Start here with Episode #1

Gabriela is back after being on metformin for 3 1/2 weeks. We hadn’t gotten any phone calls from her since she started, which to me means two things. One is that she didn’t have terrible side effects, because she would have called us. The other is that she never got her period, because she was supposed to call us when her period came, so that we could add the Clomid. For women with no periods on their own, metformin can help them ovulate and get regular periods. So for those patients, we are happy when they get their period. For Gabriela, however, she DOES get periods on her own, so her not getting her period was even more suprising.

Everyone knows that the most suspenseful part of reproductive endocrinology is after each IUI or IVF cycle, when patients come in to have a pregnancy test done. However, not many realize that the next most suspenseful scenario is probably the follow-up visit after starting a patient on metformin. Sometimes patients come back and report that they had horrible side effects of diarrhea and stomach upset. They didn’t notice any change in their sweets cravings or carbs cravings. They didn’t notice any improvement in their sluggishness and sleepiness, especially after meals. They felt horrible for three weeks and were tempted to quit the medication and not only that, they gained 2 pounds. This type of disappointing outcome or something similar happens in about 1 out of 5 patients, and for them, we usually discontinue the metformin immediately. The other 4 out of 5 have more promising results.

Gabriela’s was definitely one of the better responses. First of all, she had a huge grin on her face and surprised me by joking that she totally loved me. Before I could respond, she said that my giving her metformin was the greatest thing anyone had ever done for her and she explained that she felt better these past 3 1/2 weeks than she ever did in her life. Her waistline had shrunken and she was in need of some new clothes. Our scale said that she was at 154 pounds, down 6 from before she started the metformin. She says her husband and co-workers all were amazed at how much weight she lost in such a short time. When I asked her what she thought was the reason for her weight loss, she said it was definitely her decrease in eating sweets. She went on to share that after her last visit when she was first started on the metformin, she went home and did a lot of research on the internet and became even more convinced that she did indeed have PCOS. She also came to the realization that she probably ate a whole lot more sweets than she realized. At work, there was always some candy available and she unavoidably kept consuming it all day without thinking. However, ever since starting the metformin, she no longer felt the same uncontrolled urges. She would still sneak a bite of chocolate every once in a while, but that bite was enough to make her happy so she stopped. Whereas she used to be ready to take a nap after lunch every day, she now reports greater energy and no desire to nap. She hadn’t really increased her exercise habits any more than before, but she reported that she is looking for a personal trainer now and is inspired to start working out to further help her weight loss. And with regards to side effects, she had mild diarrhea for the first two days and no more since then.

I was thrilled for her. This was pretty much a perfect textbook response. I told her that her weight change and her dramatic change of symptoms were pretty convicing, and the right thing to do would be to keep her on the metformin. I refilled her prescription and told her that the next decision was whether to start fertility treatment with Clomid and insemination as planned or try on her own for a while. Because the metformin was making such a dramatic difference in her life, it wouldn’t be unreasonable to see if it also made the difference in her ovulation status. I felt she could give it maybe 3 more months on her own now. She disagreed with the plan. She was so excited about the progress that she wanted to just keep the momentum going. We therefore agreed that with her next period, she would come in and get started on Clomid. She thanked us again and happily left the office.

Weeks went by and still no call regarding her period. When she finally did call 3 weeks later, it was to tell us that she had done a home pregnancy test and that it was positive!! She had gotten pregnant on her own.

To briefly summarize after that, her pregnancy was monitored for the first trimester, while she remained on the metformin. After 12 weeks gestation, she graduated from our care and went on to her OB, who kept her on the metformin as well. She was later diagnosed with gestational diabetes and given a combination of insuilin and metformin throughout the pregnancy. She delivered a happy 8-pound baby boy.

Start here with Episode #1

To summarize, Gabriela and Ross have been infertile for a little over a year. They have finished an initial round of testing. The basic testing is not complete, because we still don’t know for sure that Gabriela’s tubes and uterus are normal. However, we have found another problem to address first, namely a severe case of insulin-resistance, one of the most classic components of PCOS. Ross’s sperm count is also on the low side, but certainly within the limits of normal. All other findings have been negative so far. It’s time to make some decisions regarding what to do next. We discussed the advantages and disadvantages of each choice, keeping in mind that these are not necessarily mutually exclusive, meaning it’s OK to come up with a plan that combines two or more of the following choices: 

• Continue trying on own for another 6 months. You might wonder why this is a choice. If patients come see a reproductive endocrinologist, doesn’t this mean they are ready to dive into full blown treatment? Well, not necessarily. I’ve had patients who felt a little anxious and didn’t want to wait a year to find out that there’s a problem. So sometimes, they come in after 5-6 months for a basic checkup. If the sperm is good and ovulation appears normal, only THEN do they feel comfortable going back to trying on their own. A lot of them will get pregnant on their own this way. However, Gabriela and Ross are not good candidates for this option. First of all, she is over 35. They have been trying over a year already AND they have a clear problem with regards to their insulin resistance. It’s possible we could try to address the insulin resistance problem and then let them try on their own, but they expressed that this option is not aggressive enough to their liking. They want to do more.
• Get an HSG to test the tubes. As mentioned in the previous episodes, we still don’t know for sure that her tubes are even patent. This is a reasonable thing to do. However, given the fact that there is another strongly suspected problem (PCOS and insulin resistance) and that there are no risk factors for tubal problems, I recommended holding off on this test for now.
• Take metformin. Given that her most obvious problem is the PCOS / insulin resistance, this is a smart choice. Metformin is the oldest drug used to address insulin resistance. There are new agents out now, but there is limited experience with those. Based on Gabriela’s dramatically abnormal blood tests, her symptoms and her family history of insuiln resistance, it is strongly suggested that she start a trial of metformin.
• Take Clomid. Metformin addresses the insulin issue. Sometimes, that is enough to get women to have good ovulation. Other times, it’s still not enough. In those cases, it is sometimes helpful to combine metformin therapy with Clomid, which is a gentle way to help stimulate egg development.
• Take injectable FSH. Injectable medications are stronger and more effective than Clomid at stimulating ovulation and getting a successful pregnancy. However, it is much more expensive and much riskier for getting twins or triplets. I advised her to not take injectables yet, but I forewarned her that if she doesn’t develop good eggs on Clomid and metformin, that we might have to add some injectables.
• Do insemination. Doing IUI increases the chance of pregnancy and is especially important for patients on Clomid in whom their cervical mucus gets adversely affected. This is best done in conjunction with ovarian stimulation using either Clomid and/or injectables.
• Do IVF. If the fate of the earth depended on this couple getting pregnant immediately next month, then we would do IVF as the ultimate best treatment. However, for this couple, it would be overkill and they should start with more conservative measures first.

After a lengthy discussion and answering all their questions we agreed on the following plan. First, Gabriela would start taking metformin. Then after three weeks, she would come back and discuss how it was working. Meanwhile, we also planned that with her next period, we would start her first treatment cycle with Clomid and IUI.

We were all satisfied with the decision. Gabriela’s liver and kidney function were checked already, so we knew she was safe to start the metformin. Her weight was checked and documented: 160 lbs. I warned her about the side effect of diarrhea that was commonly seen with metformin and advised her to start cutting back on sweets and fast carbs. She will be back in three weeks.

Click here for Episode #4

Start here with Episode #1

When Gabriela and Ross had their initial consultation, Gabriela was on day #5 of her cycle. Had she instead been near the time of her ovulation, I should have been able to see a maturing follicle on ultrasound rather than seeing the PCOS ovaries that I described last time. Also, had that been the case, we would have put off testing Ross’s sperm until Gabriela’s fertile period had passed, because even after patients come under our care, those that could potentially conceive on their own still are encouraged to keep trying while we work on getting their tests done. We would have wanted him to save his sperm for trying to conceive, and only after Gabriela’s fertile period has passed would we want him to produce a test sample. I can recall several couples who come for consultation and before all the basic tests were done, end up getting pregnant on their own.

SEMEN ANALYSIS: Anyway, Ross followed our instructions and waited for two days of abstinence before doing his sperm test. Since Gabriela was not expected to enter her fertile window period for another week, this was a good time to do the test without compromising their chances of conceiving naturally. He produced the sample at home using the sterile cup we gave him on their initial visit. After he dropped off his sample, I told him that I would examine it myself and give him a call later that morning. My staff took the sample to the back lab. They waited 10 minutes for it to completely liquify. Sperm undergoes certain liquefactory changes after it has been ejaculated and we usually wait for those changes to finish before testing it or before using it for insemination purposes. When it was ready, a drop was placed in the special chamber and I was called to examine it. Here are the results.
Count: 55 million sperm per cc
Motility: 49%
Volume: 1.3 cc
Morphology not assessed. DNA testing not done.

COMMENTARY: Most of time when I first test a husband’s sperm, I’m doing it as a screening test. In other words, I’m looking for a real obvious problem - either a very low count or terrible motility. There are more advanced tests such as strict morphology and DNA integrity that I save for later, only if needed. This is to help save money for the patient, because a basic count and motility is very economical, yet useful. The test costs about $80. So Ross’s sperm shows a count slightly less than the typical 80-150M/cc, but it is not below the cutoff of what we consider abnormal, which is less than 20M/cc. This helps guide us to focus back on Gabriela for now. Ross was very relieved to hear this.

GABRIELA’s BLOOD TESTS:
TSH: 3.0 uIU / mL = normal thyroid
Prolactin: 18 ng/mL = normal prolactin level
Fasting: GLUCOSE 105 mg/dL. INSULIN 14.9 uIU / mL
1 Hour: GLUCOSE 250 mg/dL. INSULIN 228 uIU / mL
2 Hour: GLUCOSE 159 mg/dL. INSULIN 189 uIU / mL
3 Hour: GLUCOSE 173 mg/dL. INSULIN 158 uIU / mL

COMMENTARY: Two specific hormonal problems that contribute to infertility are an underactive thyroid and an abnormally high prolactin. A lot of times, people with hypothyroidism have weight gain, a tendency to feel tired and swelling of the neck. People with severe hyperprolactinemia will notice milk coming from their breasts. Gabriela’s tests confirm that she has neither of these problems. However, her insulin testing is very interesting. The test is done as follows. Early in the morning, before eating anything, the patient has her blood drawn. Normal fasting glucose (blood sugar) should be below 105. Normal insulin should be below 15. Then the patient is given a drink consisting of 100g of concentrated sugar water. Blood is drawn every hour for the next three hours. The results are interpreted based on how high the values are AND on how they relate to each other AND on how they change over time. Gabriela’s tests are extreme. Rarely will you see such high insulin values, especially her 3-hour value. These results strongly suggest an abnormal sugar metabolism due to inefficent insulin action, also known as insulin resistance.

The initial round of tests was very fruitful and helps guide our next steps. We reconvened and began an in-depth discussion regarding which one or more of the following seven choices to do next.

CHOICES:

• Continue trying on own for another 6 months
• Get an HSG to test the tubes
• Take metformin
• Take Clomid
• Take injectable FSH
• Do insemination
• Do IVF

Click here for Episode #3

Gabriela and Ross (they asked me not to use their real names) came in to see me for help in conceiving. They had discovered me quite randomly, having been referred by Gabriela’s co-worker’s brother’s wife, who had been our patient and who had successfully given birth to twins conceived by IVF. Gabriela was 36-years-old and described her work managing a business as being very stressful. Ross, who was 41, described his engineering job as being laid-back and interesting. The two of them got married a little over a year ago, after having met at a relative’s wedding one year before that. They described their lives as being secure and happy, other than for their being childless still. They never used any contraception after their marriage and while they didn’t predict for themselves to get pregnant instantly, because of their age, they didn’t really expect that they would still be childless a year later. They were resigned to keep patiently trying on their own, until fate intervened and Gabriela struck up a conversation with her coworker who was happily sharing the story of his brother’s newborn twin baby girls. Gabriela says she took it as a sign and had excitedly gone home that day and told Ross they were going to go see a fertility doctor ASAP.

INITIAL CONSULTATION: They came together for their first visit. After getting acquainted, we got to work gathering clues to help solve their problem. I began, as I usually do, by tackling the three primary areas where fertility problems could lurk - the husband’s genetic contribution (the sperm), the wife’s genetic contribution (the eggs) and the playing field where the two meet (the wife’s cervix, uterus, Fallopian tubes and pelvic cavity).

SPERM ISSUES: Ross had never been involved in any pregnancies in his life. This was not a surprise, as this was his first marriage and he had not had any situations in his past where he could have fathered a pregnancy. He was healthy, other than for having a BMI of 29, which he described as being typical of how heavy he had been for the past 10 years. There was nothing new or different lately with regards to his level of health. The couple described having sex once to twice a week. The sex was not painful nor difficult in any way. In the past few months, they had started charting Gabriela’s temperature and using ovulation kits to help with the timing. He was not on any medications. I told them it was good news that they didn’t have any risk factors for sperm problems. However, the next step would still be to check a semen analysis. They were reminded that any perfectly healthy male without any past record of having gotten anyone pregnant could still have a surprisingly bad semen analysis. The only way to know is to test. PLAN: Semen Analysis.

OVULATION ISSUES: The next question to address was Gabriela’s ovulation status. She reported that all her adult life, she had regular periods that came every 28-32 days. There were three months in which she did ovulation kit testing. It showed positive each time. She answered no when asked if she ever noticed milk coming from her breasts. (This would be a warning sign for elevated prolactin hormone, another contributor to infertility). She reported a normal energy level and no symptoms that would be suspicious for an underactive thyroid, except for one. She reported gaining 20 pounds in the past three years. When questioned further, she expressed frustration and puzzlement about her weight. She was not eating any differently than when she was younger. She had not been more physically active in the past than she is now. So she was especially perplexed about the weight gain. I asked her if she had any diabetes in her family and she replied that her mother had been diagnosed with diabetes at age 40 and her sister had had diabetes of pregnancy.  I told her that she does not fit the classic description of PCOS, because she is having regular periods and having positive ovulation testing. However, there are many clues that point to her having the insulin resistance component of PCOS so I told her we would do some testing. PLAN: Check thyroid status. Check for insulin resistance.

ANATOMICAL ISSUES: On ultrasound exam, she had a normal uterus. It was not unusually large, nor were there any fibroids seen. The uterine lining was seen very clearly. Her ovaries were interesting in that they had a classic PCOS appearance, with many strings of cysts around the periphery. I told her that at some point, we might have to check if her tubes are clear, but since we have some easier things to address first, that we would put off the testing (with an HSG) for now. The plan might be different had she had any high risk factors for tubal problems, such as extremely painful periods, previous pelvic infection or previous pelvic surgery, but without those, given the rest of her situation, an HSG was not the first priority at this time. PLAN: Nothing at present.

So, to summarize at this point, we have a nice couple with no past pregnancy at all for either partner, who have been having regular unprotected sex for over a year, but yet, remain infertile. We explored the three basic areas of fertility problems and came up with a plan for further testing on two of them, while postponing any action on the third. The couple will have the proper tests and come back to discuss the results afterwards.

Click here for Episode #2

During the initial consultation visit, I ask my new patients (both husband and wife) what kind of work they do. First of all, this helps me form a clearer mental image of who they are. It also helps me screen for any unusual stress-filled situations in their lives that need to be addressed in order to help restore their fertility. Sometimes, I get a general answer that needs clarification such as "I work in computers", "I do import/export" or "I’m a consultant". They then can clarifiy for me by being more specific, "Well, I sit at a desk all day answering calls from angry impatient people who have just suffered a car accident and I work to process their insurance claims", or "I fly around the country and evaluate a company’s computer software needs and then I assemble a team to customize a package for them and then we all go there and train them to use it as quickly as possible"

When people ask me what kind of work I do, I can answer their question many ways. I can answer very generally and say I’m a doctor. Or I could be a bit more specific and say I help people get pregnant. Or I could be even more specific still as describe my exact daily actions, as I did in a previous post.

However, if you really want an exact, analytical, more useful answer I would best reply by saying I work to achieve the general goal of helping people have babies and my work can be thought of as being organized into individual cycles. This last part is important to recognize and I will elaborate shortly, But before we go there, let’s discuss another example. If you were to ask what Kobe Bryant did for work, the general answer would be that he plays basketball. However, a more specific analytical answer would be that he works to get a basketball into a designated basket as often as possible while trying to prevent the same ball from going into the opponent’s designated basket. That is the defining concrete goal of his work. All the other stuff such as the passing, the rebounding, the dribbling, the shooting drills during practice, the conditioning, the strategy sessions with the coach studying game film are all just supporting actions that help modify the main task which is to drop the ball into the basket.

In a similar vein, my main work task is to do successful treatment cycles. All the other stuff, such as ordering diagnostic tests, counseling patients, training my staff, keeping my office infrastructure running, studying to keep up on the latest in my field and taking measures to avoid burnout for me and my staff are just supporting actions for the main agenda, which is to have a successful treatment cycle.
Below is a summary of the different types of treatment cycles we do:

• IUI CYCLES: The standard simple treatment cycle is an intrauterine insemination (IUI) cycle. This consists of purifying a husband’s sperm sample and transporting the final improved concentrated product deep into the wife’s uterus on the optimal day (or even at the optimal hour).
• IVF CYCLES: This is the gold standard most advanced form of treatment. This consists of taking the eggs out of the wife’s body and directly putting it together with her husband’s sperm to create embryos. Then, the best-looking of the embryos are selected and placed directly into the uterus.
• NATURAL CYCLES: While over 90% of the cycles we do are either IUI or IVF, there are some patients for whom we help get their eggs ready and monitor to tell them the optimal timing. Then they just proceed to have sex naturally and get pregnant that way.

As I said earler while the heart of what I do is centered around the above-mentioned cycles, I do a lot of supporting actions as well, actions that help improve the success of the actual cycles:

• CONSULTATION: One of the most important skills for an RE is to decide which type of cycle is best for each individual patient and when to perform them. Some patients are better off trying on their own for a little longer. Others should start by trying IUI. Others are best served by going directly to IVF. Sadly, still others are best advised to give up and look at alternatives such as adopting or quitting all together. Making the optimal decision regarding which option is best requires gathering information through interviewing the patients, examining them and ordering tests.
• SURGERY: Many times, the success of a cycle depends on critically improving the condition of the patient’s uterus, where the baby is destined to live. Some common crucial ways of doing this including removing any offending tumors or polyps from the cavity and removing any diseased Fallopian tubes that might have a tendency to leak embryotoxic fluid into the cavity and kill the embryos.
• MAINTAINING INFRASTRUCTURE: In order to conduct my treatment cycles, I need to have a physical location with propertly functioning equipment and well stocked supplies. More important, I need a team of top-notch staff. Much of my time is spent recruiting and training a great team and making sure that I can do my part to fulfill their needs and wishes as well, so that they can come to work every day with enthusiasm and happiness, ready to do their best for our patients.
• EDUCATION AND SELF-DEVELOPMENT: Since I am responsible for coordinating all this in the first place, I take on the burden of always learning more. This is not a minor point and is arguably one of the most important things a good reproductive endocrinologist does.

There you have it. So the next time someone asks me what kind of work I do, depending on my mood, I can give them the abbreviated "I’m a doctor" answer or I can direct them to this web page for the long detailed version.

Two of my core beliefs are currently having a knock-down drag-out war with each other. One belief is that if you correctly choose a career that is fun, stimulating, enjoyable and spiritually rewarding, then you will never really "work" a day in your life.  I still hold this to be true. The other belief is often known as the law of diminishing returns.  This law states that each additional unit of something valuable or desired is valued or desired a little bit less than the previous unit. If you give a boy who loves chocolate a large slice of cake, he’ll be happy. A second slice will still make him happy, but not as enthusiastically as the first one did, and so on. Giving him that 37th slice won’t make him much happier than receiving that 36th slice. You get the point. This is a fundamental law of life, so to say that this is one of my beliefs, is like saying I believe in the law of gravity or in the law of 3+6 = 9.

So why do I bring this up? Well, I love my work. I love solving mysteries as to why a certain couple is not getting pregnant. I love coming up with what I believe to be the best strategy to help them conceive. I enjoy reading and learning new developments because I know that my time spent studying can potentially make the difference between success or failure for one of my patients. I especially love sharing in the excitement of finding out a positive result!

However, as much as I love all this, there reaches a point where each additional consecutive hour doing it begins to bring a little less joy and satisfaction than the previous hour, especially as much as it robs from my opportunity to do something else. This past month, many more new patients came to the practice than would be expected given our usual monthly average. Now I was pretty sure that the reason for this was that it was January, when there is almost always a large rebound in activity after the holiday season lull. Plus, we also had some other unusual things to take care of, as I have mentioned in previous posts. This greatly added to the illusion of feeling like things were even busier. However, the pace seems to have let up only slightly in February. So yesterday, on President’s Day, when most of my friends are at home doing nothing, my staff and I saw about 30 patients. The sense of accomplishment we got after taking care of the #30 didn’t really feel as rewarding as it did for #20. No surprise.

So what’s the solution to this dilemma? I’ve been trying as much as feasible to take a long break during lunch to either nap, go to the gym or go home and play piano (I live less than 5 minutes from my office). Each of my staff also get a staggered 90 minute lunch break, although most times they don’t take it, preferring the option of working straight through. That doesn’t work well for me, though as the times that I’m forced to work straight through, I find my productivity slowing greatly by late afternoon.

There is a cost associated with taking a long lunch break. At least one night out of each week (like now) and a few hours each weekend, I have to come back to the office after hours to catch up things. This is when I will review the old medical records from patients who failed at other practices. This is when I will catch up on journal articles. This is when I blog. However, I can come and work for an hour, go have dinner with a friend, and come back and do another hour of work. For me at least, it’s definitely more painless breaking it up into chunks like this.

I often share a reminder about the law of diminishing returns with my patients by discussing the difference between the freedom of childlessness and the joy of parenthood. When a couple first gets married, they cherish the freedom of not having any children to burden them. However, each successive year of childlessness has decreasing appeal, until the couple begins to essentially wish for the chance to give up their freedom. Then the baby (or babies) come into the picture and life is completely different, because it seems every waking moment now belongs to your child. From time to time, you will find yourself longing for a brief taste of your past lifestyle. Trust me. Again, I’ve heard this time and time again from patients after their treatments succeed and their child-free years are a thing of the past, forever.

Here are some tips to consider:

• During this time while you are focusing on trying to conceive, make the most of your freedom. Have a date night. Enjoy your reading time. After your baby is here, you will look back and miss these chances.
• Make a conscious effort, even AFTER the baby arrives, to dedicate some time to yourself on a regular basis. This could take the form of one spouse taking the kids for half a day while the other gets his/her free time. Better yet, at least once every two weeks, leave the kids with someone you trust and rekindle the habit of having date night for just the two of you. I know babysitters are costly, but you’ll find it’s worth it.
• One interesting tip I hear over and over again from couples who have done repeated treatments and now have several children (including some twins maybe) is to arrange regular one-on-one "dates" with each child. So one weekend, dad takes the 6-year old boy to the baseball game and the other three kids stay with mom. The next weekend, mom takes one, and just one, of the 4-year-old twins to the zoo. There will be unique value gained from these experiences, so as to make it worth the added effort.

A few hours of a novel experience have much greater value than several hours of the same routine over and over. So, now all of you who find yourselves in a rut of diminishing returns, please go out there and do something different from whatever you’ve been doing over and over these past months.

Phone conversation between one of my staff and a patient’s husband who was a former competitive athlete and who admitted to taking "a whole lot of steroids" in the past.

STAFF: Hello, Mr. ___ . This is ___ from Dr (IVF-MD)’s office. We have the results of your sperm test back from this morning. I’m calling you now to let you know that the count is normal, but the motility is a little low.  The doctor will be calling you shortly to explain the significance of all this and to answer your questions. OK?
PATIENT: OK. Ma’am, can I ask you a question?
STAFF: Sure, I’ll try.
PATIENT: My buddy told me that it was the guy who determines whether the baby is a boy or a girl. Is that true?
STAFF: Well, if you mean is it the sperm that controls whether it’s a boy or girl, yes. If it’s a sperm with an X-chromosome, it will make a girl and if it’s a sperm with a Y-chromosome, it will make a boy. The woman’s egg always provides an X-chromosome.
PATIENT: Oh (pause). So it IS true? That it’s the guy that controls the sex of the baby?
STAFF: Yes, basically.
PATIENT: Oh OK. So how do I do that?
STAFF: Do what?
PATIENT: Pick the sex of the baby.
STAFF: Er…well actually, you can’t choose. It’s just that the sperm is the determinant.
PATIENT: I don’t get it.
STAFF: It is the sperm that determines the sex, but you can’t voluntarily control that. (Thinks to herself "Well not without IVF/PGD anyway", but decides not to say it)
PATIENT: Well, we’d like a boy. So can you tell me how I can determine a boy?
STAFF: Er…you have to just hope it’s a Y sperm that gets the egg.
PATIENT: (Pause). You mean my friend was lying?
STAFF: Well..er…(pause). Yeah.
PATIENT: Ha! That’s what I thought. He does that to me all the time. OK, thank you ma’am.
STAFF: (sighs) OK, sir. Have a nice day! Please call us if you have any more questions.

I get a few emails asking me what brand of ovulation kit or what herbal fertility potions I recommend. Sometimes the questions mention specific trade names, as in "What is your opinion on Brand XYZ fertility vitamins?" It puts me in a difficult situation, because most of the time, the truthful answer is that it will not help your fertility, but it won’t do much harm either except to your bank account. However, I can’t bring myself to say bad things about something unless of course I need to protect my readers and patients against blatant harm.

I once had a situation where a company that made a particular nutritional supplement that was allegedly helpful to sperm sent their pharm rep to my office to detail the product. I was asked if I regularly tell my patients about it. I gave a truthful answer which is that I will occasionally mention it if a patient specifically asks, but I will also tell them it has no proven universal benefit. If they want to try it, it might help, and there’s probably no harm other than a big waste of money and time. Well, a few weeks later, I was speaking with a referring OB/Gyn who told me, "Oh, by the way, I heard that you are recommending "product XYZ" to your patients."
"No. What ever gave you that idea?", I replied.
"The rep visited my office and told me that you specifically recommend it. Do you really think it’s helpful?"
I was angry for all of twenty seconds and was contemplating calling and chewing out the rep, but I decided it was not worth my time. Instead, I stopped mentioning their product and even got to the point of telling patients who ask, "I personally don’t have a good impression of that company’s ethics" and that usually ends the conversation.

Patients put trust in me and if I praise a particular product, they expect that I have researched it and that I would enthusiastically recommend it to my own family members.  I think professional endoresments or celebrity endorsements still work a lot better at manipulating gullible consumers’ decisions than they should, but the public is getting smarter over time. After all, does anybody really think that T-Mobile is a better cell phone plan just because Catherine Zeta-Jones researched it thoroughly and swears by it? Should I step up prescribing Viagara because baseball player, Rafael Palmeiro and NASCAR driver, Mark Martin both love it so?

Here is a funny blog article that shows to what extreme professional endorsements insult the intelligence of the consumer.

Keep a lookout in the future. If I tell you about a great new fertility product, it will either be because I believe in it, or because the company paid me $200 and a steak dinner to say so.

Hello Dr.

I’ve been on two cycles of clomid (50mg/100mg) but the follicles never matured =(. I haven’t been diagnosed with PCOS and have ovulated on my own in the past. My RE did blood work on cd10, 12, 14 and my estrogen levels were 55, 57, 65 and then 54. What could be the reasons the follicles weren’t maturing and what causes the estrogen level to remain low. I understand estrogen level has to be above 200+.

Thanks for your help.

Jen
Orlando, FL

Monitoring of Clomid cycles is helpful because even if you don’t get pregnant, it’s helpful to know if you’re at least ovulating. To monitor with blood tests rather than ultrasounds offers little advantage, unless of course, the capability of doing ultrasound is not available. I’m not sure if in this case, there were ultrasound exams done in addition to the estradiol tests, but it doesn’t matter. The obvious conclusion is that even with the Clomid, the follicles are not developing. Clomid works by raising your own natural release of FSH (Follicle-Stimulating Hormone) from your pituitary gland (a small organ that hangs from your brain). For some people, this small boost in FSH is enough to get the follicles growing. For others, it’s not enough. This is a common problem. So what is there to do?

Some possible approaches to help achieve ovluation when you get to this point are:

• INCREASING THE CLOMID DOSE: I personally don’t favor this approach. I don’t remember the last time I had someone who didn’t do anything on 100mg and then went on to ovulate and get pregnant with just a higher dose of Clomid.
• ADDING OR COMPLETELY SWITCHING OVER TO INJECTABLE MEDICATIONS: This is a popular tactic and works well. The danger is that sometimes, it works too well and you end up with so many follicles that you get twins (or more). The other drawback is that it is more expensive than Clomid. However, I will repeat that it works very well.
• LOOKING FOR OTHER CAUSES: If someone is not developing follicles on Clomid, it would make sense to look at other issues such as an underactive thyroid, elevated prolactin, elevated male hormones or worst of all, diminished ovarian reserve.
• TREATMENT OF INSULIN RESISTANCE USING METFORMIN: If patients show clues suggestive of insulin resistance (unexplained weight gain, chronically feeling tired, strong carbs or sugar cravings, family history of diabetes, preferential distribution of fat around the waist, extreme post-meal sleepiness, or documented high insulin to glucose ratio on challenge testing), then metformin can not only help them ovulate, it can help them get healthier.
• NORMALIZATION OF BMI: This goes along with the concept of getting healther. A good target of BMI is between 21-23. I’ve had patients who successfully lost weight and then started to respond to the Clomid, or in some extreme cases, started to ovulate on their own and get pregnant, even without Clomid. To figure your BMI, you can use this online calculator.

Jen, it is good that you have ovulated on your own before. However, if you don’t ovulate more consistently, you will fall into the situation where on months that you DO ovulate, you have a chance of getting pregnant. But, on the months that you fail to ovluate, all you end up doing is wasting one more month of your reproductive years. I’m curious what test results your doctor has found that rule out insuiln resistance. A lot of times, if you just test fasting levels rather than checking challenged levels using a glucose drink to stimulate insulin activity, you will easily miss a diagnosis of insulin resistance. As you can see, there are still many options you can take at this point. Have a good discussion with your doctor regarding which of these tactics to try next. And let us know as soon as you succeed. Good luck!

This weekend, a friend invited me to play in a poker tournament on behalf of a charity that gives support to crime victims. It was organized by an exceptional group of women who regularly devote their time and energy to doing philanthropic activities. I didn’t do well in the tourney, but was glad to have participated. It gave me a chance to play poker again, — something I hadn’t done for almost a year. This morning, while trying to answer a question posed by one of my patients (who turned out to be a poker fan herself), the idea of cards was still fresh in my mind, so I was inspired to answer her question using a poker-related analogy.

 "Julia" (the patient who asked me not to use her real name) is a 28-year-old software consultant who has been married and trying to conceive for two years now. She does not have regular periods and clearly does not grow eggs on her own. She came to see me for help. We agreed to start very conservatively with a monitored cycle of ovulation induction. Last month, on Clomid 50mg, she produced one lovely follicle and got together with her husband at the perfect time. As excited as she was that she finally ovulated, it was devastating when she she found out that she wasn’t pregnant. Her question was a common one. If there was an egg and if the sperm is normal and if they got together at the correct time and if her tubes are clear, then why didn’t she get pregnant? What went wrong?

Well nothing necessarily went wrong. The official medical answer is simply that conception is a probabilistically-determined event. What does that mean?

Let’s play a game. Imagine that you have a deck of cards which will be used to magically determine your fertility. Every month, this deck of cards is thoroughly shuffled and cut and you are asked to draw one card. If that card is a heart, then congratulations! You’re pregnant and it’s time to celebrate. However, if that card is anything other than a heart, then your period will come and you will have to wait until next month to try again. Actually, this is a fairly accurate mathematical representation because the monthly probability of conception for a normal fertile couple is very close to 25%. This means that when an egg is released and the couple have regular sex at random times about twice a week, the chance of them getting pregnant that month, if they are normally fertile, is 25%.

So month after month, women all across the country who are trying to conceive shuffle their decks and draw their cards. Some of them draw a heart on their first month. These are the lucky ones that go off the pill and get pregnant right away. Others have to play this game for 6 or 7 months before they finally draw their lucky heart. Remember that about 85% of normally fertile women will get pregnant within six months.

Pretty simple so far? OK. Let’s go on.

When you are playing poker in any semi-official capacity, the first thing you do before starting the night is to fan out the cards face up so that everyone can verify that we’re playing with a normal deck. There should be 13 spades, 13 diamonds, 13 clubs and 13 hearts. Real life is not so neat. Yes, it’s true that while a couple of NORMAL fertility does get to play with a standard deck, there are couples out there who have DECREASED fertility, so that instead of having 25% hearts in their deck, they might have to play with a rigged deck that has only 8% hearts. So what happens to these unfortunate couples who have a substandard deck of cards? Well, some of them will be lucky and totally beat the odds by drawing a heart on the first try, despite the chance being only 8%. Because all they know is that they got pregnant right away, they will falsely go through life believing that they have normal fertility. The only time that they begin to suspect otherwise is later, when they find themselves taking a long long time to conceive their SECOND child. Of course, not all couples will be so blessed as to hit on the first try. The rest of the couples with the 8% deck might take as long as 15 months to finally draw a lucky winner, especially if their luck is a little below average. By this time, most of them will have already started toying with the idea of seeing a doctor. In practice however, many couples with a 8% deck will conceive on their own. It will just take them longer than the usual easy six months.

A VERY UNFAVORABLE DECK

Let’s go on. There will be still other couples who are even less fortunate and they will have to play with only a single heart in the entire deck, thus giving them a 2% chance of conceiving. This can be for many reasons. Either the husband has a terrible sperm count (but still has SOME sperm), the wife has really poor egg quality (but still drops a normal egg on a rare occasion) or the pelvis is pretty scarred up with endometriosis (but not entirely scarred up). These couples with a 2% deck usually find themselves playing for several years before drawing their one lucky heart. Most of these couples will rightfully get impatient, tire of the game and come in to get medical help. But remember that over the years, with advancing age, your deck of cards will change to have fewer and fewer hearts. So some of these couples might tragically take so long to conceive that they no longer have any hearts in their deck and thereby wind up forever childless.

Before we talk about how fertility treatment can help increase your odds of drawing a heart, let’s discuss another group of patients, those who don’t ovulate at all. There are some couples who are POTENTIALLY very fertile. His sperm is great. She is young and her egg quality is wonderful. Her Fallopian tubes are stellar. These couples actually have a deck stacked in their favor, meaning they might even have 30% hearts in their deck. However, due to ovulation problems, they don’t release an egg consistenly every month. One common way to know this is if a woman describes her periods as being so irregular that she only has two periods per year. When periods are this irregular, you don’t know for sure if they are even ovulatory cycles or instead are completely anovulatory cycles that just happen to end up with some odd bleeding. So here we have a couple with a deck packed with hearts, but they are not allowed to draw a card at all because of the lack of ovulation. Well, maybe they might get to draw 1 or 2 cards per year if they can ovulate once or twice, but their good deck is not being utilized to its full potential because they don’t get a monthly draw the way other couples do. For these couples, it is especially dangerous if when getting treatment, they go from ovulating zero eggs per month to ovulating, let’s say, six eggs in one month. In that case we would be taking their supercharged deck that normally sits idle each month and then all of a sudden drawing six cards at one time. The danger is that you’ll get a hand that consists of three or more hearts, meaning you get triplets or more. Yikes. This is the reason that we are especially cautious with completely non-ovulating women. For them, when we start treatment, we like to begin with helping them make just one or two eggs. If after a few careful cycles, they demonstrate that they can make eggs, but still not get pregnant, then that calms our fears a bit about them having a super-charged deck of cards. Then, we slowly increase the number of eggs until they finally get pregnant.

WHAT KIND OF DECK IS YOUR DECK?

If you are still with me, let’s go on to discuss another commonly asked question. How can I know how fertile we are? In other words, how can we figure out if we have a great 30% deck or a bad 2% deck of cards? Is there a way to peek at our deck? The answer is no. We can’t determine for sure what your deck is like, but we can over time, make some pretty accurate assumptions. In science, there are two ways to conclude something. One is by logic and the other is by evidence, meaning we believe things that make sense and we believe things that we actually observe.  If you were to ask me to guess what your monthly odds of conceiving are, ie. what  your deck of cards is like, I would start out assuming a standard deck (because most average people are … well … average) and then I’d make an adjustment for age. If you are older, I would mentally imagine fewer hearts in your deck. If you are younger, I would mentally picture there being more hearts. Then we start the game and begin to gather the evidence. Let’s say the first month that you stop using any form of contraception, you fail to get pregnant. You have drawn a card and it’s not a heart. You put the card back. No big deal. Just a bit of bad luck. Then, next month, you shuffle the deck and draw another card. Still no heart. Mind you that you don’t get to actually look at the deck at any time. Your only actual knowledge about the contents of the deck is based on the cards you draw. In other words, your only information about your odds of getting pregnant comes from observing whether or not you get pregnant each month. Third month, you draw a card. Yay! A heart. Your assumption that your deck is a normal one is probably correct. In any case, you don’t care, because you’re now pregnant and have other things to start thinking about. But what if things happen differently? What if your third month is also negative, as are your 4th through 24th months? This means you have now gone two years without getting pregnant. Are people going to tell you that you’re deck is normal and you’re just unlucky or just not timing it properly or just stressing about it too much? Maybe. But they would be wrong. The most logical conclusion is that there is something wrong with your deck. If you go two years without conceiving, you must face the fact that you don’t have a normal 25% monthly chance. There might be very few hearts in your deck, or heaven-forbid, no hearts at all!

This nicely illustrates the principle of how I would estimate your chances of conceiving. First, I make certain estimates regarding your deck of cards based on your age, lab tests and whatever other clues I can gather. And then I study what your past history of card draws has been.

OK, enough for now. It’s time for me to take a very short break to play some online poker on Facebook. Next time, we’ll continue and describe the ways we can help you cheat and turn things to your advantage so you will be able to draw your first heart sooner.