I am 41 and my tubes are blocked. I had to go out ofstate to do a Fallopian Tube surgery with a tubal surgery specialist. I was told it had a 70% chance of being successful, but it failed. I am sad the doctor was unable to unblock my tubes. What can I do now?
Minerva from Walterville OR

You’re correct. Yours is a sad story indeed. A woman with blocked tubes is faced with three choices: Try and get the tubes unblocked through surgery, have a baby using IVF or abandon the pursuit of any future children. While each of these first two strategies has its pros and cons, in most cases, IVF is the better way to go. There are several reasons for this.
When making a decision of which method to consider, you might take three main factors into account :PRICE, CHANCE OF SUCCESS and INVASIVENESS. When comparing price, you can research what is available in your area, but in general, you might find tubal reversal procedures running about $5000 to $11000 and IVF procedures running $10000-$15000, so it would appear that tubal reversal holds the edge here. If the prices you find differ from these ranges, then of course you would adjust your strategy accordingly.

Comparing success rates gets tricky because IVF is intended to result in an instant one-time pregnancy from a one-time procedure, while tubal reversal (if successful) is intended to give multiple low-chance attempts over the course of a woman’s remaining reproductive lifetime. I did many tubal-reversal procedures earlier on in my career, but I have not done a single one in over six years. So while you may keep this bias in mind, I still feel there is a very good reason for this bias. It’s because in almost all cases of patients coming to see me to discuss these two options, it turns out that IVF is as good an option or better than tubal surgery. Over the years, the success of IVF has gone up with technological advances in embryo culturing technique in the lab, so much so as to make invasive surgery less practical an approach in comparison.

In a good case scenario (33-year-old with tubal ligation), the chance of a baby can be over 60%, depending on the program and on depending on many factors having to do with the patient herself. In a bad case scenario (40-year-old with endometriosis), the odds could be closer to 15%. Compare this to tubal surgery, which requires two areas of success. First, there is the success or failure of the surgery. If the surgery fails to reconnect the tubes, then the whole project is shot. Even if the tubes DO successfully get reconnected, then comes the monthly attempt of getting pregnant which might be as high as 20% chance PER MONTH chance in the better-case scenarios and lower than 1% chance PER MONTH of getting pregnant in the less favorable scenarios.
With regards to invasiveness, the edge goes to IVF. An egg retrieval is a very easy procedure using just a needle. The patient is comfortably under anesthesia and the procedure is over in less than 20 minutes. A tubal reversal will at the very least involve laparoscopy, which involves three very small surgical incisions, one below the umbilicus and two in the lower abdomen. In comes cases, the procedure involves a large surgical incision. A tubal reversal surgery will take over an hour and sometimes up to three hours. One disadvantage of IVF is the ovarian stimulation which accompanies it, which at best is a little uncomfortable and at worst can result in serious ovarian hyperstimulation.
I’ve had many patients come for IVF after having failed a tubal reversal and get pregnant with the IVF. I try my best to track my patients, but I realize the tracking is not 100% perfect. Still, I have yet to encounter a patient who has failed IVF and then gone on to have a pregnancy with a tubal reversal. I do have one patient who failed IVF at age 38, then went on to have tubal reversal done. It was successful in opening up the blockage, but she never got pregnant. She then came back to see me in her early 40’s and did IVF again, this time successfully.
Minerva, in your specific situation, given your age, I think most RE’s and even most tubal surgeons would agree that IVF is the better way to go for you. Your case was especially sad, because the tubes did not get reconnected. But honestly, even if the surgery had been successful, you would still have a challenge ahead in trying to get pregnant month to month. At this point, I would strongly frown upon any attempts to do another tubal surgery, especially having failed one already. IVF is not a fantastic option, but still is the best one left for you. Your RE can give you a better estimate of your chances of success after evaluating your ovarian age. Good luck!

Hi Dr.
On CD 3 during my ultrasound they noticed left over follicles from Cycle #1. Just when I thought I was going two steps forward I feel as though I took two huge steps backwards.
My follistim injectables were 300 iu for 5 days and then they lowered it to 225 iu for 2 days and then I triggered with Ovidrel so I guess the RE really wanted to stimulate those ovaries. Guess what? It worked! When they did my Progesterone levels it showed I ovulated. So not sure what went wrong there.
E2 levels were so out of whack (263). Just a side note, I started taking Estrodial as the prescribed protocol as we were heading toward doing IVF if the IUI didn’t work. I’m 42 years of age and will be turing 43 in Aug. DH for our IUIs had 14 mill. sperm and 12 million sperm. Not exactly sure if that was a problem or not. However, after the IUI didn’t work and AF came early we decided to stay on course with another IUI cycle #2. Also, came off of the Estrodial. So my point here is that I am not sure if my body overloaded on the estrogen and this was a side effect resulting from it. Anyway, the RE recommended I force ovulation and trigger with Ovidrel and come back on March 27th for bloodwork to make sure I ovualted again. With ovulation, I am guessing you get another menstrual cycle and then DH and I will start another IUI cycle hopefully in early -mid April. Keeping our fingers crossed that by having 2 menstrual cycles back to back that all my hormone levels retreat back to normal and all the bad stuff in my body leaves and we can start the process again.
However, after extensive reasearch on the internet and your site, it seems that I now have Polycystic ovarian syndrome. I do have all the sign and symptons of it especially the weight gain around the middrift area.
Do you think I should request a check for insulin resistance to see if I should take metformin and start a excercise & diet plan? I notice the success rate is a bit higher once a good diagnosis has been established for PCOS. Maybe I am wrong it was just what I was reading.
Thanks a million for reading and looking forward to your advice or questions I should be asking my RE about here in NJ so I can be successful in having a beautiful baby.
Becca from NJ.

Dear Becca,
Thanks for sharing your story. Based on what you’ve described, the biggest obstacle, as you probably already know, is the degree of age-related DNA damage in your remaining eggs. In addition, it’s well known that PCOS hinders fertility even if you do ovulate. Now you mention that you “have all the sign and symptons”. Other than truncal weight gain, you didn’t go into detail on what those clues are for you having PCOS. But giving you the benefit of a doubt, I suggest you have your RE test your insulin resistance or alternatively, if they are agreeable to it, they can just empirically try you out on metformin for 2-3 weeks. For example, if you report losing 5 pounds in 3 weeks and noticing a huge boost in energy, it would likely be a good reason to stay on it.

You also asked if you should start an exercise and diet plan. You would have to ask yourself, even if you didn’t have PCOS, what’s stopping you from adopting a healthy exercise and diet plan anyway. Right? You seem to already have many of the answers to your own questions.

Best wishes and by all means, have that talk with your RE!

Dear Doctor,
Hello, I would be very grateful if you could help me. I ahve GP in the Uk, that unfortunately only gives you 10 mins for a meeting. He told me that my test results were noraml but does not go into anymore detail.
I reaaly need an insight into what the hormone levels mean in terms of fertility.
my plasma FSH is 9.8 iul/L,?LH 4.51?serum testosterone 1.9 nmol/L?serum presterone 1nmol/ L
serum oestradiol 83pmol/L
apart from the FSH, I do not understand what thes figures mean, could you please give me some indication and direct me some websites whereby I can learn More . Thank you

Daniella

Dear Daniella
Thanks for the question. I’m sorry to hear that you were only given 10 minutes with your doctor on a complex issue such as infertility. I understand that you have government-run healthcare over there in the UK, but do you have any option to choose another doctor? The thought of being given 10 minutes with zero choice of choosing a different doctor would scare a lot of the people here in the US as we try to fight off our own government’s attempts to take over this vital part of our lives.
In any case, with respect to your question above, what you have shared are test results regarding your hormones. The FSH and LH are made by your pituitary and are involved in your body’s way of modulating your ovaries to make eggs. The next three ( testosterone, progesterone and estradiol ) are the products of your ovaries.
Depending on your age, you could have a less than average chance of conceiving or an average one. Based on those tests, you probably wouldn’t expect to have a higher-than-average chance of conceiving. As for what you should do, it depends on your age, how strongly you want to have a baby, how long you have been wanting one and what treatments you have already tried in the past. The value of doing those tests is not that great unless one of them comes back as off the charts and grossly abnormal. That’s about the best answer that I can give you without knowing your history and goals. Good luck!

I just went to the Re office for my 3 day fsh level to start ivf last month it was 10.5 and e2 was 69 this month i wanted to start and now my fsh is 15.5 and e2 is 89 my follicle count was 9 no other problems is it possible i need egg donor they told me I have to wait till it goes down what would my options be at 37

Tracey

Dear Tracey,
At 37, your options would be to go ahead and attempt a stimulation and then see how many follicles your body produces or to not take a chance, but go directly to donor eggs. Without knowing the rest of your history, I can try and assume that you have never done IVF before. Depending on how much it would cost you if you were to have a cancelled cycle and how much value it is to you to try with your own eggs, you would balance these two factors out and make a choice that is best for you. Best of luck!

hello
in 2007 I had a fsh of 6.9 in 2008 I had a successful ivf resulting in my little girl.?from that ivf I got 9 eggs out of 13 follicles.with low drugs
we have been considering ivf no2 in the hope for a sibling
my fsh is now 10.2 ( which is the higher end of normal ) and my AMH is 8 not sure is that is normal ???
I am 27 and ivf is the only way for me as have no tubes ( 3 ectopics )
so my question is with my fsh on the rise should I be having ivf sooner rather than later ? are my levels abnormal for my age ?
any advice would be much appreciated
natalie

Dear Natalie,
Yes, assuming that your FSH was drawn near day #3 of your cycle, then the value is considered less favorable than what would be expected in the average 27-year-old. As for going after your second baby sooner than later, in general, you know that conceiving at a younger age results in higher odds of success, lower risk of miscarriage and lower risk of birth defects. So if you mentally and financially ready and are really sure that you want more children, then what’s the reason for waiting? Right? Good luck!

Hi Dr. Lee,
I have followed your blog for several months now. It has been so helpful, and I thank you for that. My husband I have been trying to conceive for 3 years now, and under the care of an RE since October of ‘08. We’ve had 5 IUI’s and 2 IVF’s. Long story short, the first IVF resutled in OHSS and the 4 embryos were frozen. The second IVF only resulted in 2 embryos surviving to day 5 and they were both transferred, but I was hospitalized with the flu AND we got a negative on a pregnancy test. We had a FET this past summer and transferred 2 of the embryos. (Many details to my story but they believe the blood thinners helped us as I was diagnosed with MTHFR.) I had a successful, singleton pregnancy but delivered stillbirth at 20 weeks, 5 days. I was diagnosed with an incompetent cervix. I have read on line that this is not uncommon in infertility patients. In a nutshell, I was wondering if you would consider blogging about any of these topics in the future: blood disorders like MTHFR, recurrent pregnancy loss, incompetent cervix, and high risk issues in IF patients like incompetent cervix or placent previa. Thanks for your time, Jennifer A.

Dr. Lee,
So sorry… I left a few things out in my post. I was diagnosed with PCOS and poor egg quality. My husband was diagnosed with slightly low testosterone (I want to say just two points below normal). He had the varicocele surgery and now the urologist in the IF practice says his testosterone levels are ‘great.’ The most important part I left out was this; I have two frozen embryos left. We want to try another FET. What could/should I know about incompetent cervix that could make a different and save the next baby’s life, or is it a ‘crap shoot.’ Also, would it be safe to trasnfer two? If we chose to transfer only one at a time, are we lowering our chances of that ‘one’ embryo implanting? I have heard that women often transfer several because it increases their chances at getting pregnant. So, does that mean transferring only one will ‘lower’ your chances? Hoping my story will inspire future blog topics for you to research and discuss. Thank you again, Jennifer A.

Dear Jennifer,
In my 14 years of practice, I’ve encountered at least 20 patients who after getting pregnant with IVF or IUI have gone on to be diagnosed with incompetent cervix. Most of them went on to have a healthy baby in future pregnancies. In the majority of cases, the presence of an incompetent cerivix is picked up only after a tragic pregnancy loss. The only other way to detect it would be to monitor the cervical length meticulously. For you next pregnancy, I take it you will be under the care of a high-risk OB specialist who will likely discuss with you the option of having a cerclage, which as you may know, is a stitch to tighten up your cervix. As for your question of transferring one vs two embryos, bear in mind that each embryo you transfer gives you one “roll of the dice” to get a baby. So, of course, rolling the dice twice makes the odds of hitting a winner more likely. However, you would have the same general chance in the long run whether you transferred both embryos in two separate transfers or if you transferred them both at once. I hope that makes sense. I have discussed recurrent pregnancy loss in previous posts, but I appreciate your suggestion and I will likely revisit this issue in future posts. I hope all goes well with your next pregnancy.

As a welcome relief from all the sadder posts about the octuplets, I’m reminded that there are many optimistic diligent students who might someday be the RE’s of the future. Here are some of their questions:

How do you become an RE? What classes do you suggest I take in highschool? in college? I’m a freshman in highschool and I think I might be interested in this career. Is there anything I should know?
And another afterthought, are there any depressing side effects like couples (mainly females, I assume) that break down?

Ashley

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I thought it would be appropriate to introduce myself. I am a third year medical student that follows your blog. I have always been interested in Ob/Gyn and have been fortunate to shadow a couple REI’s from my hometown in Wichita, KS.

I am an aspiring REI. I was wondering if you could give me some suggestions on how to reach this goal. Also, do you feel it would help if completed an M.D. residency rather than a D.O. residency? I did read the part of your blog where you address that REI is extremely competitive and to make sure to be happy as a general Ob/Gyn if you weren’t able to get a fellowship.

I just completed my required Ob/Gyn rotation, and I really loved it. My attending did quite a bit of infertiity for a general Ob/Gyn, including FSH injections because of her unique situation of being in a small town. It was a great rotation.

Keep blogging! Thanks in advance.
Paige

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Hi Dr. Lee,

I’m Jay, a third-year medical student at the University of Missouri School of Medicine, undergraduate degree from UCLA 2005. I know you’re probably inundated by millions of messages like this, but I am EXTREMELY interested in going into REI as a career choice. My father is a general OBGYN but I’ve determined that REI is the way for me. Do you have any pearls of wisdom as I embark upon the rigorous application process for OBGYN residency? Anything would help. Thank you so much Dr. Lee, and congratulations on all your success. I came across your blog from StudentDoctorNetwork and have bookmarked it now to visit daily. Thanks!

Sincerely,

Jay

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Hello Dr. Lee,
I recently came across your blog and it’s so informative. I am currently an OB/GYN intern at Meharry and I have had a longstanding intrest in REI. I was just curious to know how you knew that REI was what you wanted to pursue. I guess a part of me is hesitant due to the competitiveness of getting IN to the field, but I am also not trying to let my possible future escape me due to fear! Any advice?
Look forward to hearing from you,
Nke

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Thank you all for your questions. I’ll start with the straightforward part. Ashley, in order to become an RE, you first graduate from college, and then go to medical school for four years. Afterwards, you do a four-year residency in OB/Gyn and then an additional three years of a fellowship in Reproductive Endocrinology and Infertility. You’re probably thinking “That is a quite a lot of schooling”. I’m sure you can do the math yourself, but I personally took an accelerated route (started early and skipped one year) and even so, was already 30-years-old by my final year of fellowship. Other RE’s who take a less direct route are already over 40 when they finish their training. So one big question to ask yourself is whether or not you’re willing to dedicate such a big chunk of your life to learning the knowledge and skills that it takes to be a good RE. The good news is that you don’t have to commit to that decision right this moment. You can take it one step at a time, focusing now on making the most of your high school experience and doing your best to get into a college that is good for you. By the way, if you want to immerse yourself in the field of fertility and don’t want to go the long route to becoming an RE, you could participate as a medical assistant, nurse or Physician Assistant. I realize that it’s not the same thing as being an RE, but it has its good points too. You could also choose to be an embryologist, although the everyday atmosphere is very different in that you would interact mostly with egg, sperm and embryos rather than directly with patients.

Ashley, right now, while you are in high school, rather than restricting yourself to any specific MUST-TAKE classes, your best strategy is to make the right decisions so as to maximize your options. What does that mean? I’ll share with you an answer your teachers and school counselors may never tell you. Here’s the secret. When it comes to a career in something competitive like medicine or law, there is a delicate balance between doing what it takes to “play the game”, and doing what it takes to really grow and learn as a person. Shall I explain? On one hand, many pre-med students take the extreme “Cutthroat PreMed” approach and focus single-mindedly on what it would take to get into the best college or the best medical school. Somewhere along the way, they find themselves losing their humanity and falling into the trap where every major decision is geared towards getting accepted and not necessarily towards becoming a well-rounded doctor. “Hmm let’s see, I will need to spend next summer pushing wheelchairs at the hospital so I can say I have some hospital volunteer experience and I’m going to run for Assistant Vice-Treasurer of the Lithuanian Pre-Med Students Association so that I can have some extra-curriculars to list”. If you single-mindedly focus on getting great grades, great MCAT scores and a long list of activities on your resume, but ignore developing yourself as a human being, your odds of getting into medical school will still be pretty darn good, but you have sadly missed out on a some great years of your life. And worse of all, you might find yourself being a very depressed resident or graduated doctor someday.

On the other extreme, some people take the “Rebellious Anti-PreMed” approach. They adamantly refuse to the play the game. “I’m not going to waste time studying for Organic Chemistry since I know that 99% of doctors will never use it in their daily practice. And I refuse to obsess about the MCAT. How does my performance on multiple choice questions reflect how caring and empathetic I’ll be as a doctor? I’m going to focus my energy on the practical courses like microbiology and anatomy and then round myself out with a lot of psychology, literature and history classes, as well as enriching my writing skills”. While I personally agree with this in spirit, I also have to warn you that in actual practice it doesn’t work. This attitude of not taking things like Organic Chemistry and the MCAT’s very seriously is one easy way to NOT get into medical school.

Furthermore, Ashley, it’s so good that you’re already asking questions at this point in your life, trying to get an edge for your future. If I could go back in time and meet my past self when I was in high school, one of the many things I would tell myself (besides save all my paper-route money and invest in Microsoft) is to develop a habit of regular reading. Many smart thinkers throughout the centuries have “figured things out” and put their discoveries down in words. Even if you could gain just 1% of their pearls of wisdom, your life could be significantly easier and happier. Now I know there are people who scoff at self-help books because we probably all know a friend who reads them or goes to self-help guru seminars, but yet their lives are not something that we would care for. Reading self-help books but not acting on the advice learned is like trying to get in shape by buying more and more exercise equipment. It’s not as powerful if you just read and don’t apply what you’ve learned.

Now if you want to know which specific books I would recommend, I would start by telling you that I’ve read tons of books and some of them have been tremendously helpful to me and others have been a waste of time. There are people out there who have read my “waste of time” books and found them to be the most helpful while my “changed my life” books did nothing for them. So the point is that everybody is different. To get started, visit this site and print out the books listed. Check out a few from the library. Devote at least two hours every week (more if you can) to leisurely looking through them. If a particular book does nothing for you, let it go. By the way, even if a book does not thrill you today, you can always give it another try a few years later. If however, you DO find a book that grabs you, share it with a friend and discuss it together. Anyway, Ashley, thank you for your question. I hope I was of help. If my answer was not what you were looking for, I only ask that you revisit it every few years as you progress in school. One day it will click. Oh by the way, in answer to your question about dealing with couples who break down emotionally, you are correct in guessing that this field of medicine contains some of the most emotional extremes. lt comes with the territory. You will share the agonizing pain of many couples as they have failed cycles and miscarriages, but the trade-off is huge as you get to rejoice with the many more couples who end up as happy parents! I can’t imagine many jobs that have more of these types of highs!

Paige and Jay, since the two of you are already in medical school, congratulations! You have already set yourselves above the rest of the pack, demonstrating that you have figured out what it takes to succeed. Maybe you would be better suited to give high school students like Ashley advice, since the timeline for your successful decisions is much more recent than for mine.

As for what tips I can give medical students, there is nothing secret other than to get into a good OB residency. One question is this: Is it better to go to a great OB residency that does not have its own REI fellowship? Or better to go to a lesser residency that does have a fellowship program? The answer, as always, is ‘it depends’. First of all, the question is tricky because it assumes that we know what makes a program better than another and the fact is that we don’t. Keeping all this in mind, when you are deciding how to rank your program choices, my opinion is that presence or lack of a fellowship SHOULD come into the equation. The reality is that people do their fellowships at the same place they do their residency much more frequently than could be attributed to chance. There are several reasons for this. One is familiarity. As a fellowship director, it’s safer to take someone who is well known to you and to the other faculty in your department than someone who is a total stranger.

Paige, as for your question about DO vs MD residencies, my general advice is to aim for the most competitive program that you can get. As some of you know, I am on faculty at UC-Irvine College of Medicine as well as Western Health Sciences, so I regularly lecture to hundreds of MD students and DO students each year. And while it is more than possible to become an RE through the DO route (I personally know some excellent RE’s who are DO’s), it is much easier to get there through the MD route. Again, some of this is out of our control. It’s easier for a football team to win the Super Bowl by first winning their division and getting a bye than it is to win as a Wild Card team that barely made the playoffs. However, as the 1980 Oakland Raiders, 1997 Denver Broncos, 2000 Baltimore Ravens, 2005 Pittsburgh Steelers, 2006 Indianapolis Colts and 2007 New York Giants have proven, it happens more often than one would expect.

One general tip for medical students, residents and doctors is to realize that our lives are “different”. With so much expected of us, we really need to make the most of our God-given 24 hours each day. This means we should strive to always do the best thing at any given minute. This should NOT be interpreted to mean that we should always be studying or at the hospital, because sometimes the best thing to be doing at the time is to be watching the sunset with a loved one or to be sleeping or to be at a funny movie, because only then can we be recharged to go back into the hospital at our fullest energy level. There is a term called ‘lifehacking’, which I define as squeezing the most out of each minute of life. I am a big believer in the concept. That’s why I try to learn and find the most efficient ways to do things like setting up macros for repetitive tasks on the computer and listening to audiobooks during commuting or while at the gym to make the most double use of each hour. One specific book that I highly recommend is Getting Things Done. If you find that it completely changes the way you organize your life, please drop me a line to let me know.

As for the tricky fact that in order to do REI, you have to go down the OB pathway, I can say this for myself. I’m guessing that had I not gotten into an REI fellowship and was now practicing general OB, I would still be happy. I can’t imagine I’d be as happy as I am right now, but it wouldn’t be that terrible. I say this even though I realize that the work-day (and work-night) of a general OB is very different from the work-day of an RE. So if you think that you would love being an RE, but hate OB, then my advice is not to take the gamble. As you can see from a previous post, the ratio of applicants to acceptances is around 2 to 1.

Last but not least, Dear Nke. Congratulations on not only making it through medical school but already being in the world of OB/Gyn. I hear words similar to yours all the time, not with respect to applying to a fellowship, but with respect to trying infertility treatment. Patients sometimes are afraid to try even a Clomid/IUI cycle because they have a fear that it might not work. They don’t worry about the cost or the time commitment or the risk of multiples so much as they worry about the misery of doing a cycle and failing. Sure it’s sad to do treatment and not get pregnant, but is it really all that much better to remain not pregnant because you never tried to do any treatment? As for your question about when I decided to pursue going into REI, it wasn’t until I was on my way to applying to Gyn-Onc that I changed my mind.

Anyway, I commend your attitude. You have already committed to OB, so that’s one bridge crossed. Now that you’ve done it, I encourage you to explore it open-mindedly. After all, this is just your first year of residency. Who knows? You might end up loving Gyn-Oncology or Maternal-Fetal. But I agree with you in any case. Don’t let fear of not succeeding prevent you from trying.

Patients sometimes ask, “Is fertility treatment painful?” It’s a reasonable question. I know that before I personally undergo any medical procedure, I would want to know that. To better answer this question, I’ve taken an informal survey of my patients who did IVF and asked them to share about their experiences. As can be expected, there were a range of answers. However, the overall agreement, with a few rare exceptions, is that the physical pain associated with their IVF cycle was minimal. By the way, note that we’re talking now only about the physical pain, not the financial and emotional pain (if the cycle fails).

There are several potential sources of pain during an IVF cycle. The first starts out way before the actual egg retrieval. In preparation for the egg harvest, it is standard to take injectable medications to help develop the eggs. These are done with small needles and modern injection pen devices. Almost everyone dreads the first injection just out of fear about the unknown, but after the initial anxiety is over, most women report that the injection pain is nothing. The needles are tiny and go in fast and easy. Compare this to if you had diabetes. In that case, you would be injecting yourself with similar needles many times a day.

The next potential source of pain comes as the eggs develop, when the ovaries start to enlarge, causing bloating. This is a very real phenomenon, and there’s little that can be done about it other than to limit the number of eggs that we grow. Of course, this is a tradeoff, because if you only have 4-5 eggs, the pain and bloating are minimal, but your success rate is going to be decreased. This is the part most women hate, but in reality, most women with a well-controlled stimulation don’t even experience any real pain, but merely significant bloating, which itself can be quite uncomfortable. This discomfort can extend well into the week after the egg retrieval.

The third phase where there could be potential pain comes on the day of the egg retrieval itself. Knowing full well that the eggs are removed by piercing a thin long needle through the walls of the vagina into the ovaries, many women anticipate great pain on that day. But in reality, the pain is zero during the procedure, thanks to the wonders of modern anesthesia. In our program, we have anesthesiologists on hand for every retrieval in order to keep our patients pain-free and breathing normally with normal heart rates and normal blood pressures throughout the case. Some places around the country still do their retrievals without full anesthesia. While this is a cost savings, on the surface, there is a price with regards to patient comfort and the ability to successfully harvest each egg. Way back during my training at UCLA, we used to do these cases under sedation-only and it added to the difficulty of the egg retrieval when patients would occasionally twitch or move. It’s not that hard to aim a needle into a follicle, but it becomes way trickier when your target is moving.

Either three days or five days after the eggs are retrieved, the embryos are transferred back into the uterus. The transfer itself is almost painless, but it is as uncomfortable as a Pap smear.

After the retrieval, patients begin on progesterone, which is an injection, but different from the stimulation medications. Since it is an oil-based injection, the needle is larger and therefore more painful. The opinion on this is variable with some patients reporting a lot of pain while some find it quite tolerable. The ones who really find it unbearable have the option of taking their progesterone in other non-injection forms, such as with vaginal creme or vaginal suppositories.

So in summary, with regards to physical pain, while IVF has the potential to be painful in a few phases, in actuality, there is minimal pain for most patients.

However, nine months later, there is the much greater pain of childbirth and the postpartum period, which far surpasses any pain of the IVF cycle. The consolation is that this great pain is followed by the reward of motherhood

QUESTION:

I am looking for some information on high FSH/high estradiol levels. I am 31 and had blood work done in November 2008 on day 1 of my cycle because my skin keeps breaking out, so my dermatologist was trying to figure out if my hormones were the culprit. Turned out my androgen levels were fine, but my FSH was 17.7. So, I went straight to my OBGYN who tested me on day 3 of the next cycle in December 2008. More bad news. FSH was 11.9 and estradiol was 89. He referred me to an RE and said I probably wouldn’t be able to get pregnant on my own (without drugs). Why is this happening to me at 31 years old? I don’t smoke, drink occasionally, and I work out and eat well. What could have possibly happened to me that, at 31, my hormone levels are indicating that my ovarian reserve is either low or of poor quality (or both)? I was on the pill (on and off, but mostly on) for about 12 years. I had a miscarriage (chemical pregnancy) back in October 2008 (I went off the pill in July 2008). I have a history of endometrial polyps, and had a polypectomy back in October 2006. The polyps have not come back, but despite that, I still have dull aches/cramps in my lower abdomen on a regular basis. However, transvaginal ultrasounds show no more polyps growing. I recently had a CT scan which showed a small cyst (less than 2 cm in size) on my right ovary, but the radiologist didn’t seem to think it looked too alarming. Could any of these things be related to my high FSH/estradiol levels? Is this POF/premature menopause? If so, wouldn’t my estradiol be low, not high? I’ve read that the one thing in my favor is my age. Is that true, or do high FSH/estradiol levels mean bad news, despite being only 31?

Megan

Dear Megan,

I am sad for you about your news. Your situation points out the fact that a woman’s ovaries could age faster than expected without any obvious signs. It doesn’t happen to many women, but it happens to about 1%. It’s lucky that some random quirk of fate involving your skin led you to get your FSH tested, so you discovered this now rather than waiting until after it gets above 25. Your results predict that you are likely to have a harder time conceiving as compared to other women your age who have normal FSH values. An elevated FSH at 31 years of age still gives you hope for getting pregnant, either naturally or with help. However, the odds of getting pregnant naturally are probably pretty low (less than 2% per month), whereas the odds WITH the help of medications or IVF are likely to be higher. High estradiol levels (greater than 80 pg/ml) througout one’s cycle are good, but on day 3, high values are bad. The reverse is true. Lower E2 levels on day 3 are good, whereas if they stay low throughout one’s cycle, that is bad.

As for factors that are related to this, the polyps that you mentioned are not related to the FSH. The cysts are also unrelated. Your past history of taking birth control pills would probably have been of benefit (or at least neutral), rather than contributing harmfully.

While it is a natural human reaction to want to know WHY something bad has happened, the utility of knowing why is strongest when it can guide us to do something to reverse or halt it. In this case, if your diminished reserve were due to intense smoking, chronic illness, chemotherapy, environmental toxins or surgical damage to the ovarian blood supply, then it would be helpful to think about changing our behavior. However, in many cases, diminished ovarian reserve is due to unknown causes or to factors that exerted their effect before you were even born. So asking why becomes less useful than asking “What can I do now?”

Your doctor’s action of referring you to an RE was wise. It could be very helpful for you to discuss your fertility options promptly. Some options would include injectable gonadotropins or even IVF. If you are currently using contraception to intentionally delay childbearing, you might want to rethink things promptly. There still seems to be hope, but you have been given an indirect warning signal via your dermatologist. Good luck!

Hi Dr. Lee,
Your website is great! I would very much appreciate your advice, please.
Here is the background:
- At age 39, my new husband and I got pregnant on our first try. A beautiful Honeymoon Baby!
- Six months ago (I was 41 1/2), we became pregnant again without any medical intervention. We had tried for 6 months and finally “hit it” when someone gave us a tip about ovulation predictor kits.
- Sadly, I miscarried at 7 weeks. My period returned 4 weeks later.
- Now I am 42 and am seeking fertility help. Upon reviewing my diagnostic tests, I was surprised to find out my FSH levels were 28 and I only had 5 total eggs visible in my ovaries. This seems difficult to reconcile with the relative ease to which I’ve been able to get pregnant.

My question: My FSH test was taken 4 months after the miscarriage. Could the elevated levels and low egg reserve be due to my body still recovering from the miscarriage? I would greatly appreciate any insight you may have, as I can’t find any research about the impact of miscarriage on FSH levels and egg reserve.
Thank you so much!
Joanne

Dear Joanne,
An FSH level of 28 is not unusual at age 42. First of all, if it was not done on or near day #3 of your period, there is a chance it could be inaccurate. If it was done on the correct date, then it is an unfavorable sign. However, as long as you are still having regular menses, there is still a glimmer of hope. Every RE has their own “war story” of a patient with a high FSH who went on to have a baby. I can recall a patient who had a FSH of 27 who went on to have a healthy baby with her own eggs. The bottom line is that your age together with your FSH put you in a category of women who have a low possibility of spontaneous pregnancy, but while low, it is not entirely zero.

Now to address your question directly, the fact that you had a miscarriage just four months prior to that unfavorable blood test means that you still had the capability to get pregnant. The miscarriage itself would NOT be expected to affect the validity of the test. If anything, there might be a scenario where a recent miscarriage causes a falsely OPTIMISTIC result. Meanwhile, you would be wise to just enjoy loving your precious “honeymoon baby”, while you and your husband continue to get together randomly every 2-3 days. In my opinion, IVF would not really boost your chances enough in relation to how much it costs, but you could always discuss it further with your own RE or OB. Good luck!

Hi Doctor,

Your website is very nice and it helped me to learn more about these treatments….success stories really gives me hope…

I took clomid for 5 cycles but ovulated only once and didnt get pregnant. I had an ultrasound after the 3rd cycle and found a cyst on the right ovary. As the cyst was small they continued with the clomid for two more rounds. But I didnt ovulate. So my RE changed my treatment plan.

I took prometrium for 10 days and got periods after stopping it. I had my baseline ultrasound on cycle day three. Again they found a cyst on my right ovary and they put me on BCP for 11 days. On 12th day I had another ultrasound but the cyst was still there of the same size. So my RE said it might be the same cyst that I had 4 months back .RE said either it might be cyst hanging out on the ovary or on fallopian tube. I had an HSG earlier and my tubes are clear.

RE said this cyst won’t get affected by the stimulation. So she told me to start on the follistim.

I am confused now , because I stopped BCP and RE didn’t wait for the periods to come. She asked me to start on the follistim on the third day after I stopped the BCP.

Is this correct? Should I wait for the periods to come before starting the follistim? If I don’t wait will I get periods while I am on follistim?

It would be a great help if you could answer my question. Thanks in advance.

Annie

Dear Annie,

I can’t give an answer as to what is the best treatment for you, because there are a lot of things that I don’t know about your case. However, I can address a few general topics. As you may already know, the reason that we do ultrasounds prior to starting ovarian stimulation is to check for cysts. There are functional cysts and non-functional cysts. Functional cysts could react to the stimulation medications and end up growing. Since they are out of sync with the cycle, their continued growth would end up lowering the success chances of the cycle in many ways. For example, they could grow and cause the release of LH before the follicles have time to mature. There is also the fear that the stimulation might make the cysts grow so abnormally large as to risk of a lot of other problems (ruptured cyst, ovarian torsion). A non-functional cyst, on the other hand, will not grow in response to the stimulation. Non-functional cysts are inert. The problem is…you can’t tell a functional cyst from a non-functional cyst the first time you see it. You can only figure it out by seeing what it does over the course of time.

As far as not waiting for a period after starting the BCPs before starting stimulation, you have a very valid point. I usually wait for a period so that the old lueteinized lining is shed. BCPs make the lining post-ovulatory, so that it would not be receptive to implantation. You should discuss with your RE why she chose not to wait for a period. She might have a good reason.

Dear Dr , I have been through each and every section of your website and it
is really very informative for people like us who sometimes wish to know ,
why this treatment , what would it do? It has really encouraged me to ask my
RE politely about various things and treatments she suggests.

My goal is not to make extra work for my colleagues , but there are certainly times in which part of being an RE is communicating with patients and not just being an egg and sperm engineer. I personally get a lot of satisfaction from teaching, not just teaching medical students, but also teaching my patients and my blog readers.

There is this one thing about which I’ll like an opinion from you. I’ll
try to be brief but explanatory about my history , please advise me , I
really need your advice.

My Problems - TTC for 3.5 years now, I am 29 now.
- Irregular periods(since the age of 21, was on provera to get my periods)
- Married at age 25(BCP for 6 months)
- Detected with PCOS, Insulin resistance and hypothyroidism(currently on
metformin 1500 mg, synthroid 50mg) after 6 months of marriage
- Vaginismus - to top all the above problems , I have this, I sometimes
want to run away from this truth but I just cannot , my brain just does not
let my husband in and I don’t know whether we have ever had a successful
intercourse. I had a surgery to remove the hymen which the doctors thought
might be causing pain. I have been able to get all vaginal ultrasounds and
IUIs but I still can’t let him in. I just can’t state my helplesness and
wish somebody could understand it.

Infertility problems are divided into problems of sperm, eggs and anatomy. You haven’t mentioned sperm yet, but the irregular menses suggest an egg problem and the fact that you can’t effectively have sex creates an anatomical problem. Over the course of my practice, I have encountered quite a few married couples who never have sex. There are obviously many emotional implications in addition to the fertility implications. Dyspareunia is the medical term for painful sexual intercourse. This is further divided into deep dyspareunia and superficial dyspareunia depending on if the pain is felt deep in the pelvis or on the skin and surface. Vaginismus is a case of superficial dyspareunia. Your case, while severe is not as severe as those women who can’t even get ultrasounds.

I have been working on my above problems, I started with an aggressive
approach this year when my RE said that inseminations will overcome the
vaginismus factor. I have had 3 IUIs , 2 IUIs with clomid cycles and one
with Injectables. In both the clomid cycles , I had good mature follicles
always on my right ovary on cycle day 18 . The first cycle , I had 3 that
measured 2.1, 1.8 and 1.7 but my lining was only 0.5 cms. Next cycle with
clomid on my right ovary I had only one mature follicle on day 17 of 1.9 cm
and my lining was agin a 0.6. My RE said that clomid is causing the thin
lining and moved me to Injectables with the low dose of 75 IU. I had 5 good
follicles this time on cd12 and they were 1.9, 1.8, 1.8, 1.6, 1.5 and my
lining was 1.07 cms.I had the HCG shot at 12:00 in the night and went for
IUI at 9:30 on cd14.My doctor said the chances are very high and I was
started on progesterone on cd14 itself and on CD21 the progesterone levels
came as 38.3 but I wasn’t pregnant.

My questions
1) Is one IUI enough for me, knowing my situation that aur love making is
not successful , should we go for 2 IUIs in one cycle and if 2 what should
be the timings of them?

This type of detailed variation is an individual choice between the RE and the patient. There is no clear data showing that two IUI’s are that much better than just one. The timing of IUI’s is also a personal judgment call. Many RE’s don’t time it down to the hour, but just schedule it sometime either 1, 2 and/or 3 days after the hCG shot. I like IN GENERAL, to do the IUI about 40 hours after the hCG shot, but it varies especially in patients who have had previous IUI’s in which case you can go back and see what they have done in the past, so as to fine tune the plan for future cycles.

2) can inseminations truly overcome the vaginsimus factor, if so , why do
doctors say to make love that night and the following night ?

IUI’s get the sperm deep inside the uterus. For patients with vaginismus, the sperm often doesn’t even get into the vagina. So, yes, IUI’s are mechanically very effective for overcoming the vaginismus factor. I’m not sure what you mean in your second question. We don’t typically tell that to our IUI patients.

3) Also, I think that I took the HCG shot quite late at night(As in one of
your case studies you said it should be 35 hrs prior to iUI). Please tell me
when should the HCG shot be taken and when should the IUIs be done to have
most chances?

Again, refer to my answer to question #1. It is not set in stone. By the way, please point out where exactly did I said 35 hours for IUI. It might be a mistake. Or are you sure I wasn’t referring to IVF? In that case, it is indeed about 35 hours between hCG and egg retrieval.

3)Also, my RE didn’t do a HSG for me and she wants to do it this cycle, can
I do an HSG and an IUI in the same cycle? Also, as they say HSG improves
fertility , is that true , would that really help?

Yes, it’s possible and often done to have an HSG and an IUI in the same cycle. The drawback is if the HSG shows both tubes to be blocked, then you’ve wasted the ovarian stimulation. In some patients, an HSG does improve pregnancy, both through natural intercourse and through IUI. The thought is that the dye flushes debris and "junk" out of the tubes making them cleaner than ever.

4)If due to vaginismus my chances are very low with IUI,should I just move
to IVF ?

If your only problem is vaginismus, then IUI should overcome it. Bear in mind you might have other problems, such as egg quality issues, if you truly do have PCOS, as you suggested. In general, if the tubes are open, my patients undergo 1-3 cycles of IUI before going on to IVF, but there are so many factors to consider that you had best leave the recommendation up to your own RE.

Thanks
Pia

Dear Dr.

Eve

Dear Eve,

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

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

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

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

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

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

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

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

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

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

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