Before starting a stimulated treatment cycle with clomiphene citrate (Clomid), with injectables or with a combination of both, we customarily do a baseline ultrasound sometime around day #1 to day # 5. What are we looking for with this? Actually, it’s more of what we’re NOT looking for. We’re specifically looking to see that there are no cysts. In other words, we’re looking to see that there are no follicles that are beyond a certain size. For clarification of these terms, you may consult this post.

Remember that this early in the cycle, all the follicles for that month should be very small. I tend to use 13mm as a cutoff, but I have colleagues who have a slightly smaller or slightly larger cutoff. The rationale is that if we already see something larger in size, then the cycle will be suboptimal because that cyst can grow and disrupt the course of development of any new upcoming follicles.

Another purpose of this visit is to discuss the exact formula or protocol to use for the upcoming cycle. There have been times when a patient came in to start injectables and after discussion relating to her particular case, we change our minds and decide to do Clomid-only or a combination of Clomid with injectables. We may make our final decision regarding doing IUI or just timed intercourse. We might have some adjustments regarding the dosage, as well.

By the way, sometimes for the sake of convenience, we can actually do the baseline scan a few days BEFORE the period starts. Let’s say for example that the patient is here to pick up some medications or settle her account and hasn’t started her period yet. However, she is expecting it to come any day now. We can do the baseline ultrasound today; then she can call with her period and get instructions on when to start her meds.

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.

After just one glass of wine the other night, I had a strange dream. It provided the inspiration for this post.

Imagine the journey for a baby as being like a race. The runners begin at the starting point, staring up into the distance at a road that stretches as far as the eye can see. The runners are told that their baby might be waiting for them somewhere up the road. It could be near. It could be far. Or it could be not at all. The runners can make the choice of when they wanted to start up the road, but the longer they waited, the farther away their babies might get moved. So one by one, couples made their decision to start walking up the road. The luckiest couples walked a few hours and came upon their babies right away. They rejoiced, took their babies into their arms, laughed about just how easy it was and left the road to enjoy a brand new life with their child. The rest of the couples congratulated them and continued walking. Some of them had to walk for a long time, but just as they were tiring out and almost giving up hope, they arrived at their babies. They, too, took their babies into their arms and breathed a sigh of relief that they were able to finally reach their goal. They gave thanks and were much more grateful than the first couples, but they realized that they still had it pretty easy. The remaining couples continued walking and walking and still, no baby. Some of them decided that they would remain patient and just keep walking, for as long as it took. Others quit the race and gave up in exhaustion, sadly resigning themselves that they would never be united with their baby. Still others decided in frustration that this was not working, so rather than keep walking, they stopped and rented horses. Now they were galloping along at about five times the speed of the walkers. For about half these couples, this strategy worked and they reached their baby. They realized that had they kept walking, they probably would have eventually reached their baby anyway, but it would have taken years. They were glad they took the horses instead because they were able to get there much sooner and even had time to get back on their horses in the future to go for a second or third baby. However, not all the horse riders met with success. Some of them kept riding and riding and still didn’t see any baby in sight. A few of these gave up, returned the horses (after all, feeding them was getting a bit expensive) and went back to walking. Still others got fired up and decided to look for better alternatives. They found out that they could rent cars. Now, they were roaring down the road at 70 mph and most of them happily reached their babies, but only after covering a huge stretch of distance. Of course, there were still some couples who had walked until they had blisters on their feet, rode horses until their butts ached and drove and drove until they could no longer afford the car rental and still, never reached their baby. Fortunately, not too many people fell into this category. The irony of it was that some of these couples could have reached their baby, if only they had decided to drive cars a little bit sooner. But by the time they decided, it was too late.

In reality, the pursuit of a baby is a lot like this silly story. Trying to get pregnant naturally is like walking. Doing low tech treatment, such as IUI’s and fertility medications is like riding a fast horse. Doing high tech treatment such as IVF, is like driving an even faster car. Back in ancient times, everybody walked. If they couldn’t reach their destination by walking, then they were out of luck. Then, as civilization advanced, some people could afford horses and were able to get where they wanted much faster. As the years have passed, in countries like the US, people now drive cars everywhere. True, just as there are still some underprivileged countries where cars are but a wishful luxury, for some people in the US, infertility treatment, especially IVF, is out of reach. Over the years, the effectiveness of IVF has skyrocketed and the prices have come down well ahead of inflation, but it still all comes down to a choice of where to spend your earnings. So. Do you keep walking? Do you try getting on a horse for a few months? Or do you go all out and start driving?

A lot of people ask me about unexplained infertility. Well, allow me to explain the unexplainable in very practical terms. If you have gotten pregnant and now have a baby, you are obviously not infertile, so this would not pertain to you. On the other hand, if you’ve been trying for some time, but are still not pregnant, then obviously you are not happy about the situation. I don’t want to restrict the definition of the word infertility with a set time frame, because it differs for each individual. Some people are sad and miserable if they are not pregnant after four months. Others will patiently keep trying beyond three years without any intention of asking for help. So, let’s just say if you are not pregnant yet and you want to be and you have been having unprotected sex for at least six months, then this will be of interest to you.

Prior to any sort of investigation, all infertility is unexplained. After a proper infertility workup, MOST infertility is still unexplained. I will repeat this, modifying it a bit because it goes against what you may have read elsewhere. Repeat. After a proper infertility workup, MOST infertility is still somewhat technically unexplained. Why? It’s like this. When you have finished doing testing for infertility, there are three basic scenarios you could reach. One is the OBVIOUS PROBLEM SCENARIO. This means our testing has unearthed an obvious red-flag big problem. Under these circumstances, couples have essentially zero chance of getting pregnant without medical help. Examples of this include someone whose tubes are both blocked, or who has a husband with zero sperm or someone whose ovaries have completely shut down into premature menopause. If any of these conditions are found, then your search is over and you will have to directly address these issues, because you’re not going to have a baby without medical help.

The second scenario is the EVERYTHING NORMAL SCENARIO. In this case, everything that you have tested, and I’m talking about the basics of a semen analysis, HSG and documentation of ovulation, comes back normal, or even above-average. This is what is classically referred to an unexplained infertility. It means everything looks fine on paper, but yet you are still not getting pregnant. Very frustrating.

The third scenario that is found in reality every day, but is not classically defined by medical textbooks is the SUBOPTIMAL FINDINGS SCENARIO. In these cases, there are found to be one or more things that are not quite perfect, but yet are not bad enough to sentence you to zero chance of conception. These include things like a low (but not zero) sperm count, one-sided tubal blockage with the other side open, surgically-documented scar tissue or endometriosis or evidence of inconsistent, but not absolutely absent, ovulation, or just advanced ovarian age whether chronologically (you really ARE 36) or biologically (you are 26 but your ovaries act 36).

Sometimes, a patient comes to me feeling like they know their diagnosis. “Doctor, we have already been checked out by our OB and we now that the problem is my husband’s sperm”. For example, this might be said to me by a couple for whom the semen analysis shows a 13 million / cc count with 39% motility. This is certainly below average and even in the abnormal range according to set criteria. However, if you went to every first-grade class in the country, hunted down the biological father of every healthy child and subjected these fathers to a semen analysis, I would bet that you would find not one, but many samples which have counts less than 13 million. As an additional example, if you did an HSG on every mother, you would find quite a few who have one blocked tube. So basically, in these situations, you have found something, but it’s not necessarily enough to explain the infertility, because it can’t pass the litmus-test question “Can other people with this condition ever get pregnant?” By the way, having said that, in very rare cases, even couples in the first scenario, the OBVIOUS PROBLEM SCENARIO, have been reported to get pregnant. How can a woman with two blocked tubes get pregnant? One theory is that the test was a false positive, like perhaps her tubes went into spasm at the time of the HSG and showed up blocked when in reality there was still a tiny tiny passageway or perhaps the films were misread by the radiologist or perhaps a clerical error led to the report of someone else’s test under her name. You get the point. These situations are extremely rare, but not entirely impossible.

So as many of you know by now, my way of thinking is always focused on solutions, decisions and actions, so while it’s a fascinating intellectual exercise to discuss these definitions and scenarios, the key question is what do we do about it? In the first scenario, the OBVIOUS PROBLEM SCENARIO, you would directly address the obvious problem. Duh. Depending on which problem, some solutions would include IVF, sperm donation, egg donation or attempted sperm extraction.

For the couples in the SUBOPTIMAL FINDINGS and EVERYTHING NORMAL scenarios, there is overlap in the treatment options. The focus becomes more of a shotgun strategy, meaning we can just try to universally give everything a boost. Get some improved egg quality and quantity (ovulation medications). Send the sperm closer to the egg and with perfect timing (IUI). Minimize uncertainty by physically putting the eggs and sperm together in the laboratory (IVF). We do this even if that’s not the suspected problem. So we give fertility medications to a couple with low sperm, in the hopes that more eggs will make up for fewer sperm. It’s like a football team with a terrible defense signing a top free-agent QB and RB and WR to try and overcompensate for the shortcomings on the other side of the ball.

The choice of which strategy depends on many factors including medical ones (test results, past treatment and response history) and non-medical ones (financial choices, personal attitude towards medical treatment, sense of urgency). We will address the important issue of how to approach unexplained infertility in future posts. But just remember the take-home message. In a strict sense, MOST infertility is unexplained.

OK, so you have decided you want to have a baby. Perhaps this means you are going to stop taking those birth-control pills that you’ve been on since your wedding day. Or perhaps it means you and your husband will simply stop using condoms. Or for some of you, who have been less diligent about birth control, perhaps it simply means no longer “pulling out” or no longer avoiding your supposedly fertile days, whatever you think those days may be. Your mind is innocent and worry-free. You are expecting that you will get pregnant so easily. You had no suspicion that you would ever find yourself hurled one year later into a world of taking your daily temperature and peeing on ovulation sticks. You never expected the day when 90% of your web activity is related to researching infertility. You never imagined a time when your every waking thought centers around why you’re not getting pregnant.

In the very early stages of this transition from happy-go-lucky to the fertility-obsessed, as you first become acutely aware of all your friends and neighbors and every woman at the supermarket being pregnant while you are not, what is the first question that takes shape in your mind? I’ll give you a hint. It is NOT “Why do all their husbands have good sperm and mine doesn’t?” or “Why are their Fallopian tubes so efficient and mine are not?” Nope. The first question that comes to mind for most women is “Why is everyone else having sex at the correct time and we are not?”

As human beings, our brains are quick to attribute a cause, whether real or imagined, to things that we don’t understand. In medicine, you see it all the time. For example, as a medical student, I remember a young man who came to the emergency room with a complaint of feeling sick, bleeding from the nose and having trouble breathing. Eventually, the workup revealed that he had leukemia. After the initial shock, his first question was “You know? Six months ago, I was in Mexico and I got really sick after eating some bad food. Do you think that’s what caused this?”

We see it all the time when counseling patients after a failed IUI or failed IVF cycle. They are quick to come up with a lot of potential explanations. “I was one hour late with my injections one day. Do you think that’s why it didn’t work?” “I noticed you said that my lining was only 8mm. I was talking to your other patient in the waiting room and she got pregnant with a 10mm lining. Do you think my lining is the reason I’m not pregnant?” “I heard that Brand X fertility medicine is better and I took Brand Y. Do you think that’s why the cycle failed?”

As women first begin to suspect they have a fertility problem, often their first inclination is to blame it on their not having sex at the correct time. Witness the booming industry of home ovulation tests, books that teach you to obsess about your mucus or websites with software for tracking your temperature. So, is poor timing truly the culprit for most infertility? No. No. No. With a mixture of common sense and looking at published reports, we can better get at the truth.

The truth is this: If you can have sex at a reasonable frequency (every 2-3 days) then just do it and completely forget about timing it. However, if you can only have sex once or twice a month, due to your schedules or for whatever reasons, then it’s very helpful to time it. A lot of couples make the mistake of obsessing about timing, when they already have sex frequently anyway. By trying to time things, they actually wind up having LESS sex than they normally would, thereby potentially reducing their fertility.

When can a woman get pregnant? In theory, the six-day period prior to ovulation is all a potential time for conception. To fine-tune it further, the two or three-day period prior to ovulation is the window period of highest fertility. Therefore, the BEST STRATEGY is to have sex every day. But doesn’t that result in depleted sperm? No. Contrary to myth, for men with good sperm counts, there is no significant depletion of the sperm parameters of count nor motility, even with daily ejaculation. I know this is counterintuitive, but research confirms it. Furthermore, there is even evidence suggesting that men with BAD sperm counts don’t even suffer a significant drop in these parameters neither. My own personal observations looking at samples from couples who do double IUI’s on back-to-back days confirms these findings. Most of the time, the second sample is better, equal to or just slightly worse than the first. Only rarely is it significantly worse.

OK, so what if daily sex is not practical for you? First of all, don’t feel bad. I can tell you from working with hundreds of married couples that daily sex is not the norm. Fortunately, a strategy of aiming for every 1 to 3 days is more than sufficient. By doing this, you absolutely ensure yourself of getting together during the 3-day window period. With the exception of ultrasound, all methods of trying to predict ovulation (temperature, ovulation kits, mucus checks, calendars) have inherent flaws and are not able to be 100% accurate.

So then you might ask, of what possible value is it to chart temperature, check mucus and do ovulation testing? Well, for most people it is of zero value. There is no research that suggests any benefit of all this diligent tracking over simply having sex every 1-3 days. But again, if you are unable to consistently have sex every 1-3 days, then charting or being aware of mucus can help you focus the general window period during which you should concentrate your frequency of intercourse. Just don’t obsess about predicting the one EXACT day of ovulation.

Having said all this, in my opinion, there are still two more possible ways that charting and timing might be of some benefit.

1. If you find it stress-relieving to be more in-control, then charting and timing might be of help in relaxing you. You are not doing anything to boost your chances of conception by timing things, but you might feel less anxious if you feel more in-control, and that could have positive benefits.
2. If charting and checking for ovulation results in clues telling you that you are NOT ovulating, then you will be alerted to seek medical help sooner than later.

So in conclusion, rather than obsessing about the proper timing of intercourse, just go for a sexual frequency of every 1-3 days and forget about the charting and the fertility awareness. Any questions?

Taking action to improve your fertility does not always need to cost you money. Many infertile couples delay taking action to get pregnant because they think they can’t afford medical treatment.  In fact, there are things that you can do to boost your fertility naturally that actually GIVE you money back. Too good to be true? Not really. Here are FOUR ways.

1. Cut back on cigarettes: Smoking accelerates aging. While young beautiful movie stars are often seen smoking, the harsh reality is that over time, long-term smokers end up looking much older than if they had never smoked. Smoking also ages your ovaries, sending you into menopause at an earlier age than if you didn’t smoke. The research data shows that women smokers have a 60% higher risk of being infertile as non-smokers. Miscarriage rates and obstetrical complication rates are also higher in smokers than in non-smokers. While the effect is not as dramatic in men, there are observed adverse changes seen in the sperm of smokers. BOTTOM LINE: Take all the money you spend on cigarettes, put it in a jar and you’ll end up both wealthier and more fertile.

2. Cut back on caffeinated drinks: While one cup of coffee, tea or energy drink per day is not expected to adversely hinder your fertility, higher doses (the equivalent of 4-5 cups daily) are associated with decreased fertility and a higher risk of miscarriage. BOTTOM LINE: Take all your Starbucks money, put it in a jar and you’ll end up both wealthier and more fertile.

3. Spend less on food and/or get a part time job that involves physical activity: This part does not apply to everybody. If your BMI is under 20, you should try to GAIN weight. However, if your BMI is over 25, the closer your bring it to the optimal 21-24 range, the better your expected fertility. To calculate your BMI, you can use this online calculator. If your BMI is over 25, once or twice a week, try substituting a light snack instead of eating a full dinner. Even better, try to find a side job that involves a lot of physical activity. BOTTOM LINE: Cut your food intake, put the savings in a jar. Get a side job, take the bonus earnings and add it to your jar.

4. Don’t waste money on recreational drugs: There haven’t been a whole slew of research studies on the effects of illegal drugs, because it’s hard to collect accurate data. However, there IS actual research data that at least one substance, marijuana, is linked to decreased fertility in both men and women. BOTTOM LINE: Take the money that you would give to your friendly neighborhood drug dealer and put it in a jar instead.

By the way, notice that I don’t mention anything about saving your liquor store money. The truth is that regular moderate alcohol consumption (1-2 drinks daily) is NOT associated with decreased fertility. There has been some evidence that it can slightly improve fertility to have 1 or 2 drinks daily as compared to having zero alcohol. The danger of alcohol consumption in women trying to conceive is that they might inadvertently continue drinking after they get pregnant without knowing it, and that can be very bad for the fetus.

So in conclusion, if you follow the above four guidelines, you will boost your fertility and you will start accumulating a nice chunk of money in your jar that you can use either for fertility treatment if you still don’t get pregnant. If you do get pregnant naturally, then you can use that money for diapers.

“I want to know how to get pregnant naturally.” This is a commonly uttered sentiment, even from patients who have already decided to take the time and money to come see me for consultation. You would think that by the time someone comes to an RE, they are already fed up with trying naturally. However, some patients find value in coming to me for evaluation and advice, without necessarily wanting to take the step towards actual medical treatment.

I usually start by explaining to them that many couples in the world will end up getting pregnant naturally. Typically, these couples don’t need any help and it just happens. So by virtue of the fact that they have made the effort to see me, it is likely that they have already tried on their own and something about this strategy was unsatisfactory enough for them to make them want to come see an RE. I then acknowledge the fact that some patients who give up on trying to conceive on their own, still have the possibility of doing so. Making the right fertility decision requires a balance between giving an adequate try on your own, when appropriate, vs. knowing when to get help when you’ve already wasted too much time in futility. It might not always be an issue of YES or NO, whether you can get pregnant naturally. It might also be an issue of WHEN. For example, if you are 30 years old and were told that without treatment, you had a 10% chance of getting pregnant in the next five years. But WITH treatment, you had a 80% chance of getting pregnant within the next four months. Even though you still have a chance of getting pregnant naturally, there is ample justification for you wanting to take the treatment route.

So the big question is when is it possible for an infertile couple to still get pregnant naturally? Well, as long as you are developing eggs, as long as there is a reasonable amount of sperm and as long as the tubes and uterus are clear, then there’s the possibility of getting pregnant naturally. In general for average couples, this chance is around 20% per month, but in some super-fertile couples it can be higher, like maybe 25-30% and in sub-fertile couples it would be lower, maybe 5-10% month. For couples who have the label of unexplained infertility, their odds are closer to 2-3% per month. You might wonder why a couple would just settle for a 2-3% per month, when they can boost their chances through IUI and IVF. Well, although IUI (low-tech treatment) and IVF (high-tech treatment) dramatically increase your chance of getting pregnant, you have to take into account the costs of infertility treatment and balance just how badly you want a baby RIGHT NOW vs. how patiently you are willing to wait and/or take the risk of still not being pregnant in three years.

So many times, my new patients and I spend a significant portion of our one-hour initial consultation discussing their situation without ever venturing into the topic of actual medical treatment. Rather, we focus on playing detective to discover their specific fertility problem or problems. Then, for the appropriate candidates, we talk about ways to boost their chances of conceiving naturally.

For these couples, the focus is on these three questions:
1. What can I do to improve my natural fertility?
2. When and how should I have sex?
3. When should I give up and move on to medical treatment?

Some of these issues have been discussed already in other posts, but I will review the rest here shortly.

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.

On my older blog, I shared a story about a woman who got tired of waiting to meet Mr. Right and instead chose to become a single-mother-by-choice through donor insemination. Hers was an especially happy story, because not only did she have a wonderful baby, she later wound up meeting a man, getting married and having another child with him.

I recently came across an article that tells a different story of another woman who also decided to become a single-mother-by-choice rather than settle for any of the guys she dated, because none of them were quite perfect enough. In her article, she openly wonders if she might have been better off just "settling".

I sent this article to a lot of my single friends, and not to any surprise, most of them disagreed with it (as did I). It’s still a consensus that no matter how strong of an argument is presented for people not to be so picky, there will still be a strong resistance to stubbornly hold out for Mr. Right. By the way, for one of my friends, she liked the article because it made her more appreciative of her current boyfriend, who although not everything she always dreamed, is a very solid guy. She’s going to give the relationship every chance to work, instead of restlessly looking for something "better".

So for all you married women undergoing fertility treatment, be thankful that you have at least found the man of your dreams father of your future baby

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.