There are some in this world who claim that what I do is vile and despicable. No, I’m not manufacturing toxic waste that will decimate our environment and I’m not selling crack to destroy the lives of countless addicts. Instead, I’m responsible for helping bring something into this world that is much much worse —- CHILDREN!

Today, an article in the Washington Post describes how some people view parents with families of more than two children as being "showoffs". How have we gone from the normal traditional view that family and children are a good thing to this type of crazy thinking? I’ve certainly helped many patients have more than one child (often two at one time) and a lot of these families come back to discuss having even MORE children. I will have a thorough discussion with them regarding this big decision, making sure they look at the pros and cons. Then, I embrace their right to have a 3rd, 4th or even a 5th child if that is their choice. I also wholeheartedly embrace their right to stop at two. In fact, I strongly embrace the right for people who refuse to have any children at all. While I’m certainly generous with my embraces for people’s freedom to choose, I have no hugs to give to those who butt into other people’s lives with their own judgmental criticisms, or worse yet, who take actions to restrict other people’s freedoms.

Worshippers of the Immaculate Church of Dr. Al Gore don’t look at children as being human beings, but rather as vermin attacking the planet earth. They don’t care as much about the cute little footprints of babies’ feet as much as they care about the carbon footprint, whatever that means. Fine, they can rant all they want, as long as they don’t try to seize more and more power in controlling what other people do. In fact, I am actually quite enthusiastic about saving energy and about not being wasteful. My family is actively involved with the environment and we have started a worldwide recycling and waste disposal company. However, we do these by choice.

Then you have the Voluntary Human Extinction Movement that believes…well perhaps you should read for yourself. I know they claim to be just joking, but still.

Again, the beauty of our country, or at least, our country the way our founding fathers established it, is that everyone is entitled to their opinions as long as it does not infringe on the right of others. So we will just let them spout their views all they want.

Meanwhile, my patients, staff and I will continue to work together very hard, expending our blood, sweat and tears towards bringing babies into the world and delivering them into the arms of loving parents. We will just offer a polite smile to those who scream of the environmental atrocity that this represents as long as all they do is talk and scream.

However, if the crazies ever start taking ACTION to oppose us, such as China’s one-baby policy or laws banning IVF or regulations to restrict our reproductive options, then we will be ready to fight for our rights! It hasn’t happened yet in this country, but in Europe, patients are restricted in how many embryos they can transfer and what types of fertility options they can choose (such as bans on egg donation). A few determined European couples are coming to the US for fertility treatment to pursue their dreams of having a family, but if our own government seizes more power in this area, then we won’t be able to help them, let alone help ourselves.

Please excuse me now. I must get ready to unleash some more future polluters and resource consumers into this world.

Click here for episode 1

RECAP: Aimee and Boyd have been infertile for three years. They’ve finished basic testing under the care of their regular OB. They’ve also been tried unsuccessfully on six cycles of Clomid. Their only significant findings include minimal endometriosis and periods that are just a tiny bit longer than average.

What additional testing would you do?

Before we answer that, let’s think about the basic principles of medical testing. This applies to infertility testing as well as to ANY general medical testing. Here are the factors to consider before deciding on whether or not to get particular test.

USEFULNESS: This is defined by whether or not the test results will affect your decisions. Some tests fall in the category of "gee, that’s nice to know", but since it does not change management, there is little reason to do it.
LIKELIHOOD OF POSITIVE FINDING: How likely is it that the test result will come back abnormal? For example, if there is some tropical parasite that is the cause of infertility in one out of a million couples, is it really worth testing?
COST: How much will doing the test cost you in terms of $$$, as well as inconvenience and/or suffering and/or danger? If we want to get really fancy, we can even factor in the cost of following up a false positive. This is a huge issue in general medicine. The only way for doctors to safely defend against frivolous lawsuits in this country today, is to do a lot of testing, much of it unnecessary from a medical point of view, but crucial to do from a medico-legal point of view. Sometimes, the testing will falsely end up showing something that is not really a problem, sort of a false alarm (better known as a false positive). However, once you have that positive result in front of you, you are forced to address it, even if it means sometimes putting the patient through unneeded invasive surgery. This is not a big problem in infertility, but my heart goes out to my fellow physicians in other specialties who have to deal with this on a regular basis.

There are hundreds of possible tests that I can order, but for Aimee and Boyd, AT THIS TIME BASED ON WHAT WE KNOW NOW, there is no pressing reason to order anything else. This might change in the future as the situation evolves and we learn more things, but for now, it’s better to focus our energy and resources on treatment rather than testing.

Often, patients come to my office with an article printed out from the internet asking me to order this test that they read about. Most of the time, I will explain the rationale behind NOT doing it. Other times, I will explain the pros and cons and leave it to the patient to individually decide if she wants it or not.

I’ll give an example. There is a common blood test used to get a general idea of a woman’s ovarian reserve (to sort of get an idea of how old her ovaries are). This test is called a day #3 FSH. For reasons I won’t go into here, it is only accurate if done in conjunction with a day #3 estradiol (E2). So we abbreviate this combination of tests as a D3 FSH/E2.

So should we do this test on Aimee? Wouldn’t it be nice to get a better idea of her ovarian age?
Let’s analyze the logic using the principles mentioned above.

COST: This is a pretty cheap test, easily done for under $200. It consists of one poke to get the blood. It’s non-invasive and has virtually no risk associated with doing it, unless perhaps you pass out while getting your blood drawn and bonk your head. So cost isn’t much of a factor.
LIKELIHOOD OF ABNORMALITY: At Aimee’s age, it is highly unlikely she is menopausal or even near menopause, especially since she has regular periods, has positive ovulation testing, does not get hot flashes and has ovaries which are normal-sized. This fact alone makes me very unexcited about ordering this test on her.
USEFULNESS: If her FSH comes back sky-high (indicating she is menopausal), that would be a shock and would not make sense. But still, would it change our management? Do you think that if a test claimed she was menopausal, we would all just nod our heads sadly and agree to give up, or to move on to using an egg donor, all on the basis of a blood test? Of course not. Most likely, Aimee would not believe it and would still like to try with her own eggs anyway.

Therefore, if someone comes to me waiving a printout and screaming, "This website says all infertile women should have their FSH checked. When are you going to check my FSH?", next time I can just give them a printout of this article for them to read first.

In summary, there is no absolute MUST-DO testing to perform for Aimee. I will concede that anyone can try and make an argument for this test or that test, but it will fail to be overwhelmingly convincing if you consider the balance of cost, usefulness and likelihood of a positive. Again, this strongly applies to where we are NOW.  That may change, so that we might get some more tests on Aimee in the future, as things unfold. But I wouldn’t get anything just yet, which brings us to the next issue, that of choice of treatment options…

Click here for episode 3

This morning, I got a call from a pharmacist from a fertility pharmacy which supplies our patients with their medications. As much as my staff tried to triage the call, he refused to divulge any information to them and insisted on talking directly to me only. When I finally took his call, he informed me that a batch of progesterone had tested positive for potential non-sterility so they were issuing a voluntary recall. We had received one vial and he gave me the patient’s name. I was relieved it was her, because she is in the middle of stimulation for IVF, and therefore, she has not started taking her progesterone yet. The pharmacist said that they would immediately contact her about getting the vial back, so they can swap out a new one. I told him we will follow up from our end to make sure that goes smoothly.

I asked for clarification and learned a little bit more about their quality control process. Bear in mind that progesterone in oil is one that is compounded by the pharmacy as opposed to something like Gonal-F, Follistim or Bravelle which are produced in huge pharmaceutical plants. It was reassuring to know that even the smaller pharmacies had regular mechanisms to insure safety. He shared with me that 2% of each batch is routinely sent for testing. They do 14-day tests to check for contamination from bacteria (aerobic and anaerobic) as well as fungus. They also test the medication for potency. This particular batch tested positive for anaerobic contamination on day 13 of the 14 day watch-period. He said that usually, when a sample is truly contaminated, it grows out positive in the first 48 hours, before they even ship out the product.  But this one didn’t turn positive until day #13, making it likely to be just a false positive due to contamination at the testing laboratory. It was also unusual in that it was the anaerobic test that was positive. He added that since a small amount of an antibiotic agent is routinely added to the progesterone as part of the recipe, they don’t usually see anaerobic bacteria growing out. In any case, even though it was probably a false alarm, they were doing the prudent thing by recalling the batch.

It’s nice to know what’s going on behind the scenes to keep our medication safe.

(This couple has given permission to share their story. Their names have been altered. The dialogue words are not 100% exact, but are loosely reconstructed from memory, with the intent of conveying an accurate representation of their clinical story)

I introduced myself to my patients, AIMEE and BOYD on the day of their initial consultation. All I knew about them at this point, from observing them and from briefly glancing at the blank chart was that Aimee was 33, Boyd was 35 and that they were a healthy Caucasian couple who had been infertile for three years. I listened to their story.

AIMEE: We’ve been married for five years. At first, we weren’t ready to have kids right away, so we used condoms for a while and I was on birth control for a while. That was for the first two years. Since then, for the past three years, we’ve used no protection at all, but still haven’t gotten pregnant. Two years ago, we got tired of waiting and we went to see our OB. She’s been working with us, but she finally told us to come see you.

I asked them what they expected, back three years when they first started trying. Did they expect to get pregnant pretty easily?

BOYD: Well, we’re both pretty healthy and nobody in our families has ever had problems having kids, so we didn’t expect it would be THIS hard.
AIMEE: Well, I was 30 when we started trying. I’m 33 now and just getting a little impatient. I’ve always been good about finding information on the internet and I know all about charting. (She produced a packet of color-coded charts detailing her cycles for the past two years). I knew it might not happen right away, but three years is just too long.

I agreed.

Before delving into the medical details, we spent time on some additional background information. Boyd and Aimee had met at church and had gotten married after dating for one year. Aimee was a nurse and neither loved her job nor hated it. Boyd was a high school teacher. He also coached the baseball team. Their marriage was good and their lives were not stressful at all, other than for the fertility issue, and a brief stressful time when Aimee’s grandmother recently passed away. They have a Labrador retriever and they spend a lot of time with friends, although it has gotten a little tougher, since her friends all have babies now.

As usual, I explained to them the detective process behind finding the causes of infertility – how we look at the three key areas: SPERM problems. EGG problems. ANATOMICAL problems. Because Aimee and Boyd had been working with their OB already, most of the basic workup had already been done.

SPERM ISSUES:
Boyd has a BMI of 27 and is a healthy Caucasian male. His sperm was already tested.
Count: 190 million sperm per cc
Motility: 60%
Volume: 3.6 cc
Morphology not assessed. DNA testing not done.
COMMENT: Boyd’s test is normal. In fact, it is slightly above average.

EGG ISSUES:
Aimee has had regular periods all her life every 31 days. She has consistently had positive ovulation testing. Her BMI is 25.
COMMENT: No obvious problem here.

ANATOMICAL ISSUES:
An HSG had been done two years ago. Results show a normal uterine cavity and open tubes on both sides. They had brought their films as instructed by my staff. I reviewed the films with them and agreed that everything looked good. I also learned that Aimee’s OB had performed a laparoscopy on her a year ago and found some minimal endometriosis, which was then thoroughly cauterized. The tubal dye test confirmed that both sides were patent. Everything else had looked normal. This agreed with the HSG findings. Despite the endometriosis finding, Aimee has never had painful periods.
COMMENT: It’s not clear whether the endometriosis is the problem or just a red herring. The fact that it was just "minimal" suggests that is not likely to be a major factor.

Next, I reviewed what her OB had done since then. Aimee had taken Clomid already for six months with doses ranging from 50mg to 150mg. She had ovulated each time, or at least had a surge, according to her urine testing. They had made sure to get together the night of a positive test and also the night afterwards. After six cycles, her OB told her it was time to see me.

I performed an exam and ultrasound on Aimee and found nothing remarkable. Her uterus was tipped backwards, but contrary to myth, this should have no obvious detrimental effect on fertility. Her ovaries had estimated volumes of 27cc and 20cc, which I explained to her was very good and suggestive of young healthy eggs.

In summary, we have a couple in their mid 30’s with three years of infertility. The only finding of significance is the history of endometriosis found during the laparoscopy.

OK, class.
Are there any additional tests you would want?
What treatment options would you offer?

Click here for episode 2

Back in our ancestral times when our tribal forefathers roamed the savannah, food was scarce. Those who did behavior that increased caloric intake had a distinct survival advantage over those who were less enthusiastic about increasing caloric intake. This is why we all inherited genes that make us gravitate towards sweet foods and fatty foods. However, those very genes that gave a survival advantage back then in an environment of scarcity nowadays give us a survival and reproductive DISADVANTAGE. Sure, if we were all sitting around in semi-starvation mode, those of us who are more driven to seek something sweet to munch on would be healthier than those of us who continue to waste away. But our present day environment is not like that. Right this moment, I bet that pretty much all of you could get your hands on an instant 1000 calories within 30 minutes. I could probably do so within 30 seconds as long as I’m willing to brave raiding my nurses’s fridge. In this state of plenty, those of us who have the will power to RESIST sweets and fats end up healthier and more fertile.

In general the optimal BMI for fertility is around 21, according to a recently published book on Fertility and Diet. To get your BMI, you can use this online calculator. As women who suffer from PCOS often learn, obesity is detrimental to fertility by affecting egg quality and therefore embryo quality. If we are careful not to think in absolutes, we can then accept that many thin women get pregnant and many obese women get pregnant, many thin women are infertile and many obese women are infertile. But, IN GENERAL, your chances of conceiving and delivering a healthy baby get better as you get closer to a BMI or 20-24. In general, obese women have a higher chance of miscarriage and a higher chance of obstetric problems during their pregnancies.

Besides affecting egg quality, does obesity affect fertility in other ways? For example, does it affect the lining of the endometrium and its ability to sustain implantation? If so, is it the egg quality that is hurt by excess body fat, or is it the lining that is hurt by it? Well, in the past, we could not have answered this question, because all obese women would make "obese-woman eggs" and carry them in their "obese-woman lining". There was no way to separate the two. Now, however, with the advent of egg donation, we can study the effect of obesity on the lining separate from the effects of obesity on eggs. A recent journal article reports on findings that do not paint a ROSY picture for those who carry excess body fat.

In a recent paper out of Spain, researchers looked at women who were undergoing IVF with donor eggs. The beauty of this study is that the researchers were able to separate the effect of embryo quality from the effect of the body that was carrying the embryos. Because all the patients had an equal chance of getting good embryos from donors, then the differences in success rate, if any, could be better attributed to factors about their own bodies independent of any egg factors.

This ambitious study included data for 2656 cycles from the year 2001 to 2005. The overall pregnancy rate for these egg donor IVF cycles was 59% with a miscarriage rate of 16%. But there was a marked difference between women of different BMI groups. The study divided women into 4 categories of BMI: THIN = under 20. NORMAL 20 to 24.9. OVERWEIGHT 25 to 29.9. OBESE = greater than 30.

As you can see, those in the obese group did the worst overall with regards to the chance of taking home a live baby.

The researchers concluded three things.

• THE OVARY IS NOT THE ONLY FACTOR RESPONSIBLE for the poor reproductive outcome in obese women.
• UNDERWEIGHT WOMEN DO NOT SUFFER FERTILITY IMPAIRMENT for uterine reasons. While it’s true that underweight women do have more fertility problems than normal women, it seems that this is related to ovulation problems, which in this study, did not come into play.
• BEING OVERWEIGHT implies a more negative reproductive outcome. Therefore, women should be counseled about weight control.

Personally, my patients know that I am pretty aggressive about encouraging women to control their weight and get healthier when pursuing having a child. However, I do promise to do it in a non-nagging way .