“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 previous posts, but I will review them 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.

Before technology gave us the option of doing IVF-ICSI, the only choice for couples with severe sperm problems was to use a sperm donor. Even today, there are times when donor sperm is used. These cases happen with couples who have absolutely zero sperm available (even with high-tech methods) or for whom IVF-ICSI is not feasible within the constraints of their budget. There are also women without any source of sperm who choose to get pregnant by donor sperm. One of the first questions facing patients who are ready to use donor sperm is "Where do we get the sperm?"

There are some who choose to go through a well-screened anonymous sperm bank and there are some who want to get sperm from someone they know. In general, my recommendations go more often towards the option of the anonymous sperm bank. There are three main reasons for this: Privacy. Medical safety. Legal safety.

PRIVACY: So after two years of unsuccessfully trying, you and your husband finally get around to having his sperm tested. Surprise! The results show that he has almost zero sperm. After eventually settling down from the devastating news, you start thinking about your options. You absolutely do not want to do In-Vitro Fertilization. What now? You two agree to get pregnant through donor sperm. He suggests his brother could donate, or maybe his uncle Ted. You two think about this for a minute and decide NO. By instead going with an anonymous donor, you can keep your privacy. At family gatherings, there will be no awkward situations related to running into any sperm donor relatives. What if you use sperm from a friend or family member and repeated cycles are unsuccessful? There is now the subconscious blaming of someone who was just trying to be nice and help out. Again, the privacy afforded by using totally a well-screened, but totally anonymous donor definitely warrants consideration.

MEDICAL SAFETY: Reputable sperm banks have a rigorous protocol for screening the donors. When you put your family member or friend on the spot and ask them if they will donate sperm, they may be less that honest on the screening questionnaires regarding any risky lifestyle habits they may have. This is a principle learned from the concept of directed BLOOD donors. If you put a family member on the spot and ask for a blood donation, the extreme pressure can lead them to be less than honest when replying to screening questions regarding intimate questions of sexual behavior or even drug use behavior. This results in even riskier conditions as compared to using standard banked sperm or blood. Professional sperm banks also practice quarantine, so that the sperm that you can get today has already been frozen for a year. The original donors have already been retested and found to be negative for infectious diseases. This prevents the scenario of a someone contracting HIV on Monday, testing negative on Tuesday and then donating sperm on Friday.

LEGAL SAFETY: People often advise other to avoid doing business with friends. Well, the principle applies even more strongly when it comes to having offspring. Friendships and relationships are always susceptible to change. There was a recent case this week of a woman who asked an ex-boyfriend to donate sperm for her. She promised him that of course he would not need to pay child support. He made the mistake of believing her. She changed her mind and successfully got the courts to put him on the hook for support. The decision was recently overturned. Fortunately, in the case of anonymous donation, this type of problem is not an issue.

Having said all this, there are still times when I have agreed to help patients get pregnant using sperm from known donors. When I do, I ALWAYS involve skilled family law attorneys who draw up contracts, stating as clearly as possible, the agreements of both parties. I also strongly encourage prolonged quarantee similar to that which is done by the sperm banks.

It’s a lot nicer for all involved, especially for the child, if things are not messy.

Do you want a baby this year? I am convinced of the usefulness of setting goals in life. I don’t mean just sort of having some vague idea in your mind of what you want. I mean concretely thinking things over and converting these thoughts into words. Each year, I take time not only to come up with goals, but to committ them to writing. In fact, I don’t limit this activity to just each January 1. I update my goals on a regular basis. Time and time again, I’ve shared this habit with friends who later told me that the more they got into the habit of writing down clear goals, the more that their lives gravitated towards their getting what they wanted.

The principles of goal-setting also apply when it comes to achieving pregnancy. There are two common ways of thinking I’ve seen among infertile couples. Both ways of thinking are common and normal, but I challenge you to ask yourself which type of thinking will do you more good in getting what you want? And then you can ask yourself which type of thinking is YOUR style?

Two common types of people are whom I call obstacle-focused thinkers vs. goal-focused thinkers. One type is always thinking about the unfortunate and negative aspects of their situation. The other type is always asking themselves "what do I want" and "what will I need to do to get closer to what I want". The contrast goes something like this:

• OBSTACLE-FOCUSED THINKING: It is so frustrating. My best friend just got pregnant with her third and I try to be happy for her, but it’s hard. It seems so easy for everybody else, but as for us, we’ve been trying for two years now. I’m beginning to think it’s never going to happen and I feel ready to just give up. Some people have told me that my weight might have something to do with it, but it’s not easy to lose weight for me. I try my best to eat healthy and I try my best to be more active, but each month, I end up actually gaining more. I can’t even bear to step on the scale. Yesterday, my period came for the first time in three months and I cried myself to sleep. Having a big home makes things worse when it is empty no kids. My co-workers tell me to just relax and it will happen, but that just adds to the stress. We tried going to Hawaii last winter and this summer we spent a week in Europe, hoping the change of scene would do the trick. Well, it really wasn’t all that relaxing and it obviously didn’t work. I wonder if my husband’s smoking is messing up his fertility as well. He keeps saying he’s going to quit but we both have stressful jobs and that makes it more difficult. I really wish someone would give me an answer of what I can do. I really don’t want to see any doctors or do anything unnatural. Besides, I already checked and my insurance doesn’t cover infertility. I’ve heard that in-vitro is expensive and there’s no way we can afford it…
• GOAL-FOCUSED THINKING: We were hoping to get pregnant by now, but it’s been over two years and nothing, so it’s time to try something different. I really wanted a baby without help, but I am not going to wait any longer. I’ve invested a great deal of time reading books, finding information on the internet and asking some people I trust. I realize that it would help me if I were to get in better shape. I will agree to make some sacrifices of eating slightly smaller portions and gradually, but consistently increasing my exercise level, because I know it will get me closer to having a baby and living a healthier life. If it becomes necessary, I have explored ways in which I can advance in my job or even take on an additional part time position so that I can save up what it will take to pursue some of the more costly treatment options. I am going to forego my daily Starbucks and we will pass on that cruise this year. My husband was thinking of changing jobs anyway, but now he’ll be attentive to what insurance plans his next employer offers. Hopefully, we won’t need to spend a lot, as our budget is tight, but we will keep trying things until we reach our dream of having a baby in our home…

You get the idea. Personally, my heart is more saddened by people with the first mindset, and I feel a stronger longing to help them, but honestly, the people with the second mindset seem to get pregnant faster and more often.

Now ask yourself. Which one are you? Would it be worthwhile to try thinking the OTHER way in 2008?

This past month, NEWSWEEK featured a cover story on Fertility and Diet. Feel free to read the article in its entirety, but I’ll share with you what I got out of it.

We’ve known all along that lifestyle factors such as exercise, smoking, diet and stress can affect us in important ways including longevity, energy level, mood and risk of diseases. It’s not a stretch of the imagination to think that lifestyle factors could also impact fertility.

Harvard researcher Jorge Chavarro has co-authored a book entitled The Fertility Diet, based on data collected from The Nurses’ Health Study, a large ongoing research project which gathers information on a variety of lifestyle factors and their relationship to medical conditions.

I’m going to go on to be one of those annoying people who sort of does a pseudo book review without having read the whole book ( I did read the entire ARTICLE ), but you can be the judge of whether what I say is helpful or not.

First of all, contrary to how it has sometimes been marketed, what this book is NOT is a magic remedy to BOOST your fertility. It does show some very interesting findings on the differences in fertility between women who have different dietary habits. However, there are two important points to remember. These are merely women who are trying to conceive, not women with established fertility problems. As you know, advice that is given to regularly fertile women (relax and take a vacation and oops, you’ll get pregnant easily) doesn’t work for those who have been unsuceessfully trying for years and years already. Second, all the data really shows is a CORRELATION between women who have certain diets and the % of them who conceive. It does not show that the diet CAUSES the fertility. It’s possible that the opposite direction is the case and that a woman’s fertility situation actually affects her dietary choices. It’s even more possible that there is a yet identified third factor that affects both one’s fertility and one’s diet.

Even more importantly, there is no hard PROOF that actively changing your diet will change your chances of conceiving, again because no causality has been shown. Pretend someone does a research study and finds out that people with Ivy League college diplomas hanging on their walls make better engineers (I’m not actually saying this is the case, by the way). It would be wrong then to jump to the conclusion that if we started handing out Ivy League college diplomas to everybody, then we could have a nation of better engineers. Having said all that, it’s still my personal guess or opinion that changing ones diet, WOULD, at least to some extent, positively affect ones chances at conceiving.

According to the article, here is a summary of the specific dietary features that might be better:

• Eating more so-called SLOW cabohydrates (dark bread, brown rice and pasta, whole grains) in place of fast carbohydrates (cold breakfast cereals, potatoes, white rice).
• Eating more unsaturated fats (avocados, vegetable oils) in place of trans fats (palm and coconut oils, hydrogenated fats, dietary cholesterol, animal fats, lard, butter). This was one of the more important factors according to the study.
• Having a lower body mass index. Being overweight is correlated with fertility problems. The best range of BMI was between 20-24, with 21 being optimal. If you wish to calculate your BMI, try this useful calculator.
• Eating more plant protein is place of animal protein.
• Consuming whole milk and whole dairy products instead of skim milk. This was the most counterintuitive finding. It was a surprise to find out that milk with natural milk fat was actually better than skim milk. However, the benefits were seen with amounts as small as one cup of ice cream per WEEK. So if you buy that small pint of Ben and Jerry’s Chunky Monkey, it should last you two weeks.
• Exercising regularly was better than no exercise. Unless you have very low body fat, like a gymnast or ballerina, you should aim for doing more exercise rather than less. A good target is to do 30 minutes daily.

If the thought of making drastic lifestyle changes feels overwhelming, remember the principle of trying different things in an attempt to improve your odds of conceiving.  The easiest approach is to pick one or two of the above areas and see whether or not making a change in your life results in pregnancy, or if not that, at least an improvement in your menstrual regularity, especially if you are not normally regular. Remember. If what you’re doing is not working, try something different, including eventually going to see a good reproductive endocrinologist.

Now go and enjoy your holiday feasts, everyone. Merry Christmas!

You can’t control whether you get pregnant or not.

What you CAN control to a big extent are your ODDS of getting pregnant. Understanding his simple distinction can go a long towards giving you a better grasp of your situation and hopefully a better sense of control on the whole big picture. For example, next month if you make the decision to stay celibate and never have sex, then you can effectively eliminate any chance of getting pregnant. The last time someone gave birth without ever having sex actually happened around this time of year. But unless you tell me that you were just paid a visit by three wise men from the East bearing gifts of gold, frankincence and myrrh, then this probably isn’t going to happen to you.

Taking this further, if you end up having sex randomly twice this month, then you might have a chance of having a baby, but it will be low. Furthermore, if you have sex at an exact day, planned by using ovulation tests and past temperature charts, or better yet, if you have sex every two days for the whole month, then your chances get even better.

Now, taking this further, if you can somehow quadruple your egg production and then on the day of ovulation (or better yet, near the HOUR of ovulation) arrange to have 20 million of your husbands live sperm delivered right to the doorstep of where your eggs should be waiting, then your odds get better yet.

Ultimately, if you instead arrange to have your eggs found and retrieved, directly fertilized and then transplanted back into a hormonally-enriched uterus, then your odds are the best.

I think you can see the point. Choices you make, whether on the type of treatment you get in a certain month, the frequency of sex, what you eat, how much stress you have, how healthy you make yourself all can have some bearing on your odds of getting pregnant. The unfortunate thing to accept is that you can do all the right things to maximize your odds, but still not get pregnant in a given month. In basketball, your team can work hard moving the ball around and making passes to get the ball set up for a super easy shot and still fail to score because that easy shot is missed. On the other hand, you can also just fling the ball from half-court without a prayer of it going on, and most of the time it won’t, BUT, once in a blue moon, it WILL. In the first case, even if you miss the easy shot one time, as long you continue to do the right thing to set up easy shots subsequent months, eventually one will go in.

So if you have been reading this site from the beginning, you now know two important basics of fertility strategy.

• Try something.
• If time goes by and that particular something is not working, try something different.
• When trying something different, focus on doing things that are expected to improve your odds. If your odds were truly improved by your new action, then eventually it will work.
• If it doesn’t work, then it means that your odds weren’t truly improved enough by your particular choice of different action, so then try something else!

This is the basic outline of our gameplan. There are many specific ways of how we can medically and naturally increase those odds, but those are lessons for another day.

If it is your wish is to be a parent, the choices you make today will affect the odds of you actually having a little one in your home one year from now. The concept of our decisions affecting our future is true of anything in life. However, in difficult matters such as infertility, it is very easy to fall into the trap of emotional paralysis when you should really be focusing on correct decision-making. True, the heartbreak of infertility can be overwhelming for many reasons. However, in life, while we can’t always control our feelings, we CAN control our actions, so it becomes of utmost importance for every infertile couple to concentrate on making the right choices, despite the temptation to let emotions rule.

Everybody’s personal case is different, of course, but one universal way of viewing the dilemma of infertility is that of AVOIDING MISTAKES. One mistake to avoid is that of inappropriately pursuing powerful, aggressive medical treatment when it is not necessary. For example, if you are 26 years old, try for three months and then decide to spend $14000 to do IVF, although this will likely result in you getting pregnant instantly, maybe even with twins, you have lost out on the chance to get pregnant naturally and will likely have spent that money unnecessarily. The opposite mistake is to NOT take advantage of available treatment options when they in fact ARE necessary. For example, if you are 35 and have been trying for 10 years and you only get your period twice a year, by allowing your sadness to paralyze you and thereby not seek treatment, you run the danger of passing up your best reproductive years and winding up permanently childless. So how do you determine the right decisions?

You have already successfully taken the first step by allocating some of your precious time today towards visiting this and other sites. There is a great collection of valuable information (and harmful misinformation) out there on the internet. Your task is to diligently evaluate and synthesize what’s out there and make up your own mind.

After gathering information and increasing your knowledge, the next step is to face the fact that you can’t escape having to make choices. Even if you decide in frustration to throw away your thermometer, ovulation kits and charts and just give up, that too is a choice in itself and can have important ramifications.

KEY POINTS TO TAKE AWAY:

• Now and in the future, remember to keep  asking yourself on a regular basis, “What decisions do I need to make today, this week or this year to get what I want?”
• When gathering information, keep an open mind. Don’t rely solely on one source for your information and don’t get too set in your ways. If you find new information that contradicts your old beliefs, weigh the two sides objectively to see if you should change your opinion.

One very sweet new patient came to me with a tearful story of her two-year struggle with infertility. After she had failed to conceive in her first year of marriage, her well-intentioned mother-in-law stepped in to offer some "advice". The mother-in-law was convinced that this patient was failing to get pregnant because she was not resting enough. So, in a radical move, the patient reluctantly quit her job and spent the better part of the past year at bedrest. She described how each cycle, after her ovulation test turned positive, she had gotten together with her husband and then obediently stayed confined in her bed, getting up only to use the bathroom, and even then, not without feeling a bit guilty for leaving the bed. Despite her faithful adherence to this rigorous bedrest regimen, and despite compliantly consuming the wide array of Chinese herbal concoctions that the mother-in-law thrust at her, her period would eventually come, bringing with it mixed feelings of sadness for not conceiving, yet some relief at being temporarily free from her confinement. After a year of this suffering with no results, she came for medical help. Ironically, it was her mother-in-law who had asked around, found my office, and had made the appointment for her.

While this woman’s story is one extreme example, it’s by no means the only example. Several women I’ve encountered have had it in their minds that the reason they are not conceiving is because they are not resting enough. So the question comes up of what exactly is the role of bedrest is in helping fertility. And my answer is NONE. Well, almost none. Bedrest is not necessary in order to get pregnant, either for patients trying to conceive on their own, nor for patients undergoing treatment with IUI, nor even for those doing IVF. In exploring this issue, let’s remind ourselves that there are two ways to get to the truth scientifically - LOGIC and EVIDENCE.

Logic dictates that being immobilized is not a normal human state. When women have sex while they are immobilized either due to spinal cord injury or leg fractures, there is no increased fertility observed. Also, understanding the mechanism of how the Fallopian tubes pick up the ovulated eggs would suggest that adopting a variety of different body positions could actually ENHANCE egg pickup by allowing the end of the tubes to fall into different locations at different times, exposing them to more possibility of picking up an egg.

Evidence from studies comparing bedrest after IUI and after IVF embryo transfers show no advantage of bedrest. There is one exception and that pertains to a short 10 minutes of bedrest after IUI. During IUI, the sperm is delivered as a volume of liquid into the uterus. By staying flat for 10 minutes afterwards, the sperm can disperse better. In my practice, we take it one step further by using our electric beds to tilt the patient upside down for those 10 minutes. Note that this principle does not apply to regular sexual intercourse. The difference is that with IUI, the sperm in inside the uterus already. Being upside down will help it flow into the tubes which is where we want it. With sex, the sperm is not deposited directly into the uterus, but rather just into the vagina. So going upside-down after sex merely results in the sperm pooling in the upper corners of the vaginal vault and not into the uterus. Even with IUI, after those 10 minutes of resting slightly upside-down, we encourage patients to resume normal activity for the rest of the day on.

What about bedrest after embryo transfer and IVF? Historically, when IVF first came out back in the 1970’s and 1980’s, patients were instructed to be at bedrest for days or even weeks afterwards. This was not based on any evidence, but just on playing it safe because we didn’t know better. Over the years, research studies have confirmed that prolonged bedrest after IVF is not helpful and might even be harmful, presumedly due to increased stress brought on by the confinement.

In my own practice, the approach is to have the patient stay home in a happy peaceful safe environment for the day of and the day after embryo transfer. The focus is on being at peace. By staying home, no unexpected things such as minor car accidents can happen. This probably is not necessary, but any attempts we’ve made to tell our patients to have no bedrest at all are met with violent protests, so we have just fallen into this routine and have great success rates to show for it. Bear in mind that for some patients, bedrest is very stressful and is comparable to being a prisoner isolated from ones favored usual daily activities.

I have a memorable example of a patient who underwent IVF four times (two fresh and two frozen cycles). Out of those four transfers, the patient, who is herself a doctor and in her residency, went on overnight call immediately after her transfers three times. Those were the three instances that she became pregnant and went on to delivery a single healthy baby each time. The one time where she was on vacation and decided to take advantage of bedrest was the one time she didn’t conceive. At the risk of offending any statisticians out there, I do not advocate drawing any scientific conclusions from this one isolated case. However, it’s fun to mention it.

One final exception is as follows. If you have a horribly hectic schedule and you want to experiment taking off one month or two, either vacationing in Tahiti or just being at bedrest, watching DVD’s and doing Sudoku puzzles, then by all means, give it a shot. Who knows? You might end up pregnant and make for a very good story. (Please share with me if this works). If not, don’t let your mother-in-law keep you at it for a whole year, because this would violate the first rule of getting pregnant, which is "If the way you are trying is not working, try something different".

Also, bear in mind, all this discussion pertains to getting pregnant, not what happens AFTER you are pregnant. Once you are pregnant, there are several situations in which bedrest is good, but that’s for the 2nd and 3rd trimesters - a whole different story.

Conclusion: Ten minutes of bedrest after insemination can be helpful in conception. All other situations (conceiving naturally, IVF cycles) do not benefit from bedrest.

By the way, the first couple with the strict bedrest was surprised when further investigation revealed that their problem was a sperm problem. They went on to have two IVF cycles, each time delivering a healthy baby. Everyone is happy now, especially the mother-in-law.