Click here for episode 1

The pregnancy test was negative again. As sad as this is, let’s temporarily depart from the obvious emotional aspects of this failed cycle and tackle the decision process scientifically.

Caroline is 35 years old. She was presumed to not have ovulated regularly by virtue of her consistently negative ovulation tests. Her husband’s sperm looks fine. In the past few months, with the help of medication, she has been able to successfully ovulate. In three treatment cycles, she grew 0, 1 and 3 mature follicles, respectively. She still has not had an HSG to test her tubes.

What are our choices?

1. Give up and/or consider adoption.
2. Suspend treatment until another 20 pounds of weight loss
3. Move on to IVF
4. Get an HSG
5. Try another IUI cycle
6. Try homeopathic methods

Out of all these choices, my personal favorites  would be #2, #4 or #5 followed by #3. But a lot would depend on Caroline and Darryl’s personal preference.

Choice #1 would be understandable, but not recommended. Sure, they have been through a lot. They have spent a lot of money. They have spent a lot of time. Caroline has endured many injections. All this has resulted in no pregnancy. It HAS, however, resulted in progress. We now know that Caroline can ovulate. She has lost a lot of weight and is physically feeling better than ever. Caroline and Darryl made it clear to me that they had zero intention of giving up.

Choice #2 is reasonable. Caroline has shown evidence that she can get healthier. Whether or not the metformin gets the credit for her amazing weight loss is not the point. The point is, she is succeeding. So whether this is due to the medication or just to a new mental attitude, we are just happy that it’s going so well. Caroline and Darryl expressed that they wished to keep going without resting.

Choice #3 would be an even better idea if they had insurance coverage for IVF or if they had $13K in discretionary spending available. While I think that their chances of a successful IVF cycle are excellent, I am still optimistic of her chances with IUI, given that she has only failed with four eggs total so far. I would however, like some assurance that her tubes are patent and her uterus is normal.

Choice #4 is probably my top choice. An HSG will reassure us that Caroline’s tubes are open and that there are no polyps or fibroids in the uterus. If the test is normal, then we can return to do another IUI. Caroline, however, was very against this. Her reasoning, while not scientifically sound, was certainly understandable. She stated that she knew of three people who had excruciating pain with their HSG’s and she didn’t want to go through that at this time. I reminded her that those friends of her are clinically very different from her. In my experience, I’d say 1 out of 10 women have severe suffering during their HSG’s. I make it a point of surveying my patients after their HSG’s and the majority have mild discomfort only or no discomfort at all. In Caroline’s specific case, there are no risk factors for her having bad tubes. She has no history of a sexually transmitted disease. She has had no previous surgery. She does not have painful periods at all. In addition, after her IUI’s, I would do an ultrasound trying to see an image of her uterine cavity after it was distended by the IUI specimen. This allowed me a peek at her cavity and gave some additional evidence that it was normal. Because of all this, I gave in to Caroline’s request to postpone her HSG until after one more IUI cycle.

Choice #5 then becomes the most likely option.

Choice #6 is something that we’re already doing. By losing body fat and improving her overall wellness, Caroline is helping boost her chances of pregnancy, both naturally and with treatment. With regards to taking herbs or nutritional supplements, there is no proof at all that this would be worth the money.

After going over all the pros and cons, we decided to put off the HSG and do another IUI cycle. This time, we’re going to use 300 IU, which is a very high dose for an IUI cycle. However, everything we’ve learned from the previous failed cycles adds to the evidence that this is a good plan.

Day 3. Baseline scan shows no cysts. Caroline started on Bravelle 300 IU daily from day 3 to day 7.  Before we reveal what we actually saw, I should add that an ideal finding on this date would be 3-5 follicles of size 12-14mm. This is what we actually saw on day 8:

RIGHT OVARY: Not clearly seen
LEFT OVARY: (8×8) (7×7) (6×6) (7×6)
It’s only a little odd that we can’t see her right ovary clearly today when we’ve seen it easily in most of the previous scans. Sometimes things shift and move. The very fact that it’s hard to see suggests that there are no large follicles contained within it, and for all practical purposes, that’s all I need to know for today. This reassures me that we don’t need to drop her dosage for safety reasons. I keep her on the same dose for day 8 to day 11 and bring her back on day 12. This is what we saw.

RIGHT OVARY: (11×9)
LEFT OVARY: (13×11) (9×9)
Estradiol = 125 pg/ml

Yikes! This is extremely disappointing. Caroline is on her highest dose ever, and yet her stimulation is less than her previous cycle, when she was on a lower dose. Because the lead follicle on the left has made it to 13mm, we forge ahead, rather than cancel the cycle. I keep in mind that Caroline is still taking her injections in her arm, which is a little more brutal than the usual shots that go into the fat pad of the stomach area. She bravely continues 300 IU from day 12 to day 14 and this is what we see on day 15:

RIGHT OVARY: (12×11)
LEFT OVARY: (22×20) (17×17)
Today, there is some relief that we have not one, but two mature sized follicles. I give her 10,000 IU of hCG that afternoon and bring her back for an IUI in two days. We have a discussion about how it sometimes happens that a higher dose results in a lower stimulation. We also keep in mind that it only takes one follicle to get a pregnancy. I remind her that there have been times when patients fail to get pregnant with 5 follicles and 4 follicles in their first two cycles, only to get pregnant on a third cycle when there is only one follicle. Anything is possible.

Two days later, we inseminate with 27M total motile sperm, confirm that both follicles are gone and we begin the waiting game.

Click here for episode 8

In-Vitro Fertilization is the gold-standard treatment for infertility. Even so, it is nowhere near 100% successful. In general, it’s about 20-50% successful and in a very good case scenario, one can have expectations of 60-80% success. Because it does represent the ultimate in treatment, it is especially devastating when a cycle fails.

I often have to help my patients face this problem. The most common scenario is when they come to me after having failed IVF at another program. We have a policy of offering a reduced fee to those who can prove they have failed IVF elsewhere. This tends to draw more than our fair share of difficult cases. But these challenges are a very welcome intellectual puzzle for me. I analyze these cases in the following manner.

First, we acknowledge that there are three things that determine the success or failure of an IVF cycle:

1. Quality of Embryos
2. Receptivity of Uterus
3. Embryo Transfer Technique

In basic terms, the three questions are as follows. Are any of the embryos perfect enough to become a baby? Is the uterus a friendly enough home for the embryos? Are the embryos placed gently into the right location?

Whenever I get a patient who has already failed IVF at another program (or with me), I go over these three questions. To break it down even further, there are four things that determine the quality of the embryos. And there are two things that determine the receptivity of the uterus:

1. Quality of Embryos
   1. Characteristics of the Patient
   2. Stimulation Protocol
   3. Embryology Lab
   4. Luck or Randomness
2. Receptivity of Uterus
   1. Macroscopic Factors
   2. Microscopic / Hormonal Factors
3. Embryo Transfer Technique

So if your IVF cycle was successful, then congratulations! You probably have your hands full with you baby (or babies) right now. However, if your cycle failed, watch for future posts as we discuss some of these specific topics.

Click here for episode 1

Caroline and Darryl have been trying to get pregnant for almost two years now. The most obvious problem is Caroline’s failure to ovulate. First, she was started on metformin to correct address her insulin resistance. Then she was tried on a combination cycle of Clomid and injectables. She didn’t grow a mature follicle. Next cycle, it took quite a bit of injectable medications, but Caroline ovulated. We even did an insemination to give that egg the best chance.

However, according to today’s blood test, Caroline was not pregnant.

It is very normal to have fleeting thoughts of giving up when things don’t go our way. Caroline had worked hard to lose weight (now down to 228#), spent hundreds of dollars on medications, endured the daily needle injections, had gotten her hopes up with the egg that we saw, only to have it all end with a negative pregnancy test.

We reconvened to talk about options.

ME: How are you feeling?
CAROLINE: Trying to see the bright side. (smiling) I really thought this was going to do it. I mean seeing that egg on ultrasound made my eyes tear up, with joy. I realize now that one egg isn’t guaranteed to give a baby and I’m prepared to get more eggs until one takes.
ME: Hmmm. You have a pretty good attitude. And you’re right. While it’s optimistic that you got the one egg last cycle, it’s not always enough just to have one. So now we have a few choices. We can do another cycle, with a high enough dose to get multiple eggs. We can check your tubes to make sure that they’re open. Or we can wait for you to get into better shape. You’re doing a great job of that, by the way.
CAROLINE: Well, Darryl and I discussed it. We want to try one more cycle. If it doesn’t work, we might take a break. So can we be aggressive?
ME: Of course. I’m going to start you on 225, because that’s what got you going last time. Remember we don’t want to give you too much, or else you’ll end up risking having TOO many babies.
CAROLINE: Honestly, I wouldn’t mind having triplets and just getting this all over with.
ME: A lot of women say that. Many of them don’t really mean it. Haha.
CAROLINE: I know. I know.

We started the cycle.

Day 3 baseline ultrasound:
RIGHT OVARY: Nothing.
LEFT OVARY: Nothing

Good start. From her friends and online friends, Caroline knew the disappointment of finding a cyst on the baseline scan. Luckily, this wasn’t one of those months. The next decision is what dosage to start her on. Last month, nothing really happened until we raised the dosage to 225 IU, so this month I decided to start her off with that. Another tweak is the decision to have Caroline take the injections into her arm IM. I’ve tried this in the past on women with a lot of abdominal body fat with mixed results. It was certainly worth a try. There just might be better absorption of medication when given this way. Caroline took 225 IU of hMG from day 3 to day 7 and returned on day 8. This is what we saw.

RIGHT OVARY: (9×9) (9×9)
LEFT OVARY: (10×10) (9×9) (8×8) (8×7)
Estradiol = 200 pg/ml

This was a great start! There appeared to be six promising follicles. If the estradiol level would have been a bit higher, I would have been tempted to drop her dosage. But I would have met with some great resistance from the patient. Caroline was stoked and eager to continue the same dose. I warned her that if all six grew and we wound up with some additional follicles, then she would be at big risk for twins or more. She acknowledged the risk and we trekked forward. On day 8 to day 11, Caroline took another 225 IU daily. This is what we say on day 12:

RIGHT OVARY: (21×17) (11×11)
LEFT OVARY: (19×18) (18×17) (9×9) (9×9)

I was very happy with the three mature follicles. Caroline was disappointed. She had wanted all six to grow. I reminded her that this was a great stimulation and furthermore, it was SAFE! She eventually cheered up, especially after we checked her weight and found out she was down to 226#.

I launched her ovulation with 10000 IU or hCG and brought her back in two days for an IUI.

Again, it was a great sperm sample (20M total motile sperm) and again, US showed that she did indeed ovulate everything. Caroline had a lot of questions right after the IUI. She wanted to know her restrictions on activity, like what she could eat, how much she could lift and how much stress she could permit herself to be exposed to at work with her students. After we covered all her questions, I added that if she didn’t get pregnant this cycle, I would give serious thought to getting an HSG to check her tubes.

Click her for episode 7

It’s probably no coincidence that the UK’s policy removing anonymity from the sperm donation process has resulted in a shortage of donated sperm. It’s also probably no coincidence that we RE’s in the US are seeing more and more patients who come to us from Europe for their treatment.

In the US, anonymity is safe for now, but it’s something that could change.

Click here for episode 1

UPDATE: Caroline and Darryl are infertile. Caroline has had regular periods, but her ovulation kits don’t turn positive, leading us to suspect an ovulation problem. She underwent one monitored cycle where she received medication to help her ovulate. In that cycle, she not only took Clomid, but also injectables. Sadly, she did not grow follicles well. She comes back to discuss the game plan for the next cycle.

It is helpful to discuss things in terms of options. One option is to give up and do no further treatment. That is always an option. If we were to take this path, Caroline would be banking on the hopes that she could someday ovulate on her own and get pregnant naturally. The odds of this are low, but might improve as long as she continues to lose weight. In any case, it would likely take a very long time to have good news, if any.

A second option is to increase the dosage and try again. The natural evolution of treatment choices would dictate giving injectables from the beginning rather than to start with Clomid.

A third option is to increase the dosage but to patiently wait until Caroline loses some significant weight. This is not a bad plan, with the only downside being the delay in treatment.

After some discussion, Caroline and Darryl opted to do another cycle immediately.

Carolyn came in on day #2 of her cycle for a baseline ultrasound. It showed that both ovaries were quiet and without activity. She then started taking 150 IU daily of Bravelle. We switched from Gonal-F to Bravelle this cycle for the simple reason that the company was running a special discount program. It was simple. Buy 20, get 10 free. Caroline would need it, because she was taking 2 x 75 IU amps daily ( 75 IU x 2 = 150 IU).

Caroline took 150 IU of Bravelle from day 3 to day 7. This is what we saw on day 8:
Right ovary: (7×7) (6×6)
Left ovary: (7×7)
Lining: 9mm triple layer
Estradiol = 82 pg/ml

At this point, it’s still uncertain how things will progress. We forged ahead with a dose increase to 225 IU daily from day 8 to day 10. This is what we saw on day 11:
Right ovary: Nothing
Left ovary: (14×12) (10×9)
Lining: 9mm triple layer
Estradiol = 95 pg/ml

Usually, when a follicle makes it to 14mm, that’s the point where it is likely that it will continue to grow, so as painstakingly slow as this was all going, there was hope. The daily injections were not painful, but the fact that it was costing over $100 in medication (not counting the discount) every day was emotionally painful. But if those two follicles would keep growing, then next visit we will start thinking about when to trigger the follicles for ovulation. The fact that the estradiol level barely went up didn’t make me too happy, but we kept going. Caroline took 225 IU of Bravelle from  day 11 to day 13. This is what we saw on day 14:
Right ovary: Nothing
Left ovary: (17×14) (11×11)
Lining: 11mm triple layer

This was it! The one follicle was almost at a mature size. I told Caroline to grow the follicle one more day with 225 IU of Bravelle and then I had her launch her ovulation with 10,000 IU of hCG at 5PM. She came back in two days for her IUI. Darryl’s sperm sample was excellent, with 28M total motile sperm injected. Ultrasound right after the IUI showed that the follicle was gone. Successful ovulation!

For once, maybe the first time in her life, Caroline had ovulated! We waited 12 days for her pregnancy test.

Click here for episode 6

In a previous post, we discussed the general concept of TRUST. It might be helpful to read that before reading today’s piece. Now we’re ready to zero in on the specific topic of trusting doctors.

How do you come to trust your doctor?
Well, how do you come to trust ANYBODY? Simple. You take a tiny step, observe the other person’s actions and adjust accordingly.

So why is there the phrase "Trust me, I’m a doctor". Maybe there are some people who argue that there’s something inherently different about doctors. Some people might be falsely lulled into thinking that the rigorous selection processes of medical schools someone weeds out the less ethical people. Bah. Maybe some people think that the fact that we take an oath makes us more trustworthy. Even more ridiculous.

In reality, doctors should be treated as anybody else is. They SHOULD NOT BE, and ARE NOT, universally trusted any differently than those in any other profession. Just as it is not right to automatically MISTRUST people in certain professions such as used car salesmen, criminals or lawyers. We all have built-in biases based on two things - what we have personally experienced in the past and what we’ve been taught or told by friends, family or the media.

I’ve learned a lot over the years when I chose to go into business with a dentist, lawyer, accountant, hairstylist whatever. I try to slowly get to know them and give them a chance to prove themselves. If they do right by me, then I come to trust them more. If they do me wrong, then the trust erodes or even completely disappears. I’ll usually give people the benefit of a doubt at first, within the limits of what I have at risk. If I’m going to try some strange new restaurant, i don’t ponder it and research it. The risk of a unpleasant dining experience is a minimal loss. But if I’m going to entrust my entire retirement money to a certain investment, you can be sure that I’ll research it thoroughly.

Granted I realize that seeing a doctor is a much bigger investment than choosing a hairstylist, but my argument is that it’s not necessarily all THAT different. Some of my patients say they researched for weeks before deciding to make that first appointment with me. That is commendable, but not absolutely necessary. Is researching for 20+ hours really a smaller price to pay than a few hundred dollars consultation fee? I guess it’s different for everyone. My practice even offers a free meet-the-office session every month, where potential patients can come visit our office and meet us face-to-face. We don’t have many takers, but those who do end up visiting us eventually come see us as patients, almost universally.

Think of the way that trust develops. Trust is earned (or not earned) by people’s actions, not by their words alone. When deciding whether to enter into a business relationship with a lawyer, accountant, doctor, investment advisor, contractor, gardener, babysitter or whatever, we start out listening to their words, their promises. But it’s only one encounter at a time that we slowly begin to trust them.

I can speak best for my own field. When you are looking for an RE, all them will say on their website certain catch phrases such as “top expert” and “personalized care”. Some may even give objective data such as success rates, but those are often misleading or even outright lies. Words mean little in the end, because while the truly expert and truly caring practices will say that they are expert and caring, so will the poor-service places, and the average-care places. Everybody makes the same good-sounding claims.

This makes it tough for patients. You would think then that the only reliable way to know if you like a particular doctor is to try out his services, then to try out another doctor’s services and then to compare. This is not as difficult as it initially sounds and often times it is well worth the effort. I’ve had many patients come to me from other practices. I will hear from them what specifically dissatisfied them about the last doctor. When it goes the other direction and patient leave our practice to go elsewhere, I often try to find out what we could have done differently to keep their loyalty. Often, it’s something we can’t control, such as our being too expensive or too far in distance. But if it’s something that I can change, that I just didn’t think of, then it’s a positive thing because it helps guide us on how to further improve our practice. It’s especially satisfying when patients leave our practice to try another and then, end up coming back.

Our success these past years has depended a lot on word-of-mouth referrals. In this situation, we have gained the trust of person A because of the good care and good service we gave them. Then if there is a person B who trusts person A (either a friend or relative), then when person A gives their word of approval, person B comes to us already having some trust in us, sort of the Transitive Property of Trust. So this is the other way trust is earned, not by personal experience but by what someone whom we trust tells us.

Next time you do business with someone, whether it be your accountant, gardener or doctor, ask yourself whether or not your trust is being earned appropriately.
Do they things they say turn out to be true?
Do the promises they make turn out to be fulfilled?
Do you feel they have the appropriate balance of putting your best interests before theirs?

If not, then explore the options of seeing a different provider. You’ll be glad you did.

Click here for episode 1

Summary: DARRYL and CAROLINE have been infertile for 19 months. The most likely cause is Caroline’s failure to ovulate. This was suspected because her ovulation testing always remained negative, despite the unexpected finding that she has fairly regular periods. Caroline’s ovulatory problem seems to be a result of PCOS and the effect of PCOS on Caroline’s body weight. We have a plan in place to tackle the problem from both directions. Caroline is actively losing weight, through diet, exercise and metformin. In addition, we are going to give her ovulation medication to further help her ovulate. Although she has already failed several cycles of Clomid with her OB, she requested to do one more Clomid cycle, in the belief that her decreased weight and her successfully being on metformin will give a different result this time.

I picked up the chart. We still defy the temptation of going to electronic medical records, and there are many good reasons for us to keep from doing so. I saw that Caroline had gotten her period five days ago and was here for her baseline scan. The purpose of today’s ultrasound is to make sure she doesn’t have any cysts at the moment. The presence of cysts would make it wise to wait another month before doing a cycle.

I walked into the room and Caroline greeted me enthusiastically, sharing that she had lost more weight and was now down to 234#. I congratulated her and proceeded to do the ultrasound. Both ovaries were quiet. The lining was thin. No real surprise. The results were exactly as we hoped for.

As I was about to leave the room, Caroline asked if she could talk to me. I told her I would have to do two more ultrasounds, but I would be available after that.  She dressed and met me later in the consultation room.

CAROLINE: Guess what! I’ve changed my mind about the Clomid.
ME: What do you mean?
CAROLINE: Remember you didn’t want me on just Clomid. I’m sick of not being pregnant. I want to move forward and be more aggressive.
ME: So do you want to start injectables today?
CAROLINE: Can we do the combination that you talked about?
ME: Absolutely. We’ll start you on 150mg of Clomid and then add injectables.
CAROLINE: Perfect!
ME: What made you change your mind?
CAROLINE: I never told you, but i have a cousin on the East Coast who is trying. She failed Clomid for four cycles, like me, but on her first cycle of injectables, she just got pregnant.
ME: Great for her! OK, let’s try and get good results.

So, DAY 6 to DAY 10, Caroline took 150mg of Clomid. Starting day 11, she took 150 IU of Gonal-F. On day 14, she returned for an ultrasound. This is what we saw:

RIGHT OVARY: Nothing
LEFT OVARY: 7mm follicle. 6mm follicle.
LINING: 11mm triple layer.

While this was disappointing, it was not surprising. There are many different things that we could have seen today. It was possible that she would have so many eggs that we would have to consider cancelling the cycle. She could also have had 3-5 promising follicles, which is what would have been ideal. Instead, she had two follicles, both of which were quite small. I checked an estradiol level on her. It was 122 pg/ml. This led me to give her a few more days. I increased the dosage to 187.5 IU per day. With the Gonal-F or Follistim pens, it’s possible to easily do intermediate dosage, rather than be limited to multiples of 75 such as 75-150-225-300. She continued on this for three more days and then checked again.

RIGHT OVARY: Nothing
LEFT OVARY: 7mm follicle. 6mm follicle.
LINING: 11mm triple layer
E2 = 145 pg/ml

It was time to cancel the cycle. Yes it was good that we did injectables this time, not because it did anything positive, but because we saved ourselves from wasting any more time.

Caroline wound up negotiating with me to try 2 more days of injection, since she had enough left in her remaining Gonal-F vial to do so. I gave in to her request. She continued on 187.5 IU for three more days and then returned for ultrasound.

This is what we saw.

RIGHT OVARY: Nothing
LEFT OVARY: 9mm follicle. 6mm follicle.
LINING: 11mm triple layer.
E2 = 170 pg/ml.

We sadly cancelled the cycle and waited for her to call with the next period.

Click her for episode 5

Click here for episode 1

There are many things I love about being an RE, one of which is the chance to participate in the transformation of peoples’ lives, as they go from having no baby to suddenly becoming happy parents. That one is pretty obvious. Besides that, there’s another thing that I like and that’s the daily suspense. You see, every day, we run pregnancy tests to see if our patients are pregnant or not. There is no way to predict ahead of time who is going to be positive and who is going to be negative. Often, patients whose cycles seem like sure things, end up not being pregnant. Other times, patients whose cycles offer small hope end up defying the odds and winding up pregnant. This daily feature of not knowing the results really keeps things fresh and interesting for me and my staff.

Another thing that keeps us in suspense is the metformin follow-up visit. I would estimate that about 3 out of 4 first-time metformin patients demonstrate some very positive changes in their lives with regards to weight loss, increase in energy level and sometimes even normalization of their periods together with spontaneous ovulation and pregnancy.

Three weeks earlier, when Caroline was first started on the metformin, we had checked her weight in the office. Initially, she wasn’t thrilled to be weighed, but eventually gave in. Her weight had been 245# on our scale. As I picked up her chart today, for her follow-up visit, I was pleased to see that her weight today was down to 240#. With that in mind, we began our conversation.

ME: So, Caroline, I’ve asked you back today to discuss how you are responding to the medication I gave you three weeks ago, the metformin. How have things been different since then?
CAROLINE: Well…I must admit you were right, when you said that it could help me lose weight. I saw that I’m 5 pounds less than the last time I was here. I feel it too.
ME: That is wonderful news. So if you had to say, what do you think are the reasons for this weight loss? Are you eating fewer carbs?
CAROLINE: Well, I definitely don’t crave carbs and sweets as much. I mean I’ll still have a little bit, which is still enjoyable, but then I no longer want to have much more.
ME: And any side effects?
CAROLINE: Hmm.. the first two days, I got bad diarrhea, just as you predicted, but it really was just for those first two days. I think I lost the most weight during those first two days, because I felt miserable and didn’t feel like eating anything. However, even after the diarrhea cleared up, I still continued to lose weight. So happy! Oh and you know what? I really noticed a difference. I don’t get so sleepy in the afternoons any more. It’s been wonderful.
ME: Good.
CAROLINE: But I still have a long way to go. I know you’re going to say that.
ME: Actually, I was going to talk with you regarding our options at this point. But first of all, are we in agreement that the metformin is doing well for you and that we should continue it?
CAROLINE: Definitely!
ME: Then the next question to ask ourselves is what to do regarding getting you pregnant. We still have the task of making sure you ovulate. Now one thing to keep in mind is that there might come a point where you lose so much weight that things start working right and you begin to ovulate regularly. Of course, if we had all the time in the world, this is definitely one option, just to keep you on the metformin, allow you to regulate your carb intake the way you have been doing so well and allow you to ramp up your exercise habits. Then we just sit back and watch the progress. However, for several reasons, we DON’T have all the time in the world. Therefore, I have a suggestion.
CAROLINE: I’m so glad you said that, and that we’re not just going to count on weight loss to solve our problem. I mean, I’m happy with these past three weeks, but look at me. I still have a lot of weight to lose. And I’m old.
ME: You’re not older than a lot of my patients, Caroline. Come on. But I’m with you in that we should be proactive. OK, let me share with you what we can do. One. We can give you gentle pills to try and help you ovulate, or we can give you more expensive, but more powerful injectable medications. It’s basically a choice between Clomid or injectables. Either choice is reasonable for you, although I’m a little more in favor of the injectables, because of the very fact that you have already failed Clomid.
CAROLINE: OK, doctor. If you will, let me tell you what Darryl and I discussed. We really feel that the metformin is doing something. Now let me ask you, is it possible that my body has now become more normal because of the metformin and that I might respond to the Clomid now even though I didn’t respond to it before?
ME: Hmmm, that’s the big question. It’s certainly possible, but again, I think the odds would be better with injectables, or at least a combination of Clomid and injectables.
CAROLINE: Well, how about this? I really was gung-ho and ready to be aggressive, but I want to try one cycle of Clomid. Is that OK? One cycle.
ME: It’s your choice, Caroline. We can be as conservative or aggressive as you like, within reason and doing one more cycle of Clomid falls in the range of what I consider within reason.
CAROLINE: Great.
ME: One suggestion is that we monitor it. That way, we at least know if you are ovulating or not.
CAROLINE and DARRYL look at each other and nod.

The plan was set. Caroline would call us with her next period and we would bring her in for a baseline ultrasound before starting her on a monitored cycle of Clomid. With the conclusion that the metformin was a success for her general health, I refilled it for another four months. In addition, I chose to repeat the liver test to confirm that she did not have any unusual hepatic reaction to the metformin. The couple left my office very encouraged.

Click here for episode 4

Click here for episode 1

Darryl and Caroline are here for their first consultation. After breaking the ice and warming up to each other, we tackled some of the potential problems that could be contributing to their infertility. One red flag was the fact that Caroline has never had a positive ovulation test, despite taking the tests properly for six months now. The ultrasound exam further supported the diagnosis of Polycystic Ovarian Syndrome. After the US exam, we went back to the consultation room and continued our discussion.

ME: Caroline, when we first started today, you had mentioned something about the experiences you had with other doctors. Do you want to fill me in on that?
CAROLINE (sighs): OK, but it’s not easy for me to talk about it. However, if it will help you…When the first year had gone by, I went to my family practice doctor. She basically told me that it was unhealthy for me to have a baby and I should not even think about it until I lose some weight. That clearly was not the type of help I was looking for, so I went to my OB. She too, said the same thing, only maybe not so bluntly. She did try and help me with some Clomid. I took that for three months maybe four but it was making me nauseous and it wasn’t making me pregnant.
ME: Were you monitored for those Clomid cycles? Do you know how many follicles you made?
CAROLINE: No. No monitoring. But I did do ovulation kits and still, they never turned positive.
ME: So what was your OB’s plan?
CAROLINE: Nothing. Just Clomid and telling me to lose weight. I wasn’t too happy, needless to say. So THEN, I saw an ad on the internet for a reproductive endocrinologist. I went to see him and right away, the first thing he wants to do is IVF. I was happy for once that someone didn’t give up on me just because of my weight.
ME: I see, so did you actually do IVF?
CAROLINE: I almost did. But something just didn’t feel right. Maybe you can explain it. (turning to Darryl)
DARRYL: Yeah.  He really didn’t bother to ask many questions. We almost got the feeling that he was just out to sell his IVF and we don’t have insurance coverage for it. I know a bad salesman when I see one.
CAROLINE: I felt the same way. And that’s when by God’s grace, I ran into my co-worker showing the office her new baby pictures and that’s when I started talking with her and decided that I should hold off on the IVF and come get your opinion first.
ME: Who was the doctor that you saw, if I may ask?
CAROLINE: Dr. ____. Do you know him?
ME: I do. Well, I actually know pretty much every RE in Southern California. We probably all know each other. The reason I asked is that there are many excellent RE’s out here and we often see each other’s patients for a second opinion. If one of the ones whom I trust says you need IVF, I would want to explore more why they would think that. But the one you saw is not one whom I know and trust very well, so I’m going to discount what they recommended for now. That’s not to say that we won’t be talking IVF someday, but there’s certainly a lot we can explore and try before going that route.
CAROLINE: Well, I’m glad that I did come see you. I feel very comfortable right now.
ME: Good. Well, let’s summarize what we know right now, OK?
CAROLINE and DARRYL nod in unison.
ME: You’ve been trying to get pregnant for a year and a half. The sperm looks fine. There is no obvious suspicion of a tubal problem (although we don’t know for sure yet that your tubes are open). The big suspicion is an ovulation problem. You’ve tried Clomid 3 or 4 months and didn’t get pregnant. Based on your ovulation kit testing, it doesn’t seem like you even ovulated. Therefore, it would make sense that our best strategy for now, would be to focus on helping you ovulate. Does that make sense?
CAROLINE (smiling and nodding): Completely.
ME: There are a few obvious things that we need to rule out, like thyroid disease, but I’m going to go over these records (pointing to the stack of papers they had brought) after we are done talking and see what’s been ordered in the past. I might get some more tests after seeing what’s missing. You said you never had a blood test in which you were given a sweet drink to drink, right? So we’re going to start with that.
CAROLINE: Doctor, you know what’s best, but if it’s OK with you, I’d rather not waste an entire morning getting this test. Can’t you just give me that medicine that you were talking about?
ME: Well, let’s talk about that. The medication is called metformin, or Glucophage. Have you heard of it?
CAROLINE shakes head no.
ME: It’s a medicine that is often given to diabetics and it’s quite safe compared to something like insulin, which is another medicine that diabetics take.

We spent 15 minutes discussing the side effects of metformin, as well as all of the possible benefits. Our plan was set. Caroline would have some blood tests drawn today to confirm the safety of taking the metformin. These were tests of her liver and kidney status. She was to try the metformin for three weeks, after which we would meet again to go over her progress.

Click here for episode 3 

Dear Dr.

Eve

Dear Eve,

The whole concept of natural cycle IVF might sound good on paper, especially the way you presented it, but there is one huge catch! It would be feasible if the three-month process you have described really constitutes one IVF cycle. In that case, the balance of cost and success rate would be very good. However, the big problem is that what you have described is not ONE IVF cycle, but rather THREE IVF cycles, so now the cost becomes astronomical in comparsion to one good stimulated IVF cycle.

The success of IVF depends a lot on how many eggs you can get. So let’s take an example. Let’s suppose that an IVF cycle without ICSI costs about $9000 and the medications cost about $3000.

For a healthy 32-year old such as yourself, let’s assume that you will make an average of 13 eggs with mild to moderate stimulation and 1-2 eggs with a no-stim or Clomid-stim cycle. So let’s compare the yield.

One Conventional Stimulated IVF
COST = $12000.  Yield = 13 eggs.

One Natural IVF Cycle
COST = $9000. Yield = 2 eggs.

Two Natural IVF Cycles
COST = $18000. Yield = 4 eggs.

Three Natural IVF Cycles
COST = $27000. Yield = 6 eggs.

Now some say there might be a difference in egg quality between stimulated eggs vs natural cycle eggs, but this is so controversial as to having some people on both sides of the argument. Some would argue that eggs from stimulated cycles are BETTER than eggs from natural cycles and others would argue the opposite.

In either case, unless the disparity were huge, you’re still looking for all practical purposes that a conventional stimulated IVF cycle will still give you the best value for your money.

We can also look at the common sense assertion that things that work tend to be more popular. You would just ask yourself, if natural cycle IVF is so much better than stimulated IVF, then why are more than 95%+ cycles in this country done with stimulation rather than without?

Thanks for the great question. Whatever decision you make, I hope there is a baby in your future very soon!