This is the first in the “What Type of Fertility Patient Are You” series.

The NON-OVULATOR:

You have to ovulate in order to have a baby.

It’s considered normal to ovulate thirteen times a year, which means thirteen opportunities to potentially get pregnant. Some women ovulate fewer than thirteen times per year. Either their cycles are more days apart from each other or they just skip some cycles completely. This means that while the same twelve months is going by in life and they are getting the same one year older just as everybody else is, they are missing out on chances to get pregnant.

WHAT ARE THE DIFFERENT LEVELS OF NON-OVULATION?
The number of ovulations every woman has per year varies greatly. In a best-case scenario, a woman with regular 26-day cycles could potentially have a perfect year when she ovulates one egg fourteen times, giving her fourteen opportunities to get pregnant. It’s also possible for a women to, every once in a while, have a double ovulation month in which she fires off two eggs. This does not happen often, but in women with a family history of twins on their mother’s side, it happens more than it does in other women. These are the good extremes. In the worst-case scenario, you have women who go through an entire year without ovulating even once. Unless this problem is solved, they are not going to get pregnant. The rest of the population fall somewhere in the middle between zero and fourteen ovulations per year.

EXAMPLES:

• Jamie’s periods come like clockwork every 29 days. In the past year, she tried ovulation testing three times and each time, her sticks eventually turned positive. In one month, she even had her RE do serial ultrasound monitoring. With that, she saw her follicle grow bigger and bigger before finally disappearing on day #15. CONCLUSION: The best estimate is that Jamie is a normal ovulator with 12 to 13 chances per year to get pregnant. If she’s still not getting pregnant, it’s best to look for other factors, such as tubal or sperm problems.
• Heather has very irregular periods. In the past three years, she estimates having about 3 periods per year. CONCLUSION: If each of Heather’s periods is an indication of ovulation, she is having, at most, three chances to get pregnant per year. However, it’s also possible that her three periods per year are not all ovulatory cycles, in which case, she might be having zero, one or two ovulations per year. Yes, it’s possible to have bleeding without actual ovulation that month. Attempts to help her conceive should focus on getting her to ovulate more frequently.
• Leslie has regular cycles which consistently come every 36 days. Her ovulation testing lately has shown that she is consistently ovulating around day 21. CONCLUSION: She is likely ovulating. Buyt, because it takes longer than average for each ovulation, she is ovulating at most, 10 times per year. She is missing out on about three chances per year to get pregnant, compared to Jamie.
• Anne used to have regular periods in the past, but her very last period came when she was 38. After she turned 39, she did not have any more periods and she is now 41. Her random FSH value is 39 IU/L. CONCLUSION: Anne is most probably a non-ovulator due to menopause. Her condition is permanent.

HOW DOES OVULATION TRANSLATE TO CHANCE OF GETTING PREGNANT?
The focus, so far, has been on the number of times of ovulation. The number of eggs you ovulate per year is your QUANTITY of ovulation. But often, we hear talk about the QUALITY of ovulation. First of all, there is no universally-accepted definition of what egg quality means. In fact, we use the word quality, in everyday language to generally mean something that is “good”. But just ask people and you’ll get differing views on what constitutes a quality friendship or a quality tomato. So I will define for myself that when I use the term “egg quality” here, I’m referring to the percentage chance of making a baby with that egg. Someone who is ovulating a high quality egg might have a 30% chance to have a baby with that egg. On the other hand, someone with poor quality ovulations might only have a 1% to conceive a baby with each egg. So our wish list should include not just egg number but also egg quality. After all, would you rather have a single “30% egg”? Or would you rather have a dozen “1% eggs”?

WHAT ARE THE DIFFERENT CAUSES OF NON-OVULATION?
There are many different reasons for ovulation problems, but they can be broken up into two main categories. One is actual problems with the eggs themselves and the other is problems with the hormonal system that is supposed to mature and develop the eggs. Think of it as a hardware issue vs a software issue. Some women fail to ovulate because their remaining eggs are poor quality and resistant to growing well despite sincere efforts by her hormonal system to nudge them along. This is most often due to age and can be detected by checking FSH levels. Other women fail to ovulate even though they have lots of fantastic eggs. However, their problem is that their brain is not programming the eggs to mature and develop correctly. This is a much easier problem to solve. Again, just as with the computer analogy, a software problem can be fixed by changing the programming while a hardware problem cannot be fixed by anything other than replacing the components.

WHAT ARE SOME CLUES THAT YOU ARE A NON-OVULATOR?
You may be a non-ovulator if you have irregular or absent periods (anything other than a standard regular 11-13 cycles per year) or if you have consistent failure to have positive ovulation testing.

WHAT IS THE BEST APPROACH TO HELPING A NON-OVULATOR?
Find out the cause of her non-ovulation. Fix it if possible. If ovulation is restored and pregnancy still does not occur, then it’s time to look for other problems.

SUMMARY:
Some non-ovulators can be helped to ovulate quite easily. If so, and if that’s their only problem, meaning no coexisting sperm or tubal problems, they can get pregnant fast. Other non-ovulators have coexisting problems, so that resolving the ovulation issue is only part of the game. Still other non-ovulators are in a sadder state because it is nearly impossible to help them achieve a good ovulation. If you suspect that you are a non-ovulator, please consider getting help right away.

New mother-to-be at age 66. What do you think?

You’ve all heard success stories of patients getting pregnant after just taking some pills. Chances are, the pill you have heard of most often is Clomiphene citrate (CC), known by brand name as Clomid or Serophene. This is usually the first medication offered to an infertile woman by her general OB or family practice doctor. RE’s also prescribe it generously. How does it work? Well, the benefit of CC is assistance with ovulation. It can help a non-ovulating woman ovulate. It can also help a woman who already ovulates on her own by improving the quality of her hormonal stimulation, thereby resulting in better ovulation, which translates to better odds of getting pregnant. However, it is far from being perfect. First of all, not all women ovulate with CC. Second of all, ovulation is just one part of the whole picture with regards to getting pregnant. There are other factors, such as the cervical mucus and the endometrial lining, which are also important. While CC is helpful with regards to initiating or improving ovulation, it can sometimes be harmful to fertility by making the cervical mucus more hostile and making the endometrial lining less receptive to implantation.

This has been suspected by RE’s for a while when we noticed that CC can succeed in inducing ovulation about 70% of the time. Yet, only about half of these patients wind up getting pregnant with just CC alone. So the ovulation problem was being fixed, but yet, we weren’t seeing anywhere near as many pregnancies as we would expect. One possibility is that these couples had multiple problems, besides just ovulation issues. Another possibility raised was that while CC was helping with ovulation, it could be hurting with other things.

So, at what locations and in what ways might CC be harmful. I gently use the word ‘might’ because for many patients, the bad effects are not significant. Remember that people are different and respond to medications differently. Don’t go throwing away your CC and angrily calling your OB. However, while CC works great for some people, in others, it fails to solve the problem, partially because of CC’s bad side. The potential harmful effects of CC on the uterine lining are supported by a study that used special ultrasound to look at uterine blood flow. They found that CC use was associated with decreased uterine blood flow. It did not actually affect the thickness of the lining, but it did lower the propensity for the lining to be that ideal “triple-layer” appearance that we all wish for.

Another area where CC can cause problems is at the level of the cervical mucus. CC can have a tendency to interfere with the formation of that favorable stretchy mucus that sperm like.

So what can you do? Bear in mind that for most people, the downside of a three month trial of CC is just a loss of three months. While you might argue that three months is critical for someone over 40 years old, I would agree, but also add that experimenting for three months is quite feasible in almost all women in their 20’s and early 30’s. Having said that, I’m also reminded of a recent experience when a patient told me that she absolutely did not want CC because she had had a bad experience with it in the past. She told me that her OB had prescribed her CC and that it had “made her gain 20 pounds.” Not only that, the stress of gaining that 20 pounds caused her to gain an additional 50 pounds. This is the only time I’ve ever encountered such a report, but it goes to remind me that every patient is different.

Anyway, back to the lining and mucus, how do you get around the potential harmful effects of CC on these areas?

With respect to the lining, my favored approach is to abandon the CC and move on to injectables, which can be very friendly to the lining. With respect to the mucus, my favored approach is to punch past the unfavorable mucus by doing simple IUI’s. So, the bottom line is that if you have successfully ovulated on CC, but are still not pregnant after three cycles, it’s time to discuss the above issues with your doctor, keeping in mind that in some cases CC is your friend and in others cases, CC can be your enemy.

Anybody who is a regular visitor on Facebook is all too familiar with the epidemic of cute little quizzes revealing “Which Disney character are you?” or “What kind of dinosaur are you?”. That’s how I got the inspiration to start a new series of blog posts on “What type of fertility patient are you?”

It’s true that everyone is different and no two fertility patients are exactly alike. However, RE’s very naturally speak of categories, such as tubal factor, unexplained, diminished ovarian reserve or male factor, for example. Labeling patients with these labels can generally help guide our treatment. However, we sometimes have to be careful not to let labels make us too narrow minded. There is going to be a lot of overlap between the different types, especially when many couples have more than one factor.

Anyway, starting later this week, I’ll begin posting on different “types” of fertility patients. If you have any suggestions on what “types” you’d like to see profiled, let me know.

As I complete each post, I’ll put a link at the end of this post, so if you would like, you can bookmark this page now and come back later to check for updates. This should be fun for me and informative for you!

What kind of fertility patient are you?

1. The NON-OVULATOR
2. ????????
3. ????????

What happens when the beliefs of one group of people affect the freedom and rights of another group of people?

A month ago, I wrote Part 1 and Part 2 of this series on Georgia Senate Bill 169, a proposed legislation which slams into conflict two groups of people. The supporters of this bill view that laboratory embryos should be afforded the same rights and protections as a live-born child. The other group opposes the bill and believes that infertile couples who are trying to have a baby should not have their options overly restricted. So just what is this bill all about?

There are multiple components to this bill. The first part reads:

(a) It shall be unlawful for any person or entity to intentionally or knowingly create or attempt to create an in vitro human embryo by any means other than fertilization of a human egg by a human sperm.
(b) The creation of an in vitro human embryo shall be solely for the purpose of initiating a human pregnancy by means of transfer to the uterus of a human female for the treatment of human infertility. No person or entity shall intentionally or knowingly transfer or attempt to transfer an embryo into a human uterus that is not the product of fertilization of a human egg by a human sperm.

In our program, there’s only one way we know how to create embryos, namely by fertilizing human eggs with human sperm. I don’t know of any other programs that are doing it any differently, such as any using kangaroo eggs or hamster sperm, but if there are, I guess they’d be in trouble if this bill passes. Granted, this clause could also be interpreted to ban cloning. However, that would be redundant as there are already federal provisions in place aimed at banning cloning. This part of the bill doesn’t affect my patients, as we presently don’t do cloning.

The next section addresses financial compensation given for embryos or gametes. It reads:

No person or entity shall give or receive valuable consideration, offer to give or receive valuable consideration, or advertise for the giving or receiving of valuable consideration for the provision of gametes or in vitro human embryos. This Code section shall not apply to regulate or prohibit the procurement of gametes for the treatment of infertility being experienced by the patient from whom the gametes are being derived.

In a free society, people enter into agreements based on mutual benefit. Infertile couples sometimes need help from other people in the form of donor sperm or donor eggs in order to fulfill their dreams of parenthood. As a way of thanking the donors, financial compensation is routinely offered. To do away with this option would be disastrous if we look to the UK as an example. Over there, paying for donors is forbidden. This all but eliminates anyone from wanting to participate, leading to a loss of options for most couples, unless they are willing to resort to drastic risky behavior. For some of them, there is the option of coming to the US. In the past two years, I’ve had the chance to help four couples from countries in which paid egg donation is banned. After they got pregnant, they vented their anger at the unfair restrictions in their home countries which compelled them to come to the US. Well, if this happens in the US, I’m not sure where patients would go for their treatment, maybe Mexico?

The next section reads:

The in vitro human embryo shall be given an identification by the facility for use within the medical facility. Records shall be maintained that identify the donors associated with the in vitro human embryo, and the confidentiality of such records shall be maintained as required by law.

This is just plain meddlesome and seeks to slap a regulation onto something that is already routinely done out of common sense. We already document and label meticulously, so again, this would not affect us much.

Going on, the next paragraph reads:

19-7-64. (a) A living in vitro human embryo is a biological human being who is not the property of any person or entity. The fertility physician and the medical facility that employs the physician owe a high duty of care to the living in vitro human embryo. Any contractual provision identifying the living in vitro embryo as the property of any party shall be null and void. The in vitro human embryo shall not be intentionally destroyed for any purpose by any person or entity or through the actions of such person or entity. (b) An in vitro human embryo that fails to show any sign of life over a 36 hour period outside a state of cryopreservation shall be considered no longer living.

Here’s where it starts to get a little annoying. This vague statement suggests that the writers of this bill are not familiar with what actually happens in an embryology lab. When we put the sperm and egg together from a husband and wife couple, we have to assign somebody the power to determine what is done with that embryo — whether it is transferred back into the wife, transferred into someone else or frozen for the future. Whether or not it is labeled as the “property” of anyone, we have to give someone the legal authority to make the call of what happens to the embryo. This is like passing a law stating that a child can not be labeled as the property of his parents. That’s fine and dandy, but then is it OK for someone to grab a baby out of a stroller at the mall and take the baby home because it wasn’t the “property” of the parents? Very silly. Whether or not you label it a property, there HAS to be some legal designation, enforced by contract, to confer rights to certain people regarding the embryos, because you know what? The embryos can’t make decisions on their own.

The next clause appears redundant because it states:

Only medical facilities meeting the standards of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists shall cause the fertilization of an in vitro human embryo. A person who engages in the creation of in vitro human embryos shall be qualified as a medical doctor licensed to practice medicine in this state and shall possess specialized training and skill in artificial reproductive technology in conformity with the standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

IVF is a medical procedure and as such, can only be done by medical doctors. There is no real need to restate it. Again, this is verbose, but not really changing anything that we already do.

The next section is where it starts to get really intrusive:

In the interest of reducing the risk of complications for both the mother and the transferred in vitro human embryos, including the risk of preterm birth associated with higher-order multiple gestations, a person or entity performing in vitro fertilization shall limit the number of in vitro human embryos created in a single cycle to the number to be transferred in that cycle in accord with Code Section 19-7-67.

In order to grasp the impact of this intrusion, let’s review how IVF works. When a couple make the decision to do IVF,  our goal is to help the couple create some healthy embryos that will grow into healthy babies. We help do this by putting their eggs and sperm together. The procedure take a lot of dedicated work from a team of many people. The main labor is the surgery involved in extracting the eggs. The good thing is that each additional sperm or each additional egg does not add all that much cost to the process.  Therefore, it would be highly wasteful to do IVF with just one egg and one sperm. We can’t know for sure how many of the eggs we get will successfully fertilize. Out of those that do, we can’t know for sure which will continue to survive until the day of transfer. Can you imagine a lawmaker telling you that you can’t put more gasoline in our car than you’re going to use each day?

On the day of an IVF egg retrieval, we surgically remove all the eggs that stimulated for that month. We try our best to fertilize every one of them, because we know that most of them will not end up capable of becoming a healthy baby. By attempting to fertilize all of them, we get the best chance that at least one or some of them will end up being good. In a good scenario, we get enough healthy embryos to transfer as well as some additional ones to freeze for future attempts. For many couples who fail IVF in the first fresh attempt, those frozen embryos are the difference between their ending up with a baby in their home vs. remaining sadly childless.

The rest of the bill piles on further restrictions by telling us how many embryos we can transfer. This issue of embryo number is such a loaded issue that I’m going to save it for the next post.

Nadya S. is NOT in any way, representative of the hundreds of thousands of genuine loving inferile couples in the US, whose only wish is to have a child to love. She is now applying for a trademark on the term “Octomom”. If you ever see her picture and/or name on T-shirts, mugs, ovulation kits or stripper attire, I urge you to boycott the product.

It would be a shame if overreactive legislation were passed to further impede the hopes of infertile couples all because of this one case.

By the way, there is no truth to the rumors that Dr. K has applied for a trademark on the term “OctoDoc”, although he HAS been heard to have jokingly referred to himself as that during a conversation at a recent pharmaceutical company-sponsored event that he attended this past month.

Planning ahead can really pay off.

A teenager diagnosed with leukemia was advised to save his sperm before undergoing his cancer treatment. Now, 22 years later, he and his wife are parents thanks to this forethought. For patients newly diagnosed with cancer, there is an organization which provides information regarding fertility options.

Many patients are referred to me for guidance after finding out they have cancer. Often, after learning about their options, they end up saving their sperm or embryos so that they can have children in the future. While some patients will need these preparations in order to conceive, there have been other patients who make these arrangements, but then end up getting pregnant on their own afterwards.

Can the sperm of a dead man be used to create babies? A recent news story brings up this controversial topic once again. The concept of posthumous sperm utilization is not a new one and there have been many cases of babies being born to deceased men.

I have been involved in such a case myself. I can only share the basics without divulging the details. This was a couple who were in the middle of infertility treatment when suddenly the husband took ill. He went to the doctor and was diagnosed with cancer. The couple halted their treatment, but deliberately took action to freeze many vials of sperm. The husband did not survive his disease, but made it clear that he wishes to give his wife the option of using his sperm. She came back after a time and did just that. Now she is successfully raising happy healthy children conceived from her deceased husband’s sperm.

The difference in the case of Nikolas Colton Evans is that he never explicitly expressed his permission to do this. In fact, he never even went to the trouble of saving sperm ahead of time. So this is not just a case of using posthumous sperm, it’s a case of harvesting posthumous sperm.

Instead of arguing the merits of doing it, one might present the counterargument of why NOT do it, as long as the mother wishes to. Well there is the question of the rights of the deceased. Do dead men have the right to not have their sperm taken and used? What about the rights of the future children? Do future children have the right not to be conceived if their biological father is already deceased?

By comparison, this woman and this woman make Nadya look like Mother of the Year. I haven’t decided yet what is the solution for preventing grossly irresponsible women from becoming mothers. Any ideas, besides withholding welfare handouts to women until they can prove they are practicing safe contraception? So sad.

I’m OK. Thanks for asking.

It’s good to know that my two-week absence from blogging has elicited such caring inquiries from many of you, asking about my well-being. Now I need to be a bit more honest. I’m actually NOT OK.

Well, to be more precise, I’m just about as OK as anybody else who lives in the United States, or even more specifically, in the state of California, which at the moment, is not that great. For the first time since perhaps the 9/11 incident, I am questioning the security of our way of life. To put things in perspective, if you were to ask me any time in the past five years this question: “How sure are you that in the next year, you, your friends and your neighbors will continue to have adequate food, water, electricity, lines of communication and safety from people with criminal intent?”, I would have thought “Huh? What kind of silly question is that?” and then answered 99%+ sure. After all, we live in modern-day America, not some impoverished third-world country and not in medieval times. However, if you ask me that same question today, I would say that I am only maybe 70% sure. The significance of this difference to me is HUGE.

We have grown to take for granted that we will always have access to food, water and emergency medical care and that we will always be able to count on the police to protect us from criminals. But reality reminds us that we can’t always do that. The two most glaring examples that come to mind are New Orleans during Katrina and LA during the riots. I learned a lot about the reality of life during Katrina during my trip to New Orleans for the ASRM meeting a few years ago. I befriended a taxi driver and some other locals and learned their war stories firsthand. The tales were surreal, giving me a grim reminder of how quickly life as we know it can revert back to the barbaric conditions of the Middle Ages. I’m also reading a fictional book, “The Tin Roof Blowdown“, which contains some of the most gory graphic descriptions of the chaos that occurred during Katrina.

Just as I went into medicine partially out of a burning curiosity about how our bodies work, I love to regularly research psychology, sociology, history and politics to satiate my desire of knowing how the world works, and I am now of the opinion that there is uncertainty, enough uncertainty that I am officially “concerned”.

Bear in mind that I look with amusement upon the globing warning alarmists or the religious zealots who predict the Apocalypse is coming this week or that week. But I am not fanatically ranting that the world will end tomorrow, or even next year. However, let’s just say that based on my own research AND based on what my own eyes see happening in the real world all around me, I know in my heart that this country is headed in the wrong direction.

Prior to this recent revelation, the life for my staff and me consisted of working our hardest for our patients, which for me, meant willingly giving up around 60 hours per week (including many weekends and some late nights) seeing patients, talking to patients, reading up on new advances and blogging. Some friends would feel bad that I worked so hard, but I reminded them that this was my calling in life. The reward of helping people have babies makes it intrinsically fun for me. Also, as a very important added component, in return for my sacrifices, I was shown gratitude by patients, who paid fair financial compensation so that I was now empowered to accomplish my many other goals and leisurely pursuits. It was a very fair system and is basically the American way, or at least, the American way that was originally laid out by the writers of the Constitution. Equally fitting, my patients were out there productively working their hardest using whatever their own talents were to make life better for THEIR customers, patients and clients. And as a result, they were paid adequate compensation so that they could pursue their goals for happiness, which just so happened to include doing medical treatment to have babies. In this system, everybody had the freedom to choose how hard they worked, with the corresponding reward in return.

However, as I mentioned earlier, things are changing for the worse. Now, I, for one, was  glad to see George W. Bush leave office. I disagreed with his specific policies which led to a further shift in the balance from individual freedom to excessive government power. I was optimistically open-minded (but cautiously skeptical) that maybe Obama’s promises of a “change” were more than empty political promises. But, BAM! Out of the gate, like a slap in the face, the new president showed his true self. My friends tire of me reminding them time and time again that we should judge people by their actions and not by their words. Well, the president’s first major action, deceptively called a “stimulus” package, is what he should be judged by, not by his sweet words of promising to make the country a better place for the people. No, I have not read the entire word-by-word rendition of the package. But then again, neither have any of the politicians who voted for it. However, I have studied it enough to render my strong opinion that it has little to do with helping people and more to do with increasing the massively growing domination of political power.

I have an interest in discussing these details in future posts and I plan to do so, even at the risk of you readers eventually telling me “Enough politics already! Get back to writing about fertility!”, but for now, I just wanted to share with you why I have been absent from blogging these past few weeks. I compare my recent world view to that of a not-entirely-unsuspecting New Orleans resident in the few days before Katrina. Sure, the news keeps warning us something bad MIGHT happen. Sure, we can see the wind and skies outside ourselves. But we don’t really know if, when or how hard it will hit. Meanwhile, though, we’re getting ready stockpiling food, setting up emergency generators, boarding up our windows and making contingency plans to get out of New Orleans. So, in this instance, how am I getting ready for a future collapse of this country? By researching and learning so that I can share information with others. Because, unlike a hurricane descending upon us, the upcoming social and economic disaster IS potentially preventable. I am hopeful that we, as a people can wake up and reverse the ever-growing shift from government dominance to individual freedom. We’ll see.

But don’t worry, I’m still practicing medicine. In fact, things have been busy and pregnancies have been coming in bunches (little bunches, not 8-fold bunches) and I still have lots of good stories and insights to share in future posts. I just realize now that we all have to prepare for a potential disaster that I hope will never come.