to my story but they believe the blood thinners helped us as I was diagnosed with MTHFR.) I had a successful, singleton pregnancy but delivered stillbirth at 20 weeks, 5 days. I was diagnosed with an incompetent cervix. I have read on line that this is not uncommon in infertility patients. In a nutshell, I was wondering if you would consider blogging about any of these topics in the future: blood disorders like MTHFR, recurrent pregnancy loss, incompetent cervix, and high risk issues in IF patients like incompetent cervix or placent previa. Thanks for your time, Jennifer A.

Dr. Lee,
So sorry… I left a few things out in my post. I was diagnosed with PCOS and poor egg quality. My husband was diagnosed with slightly low testosterone (I want to say just two points below normal). He had the varicocele surgery and now the urologist in the IF practice says his testosterone levels are ‘great.’ The most important part I left out was this; I have two frozen embryos left. We want to try another FET. What could/should I know about incompetent cervix that could make a different and save the next baby’s life, or is it a ‘crap shoot.’ Also, would it be safe to trasnfer two? If we chose to transfer only one at a time, are we lowering our chances of that ‘one’ embryo implanting? I have heard that women often transfer several because it increases their chances at getting pregnant. So, does that mean transferring only one will ‘lower’ your chances? Hoping my story will inspire future blog topics for you to research and discuss. Thank you again, Jennifer A.

Dear Jennifer,
In my 14 years of practice, I’ve encountered at least 20 patients who after getting pregnant with IVF or IUI have gone on to be diagnosed with incompetent cervix. Most of them went on to have a healthy baby in future pregnancies. In the majority of cases, the presence of an incompetent cerivix is picked up only after a tragic pregnancy loss. The only other way to detect it would be to monitor the cervical length meticulously. For you next pregnancy, I take it you will be under the care of a high-risk OB specialist who will likely discuss with you the option of having a cerclage, which as you may know, is a stitch to tighten up your cervix. As for your question of transferring one vs two embryos, bear in mind that each embryo you transfer gives you one “roll of the dice” to get a baby. So, of course, rolling the dice twice makes the odds of hitting a winner more likely. However, you would have the same general chance in the long run whether you transferred both embryos in two separate transfers or if you transferred them both at once. I hope that makes sense. I have discussed recurrent pregnancy loss in previous posts, but I appreciate your suggestion and I will likely revisit this issue in future posts. I hope all goes well with your next pregnancy.

As you can guess, many of the tasks that we reproductive endocrinologists do throughout the day are highly repetitive, such as measuring follicles, performing inseminations, reviewing blood test results. Even the most critical tasks such as egg retrievals and embryo transfers are actions that we do over and over again.

The one part of my work that has the greatest variety, and a “you-never-know-what-you’re-gonna-get” component to it is the New Patient Consultation. If you want to know what keeps my work day fresh and exciting, well… this is it. Picture this. I’m sitting in my office working on charts when I get a notice on my computer screen from my staff that a new patient is ready and waiting. I leave my desk and head for the consultation room. I pick up the blank chart and all I see are the patient’s name and her date of birth. And then the fun begins. When I open the door to greet the patient or couple who are waiting, I know that I will spend the next hour engaged in a fascinating conversation with someone whose goal is to have a baby and who is researching to see if they want to enlist my help.

The first few minutes consist of simply introducing ourselves. There is great value in really getting to know someone, learning about a patient’s life, her philosophies, her values and her anxieties. This requires time. I sympathize with my medical colleagues in other fields who are called upon to see five or more new patients an hour. Of course, if a patient is in the ER with a laceration that needs suturing or a sprained finger that needs splinting, then a more specific problem-oriented approach might be OK. But in our field, it doesn’t work that way. Ironically, I’ve brainstormed and toyed with that notion in the past - specifically conjecturing about the feasibility of someone opening up a dedicated artificial insemination express station so that infertility patients could have the option of being helped without an extensive doctor-patient relationship. For patients who wish to save money and time, but who just wanted to have an IUI done, they could choose to assume responsibility for  predicting their ovulation day on their own and then go to some novel walk-in IUI center. Bring the sperm in. They’ll prep it and inseminate it. No questions asked. While something like that might work theoretically and might have some economic advantages, it would never fly in the real world given the strict regulations that govern us. For one thing, here in California, we need to have a set of infectious disease screening tests done on the husband before we can even process the sperm. Anyway, as I said earlier, there is great value in getting to know a patient, because in the field of infertility, there are usually multiple options available for some patients and the choice of the best option is based not solely on cold hard medical criteria, but also on personal preferences of urgency, frugality, risk aversion and religious views.

So, while the patient and I gradually get acquainted, we will intersperse the communication with me asking them questions about their health and with them asking me to explain some of the medical aspects of their situation. It’s a very fun process, because both parties get to learn. While I am learning about their medical history, I am intermittently teaching them about the medical facts and ideas which pertain to their case. Some of my questioning is done in a rigid checklist style, because I always need to know about certain mandatory things such as their drug allergies and past surgical history. However, a lot of this process is done with a great deal of improvisation. I teach the medical students at UC-Irvine and Western University of Health Sciences during their OB/Gyn rotations and over the years, I’ve tried to come up with the best way of teaching how to take a history on an infertile couple. I’ve come to learn that it’s hard to teach, because unlike other fields of medicine where the history taking is more amenable to a checklist approach, infertility requires a lot of improvisation. That’s why I’ve decided that the best way to teach it is through role-playing. The times in the past where I had a kind student volunteer offer to play the role of the infertile patient being interviewed are the times that were the most educational. If you are a regular reader of this site, you might have noticed that the previous posts with the detailed case histories were especially helpful to you, again, for this very reason.

So after we’ve gotten acquainted, processed all the mandatory medical information and sufficiently answered the patients’ questions, we wrap up the visit by exploring if we’ve achieved the following objectives.

1. The patient now has a better understanding of her fertility situation, with regards to what might be contributing factors, potential options and overall prognosis.
2. We have outlined the potential treatment options with a rough estimate of how much they will cost, what risks they involve and what is the estimated chance of success.
3. The patient knows a bit more about my own values and philosophies which will greatly shape my role as their guiding physician.

Then the patient will go home and decide, based on my medical suggestions, which treatment option is right for them, if any, and then we move forwards to do the next step that it will take in order to get them a baby.

Not ready to get professional fertility help? Many times, the uncertainty of what to expect during the initial visit to a RE makes some people hesitant about taking that first step. So to help you out, here’s a typical example of the progression of events.

Let’s picture that you want to be pregnant and have been trying for almost a year. With your job and all your other obligations, you just haven’t seen any opportunity to take action on this just yet. Besides, you and your husband are healthy and can clearly picture it happening naturally, right? Occasionally, during random moments of browsing the internet, you see some flashes of information that makes you inspired to take action, but then the motivation fades and you are back to your busy life. Over the next year, the pages on your calendar cascade down month after month, and still nothing has happened. Now it’s been two years, so you stare at your phone and eventually pick it up and call.

The voice on the other line is pleasant and you are told about the office policies, the initial consultation fee and you are given a choice of times. You and your husband decide to take the leap and book an appointment.

You arrive at the unfamiliar office and are warmly greeted with a smile, but you are immediately taken aback by the pile of forms to fill out and sign.

The first is a demographic sheet asking for your contact information, so we can facilitate reaching you, especially in an emergency. Besides the personal data, you are also asked for any insurance information that is needed. So this has practical value and you don’t mind filling it out.

The next form you will have to read and sign is the HIPAA agreement. You will have to bear with me while I gripe, but this is another reason why we should hope and pray that government-run universal healthcare never becomes a reality. Sure, everyone agrees that privacy is important, but it should not be the way it is, where physicians are made to be so terrified of a perceived infraction that we are all forced to take drastic measures. Anything that takes up our undue attention will distract from the pool of attention resources we can devote to more meaningful things, such as patient care. So we had to pay attorneys to draw up legal documents for our patients to sign. You see, while the government mandates us to abide by the rules, they don’t provide any acceptable standard documents that we can use, so we have to expend major time and energy each time there is a HIPAA revision. Also, we used to have a convenient sign-in sheet. But now we had to hide it. Technically, we also can’t risk saying hi to anybody by their name if it can be heard by anybody else in the waiting room. Basically, we walk on eggshells for something that was never a significant problem even before HIPAA. And yet, ironically, now with HIPAA, it still doesn’t prevent those news stories of people leaking celebrity medical information to the press. OK, thanks for listening. Let’s go on.

The next piece of paper is the Arbitration Agreement outlining that any disputes will be addressed by a legal professional and not by a random jury of medically unsophisticated people.  This document benefits us by protecting us from lawsuit abuse in many ways. It sets up a fair system and it also weeds out the litigious fringe problem patients who jack up the costs for everyone.  There have been a handful of people who refuse to sign the form and therefore, refuse to be our patient. One such person went on to see another doctor whom she wound up suing for something silly. She also sued her landlord for mold and sued her employer and this one store she went to. (I later found these cases listed on the internet). With an arbitration agreement, while we can still be sued if we do something wrong, it’s less likely that someone is going to file an nuisance suit against us just to exploit and intimidate us. And actually, it also benefits the patient. How? Well, in almost 13 years of practice, I have yet to be named in a lawsuit, so that helps keep our malpractice costs low. Don’t underestimate the significance of this. Due to arbitration and legal protections (MICRA) against lawsuit abuse, OB/Gyn’s in Orange County CA pay about 50K each year in malpractice costs. In contrast, OB/Gyn’s in Long Island NY pay 168K and those in Dade County FL pay 203K per year. You can probably already guess that these costs will get passed down to the patient somehow. I believe it also gives good doctors an incentive to avoid those places, thereby depriving the people in those regions of more good doctors from which to choose.

So after all this gruelingly painful paperwork, you will finally get to meet with the doctor, which we’ll discuss next post.

Before you take that first step and make an appointment with an RE, you might appreciate a preview of what to expect. The following describes this important first visit, which we officially call a New Consultation visit.

In my practice, the couple will sit across from me and we’ll spend about an hour together. Sometimes it’s just the wife who comes by herself and other times, both partners are present. There are several goals to accomplish for this visit:

I get to know the couple. I find out what their daily lives are like, what their priorities are with regards to fertility treatment and what their specific concerns and special needs might be.

The couple gets to know me. They get a feel of my communication style and my philosophies regarding the doctor-patient partnership. Some doctors are very dictatorial, meaning they pretty much call the shots regarding what happens. Generally, my style is different. I like to present options including the pros and cons of each alternative. After going over this in detail, then I’ll reveal which choice I would personally lean towards, but I prefer to let the couple make their own choice. However, it all depends on what the patient’s want. Some patients clearly don’t want to discuss the logic behind each decision, but would rather just leave it all up to me.
I gather all the medical information though questions and answers, as well as via an ultrasound examination plus review of any previous records or test results.

I offer treatment choices. Sometimes, there are a couple choices, all of which are reasonable. Then, as I previously mentioned, we’ll go over the plus’s and minus’s of each route before deciding on the final plan to take. Other times, there’s really only one best plan. In this case, we will spend time going over this process in detail, making sure to tackle all the questions that come up.

In the next post, we’ll describe an example of the paperwork involved in a New Patient Consultation visit.

Before starting a stimulated treatment cycle with clomiphene citrate (Clomid), with injectables or with a combination of both, we customarily do a baseline ultrasound sometime around day #1 to day # 5. What are we looking for with this? Actually, it’s more of what we’re NOT looking for. We’re specifically looking to see that there are no cysts. In other words, we’re looking to see that there are no follicles that are beyond a certain size. For clarification of these terms, you may consult this post.

Remember that this early in the cycle, all the follicles for that month should be very small. I tend to use 13mm as a cutoff, but I have colleagues who have a slightly smaller or slightly larger cutoff. The rationale is that if we already see something larger in size, then the cycle will be suboptimal because that cyst can grow and disrupt the course of development of any new upcoming follicles.

Another purpose of this visit is to discuss the exact formula or protocol to use for the upcoming cycle. There have been times when a patient came in to start injectables and after discussion relating to her particular case, we change our minds and decide to do Clomid-only or a combination of Clomid with injectables. We may make our final decision regarding doing IUI or just timed intercourse. We might have some adjustments regarding the dosage, as well.

By the way, sometimes for the sake of convenience, we can actually do the baseline scan a few days BEFORE the period starts. Let’s say for example that the patient is here to pick up some medications or settle her account and hasn’t started her period yet. However, she is expecting it to come any day now. We can do the baseline ultrasound today; then she can call with her period and get instructions on when to start her meds.