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

The NON-OVULATOR:

You have to ovulate in order to have a baby.

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

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

EXAMPLES:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What kind of fertility patient are you?

1. The NON-OVULATOR
2. The UNEXPLAINED-INFERTILITY SUFFERER
3. ????????