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.

FERTILITY STRATEGIES: Posts on how to logically approach the problem, choose the right decisions and take the right actions.

INSIDE VIEW: An inside glimpse of this reproductive endocrinologist’s daily work life

LIFE AND HAPPINESS: Bits and pieces from my personal life, my philosophies and beliefs, including political views

QUESTIONS AND ANSWERS: A mixed bag of reader questions

FERTILITY NEWS: News stories about fertility-related issues

REAL STORIES: Real cases from patients who have generously agreed to share their stories

UNCATEGORIZED: Anything that doesn’t neatly fall into any of the above categories

Many factors have led to this and any one of them could be enough of an excuse.

1. I’ve had to deal with the IRS. This was arguably a huge waste of time that didn’t accomplish much. The matter is finished and ironically, it turns out that I have actually OVERPAID my taxes. I mean that in the legal sense, that I paid more than I was obligated to by law. If we look at in the moral sense, almost all of us overpay our taxes, seeing how the government surreptitiously takes more than a third of every dollar that we make in some way or another through federal tax, state tax, sales tax, property tax, social security, medicaid, disability, and those $1.58 surcharges we see in our cell phone bills. To further interfere with our freedom, the government then goes on to devalue our dollar’s spending power even more by diluting the money supply and contributing to inflation. In order not to get angry thinking about it, I just realize there’s little I can do other than move to a different country. Sadly, neither of the two current major political parties seem to have any interest in reversing this runaway trend. I’ve learned long ago to focus on being grateful for the chance to do something fun and spiritually meaningful every day and not think so much about the unfairness of our over-regulating government.
2. I’ve taken time to make many improvements to our office’s workflow process. This has been very exciting and I’ll share more about this elsewhere.
3. I’m had some exciting welcome distractions in my personal life, for which I’m always grateful.
4. Honestly, I got a little bored of blogging. It’s been close to one year already since I started this site. As it happens often in my life, doing something the same way for a long time leads to my losing interest. However, this type of boredom is GOOD NEWS, as it inspires me to shake things up and try new things. As you may have noticed, I have upgraded the look and feel of this site, and I will continue to do so. I am about to start another blog (more on this later). I also have some other very exciting related projects on the horizon. I don’t want to say too much yet, until I’m ready to deliver!

So please grant me this little break and I promise you’ll see bigger and better things soon!!

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.

When patients make it to 12 or 13 weeks gestation, they graduate. We have a small ceremony and give them gifts. They celebrate freedom from taking their progesterone shots. We make a DVD of their baby doing back flips in their final first trimester ultrasound so they can watch it over and over. They say goodbye to us as they transition to their OB, relieved to be out of the first trimester, usually the most common period of pregnancy loss.

For Irene, she was not entirely free. She had to stay on her heparin and aspirin. Over the past two months, we had seen her every week and the pattern was consistent. We would show her the baby’s heartbeat on the ultrasound and she would be so relieved and happy. And then, at home, over the course of the week, the fear and anxiety would gradually gnaw at her insides so that by the time she came back for her next ultrasound, she was a complete nervous wreck.

Now on her last visit, she seemed panicked about saying goodbye to us. I knew it was because she realized that with her OB, she would be only getting visits every 3-4 weeks, which meant to her 3-4 weeks of not knowing how the baby was. I promised her she could drop by any day for a quick heartbeat check ultrasound all the way until 20 weeks when she would start feeling the baby move. At that time, she would have her own way of reassuring herself that the baby was fine.

We kept in touch with her less and less, until one day, we got the call from her husband that she had delivered a beautiful 7 pound 6 ounce baby girl, thanks to the benefits of heparin!

Imagine that four times in your life, you have been pregnant and imagine that all four times have ended in miscarriage. It’s pretty understandable that now, in your fifth pregnancy, every twinge of abdominal pain can make your heart race with panic. Every time you use the restroom, you dread wiping for fear of discovering that first brown spot or even worse, that bright red flow. Your nights are sleepless as your mind fills up with the big question of when will disaster strike again? This is the predicament that Irene was in.

I got an instant message from my staff telling me that Harold was on the phone and he sounded very distraught. I took the call. He apologized for calling, but he didn’t know what to do. Irene was falling apart. She was not sleeping and not eating. I had them come in to talk in person.

ME: Thank you for coming in. What’s been going on?
IRENE: No, thank YOU for seeing us on short notice. I am embarrassed. I can’t believe that I’m acting this way.
ME: What way do you mean?
IRENE: I can’t sleep. All I can think about is losing this pregnancy. I know it’s not healthy for me to be like this. Everything panics me. Last night, I had a stomach ache after eating some ice cream and I immediately expected to start bleeding, even though it wasn’t the same cramping pain that I had with the miscarriages. I hate it.
ME: What you are feeling is very normal, considering what you’ve been through. Let me summarize your situation, OK? We have done a thorough investigation of your case and we have discovered a very significant finding, namely that you have a positive Lupus Anticoagulant test. You remember that, right?
IRENE and HAROLD nod.
ME: There is a good chance that this is the main contributor to your miscarriage history. We have the means to address this problem and we have instituted the right action. You are taking the heparin daily, correct?
IRENE: Yes. Every day.
ME: How’s that going, by the way?
IRENE: Not bad. I do have some bruising though.
ME: OK, I’ll take a look at it shortly, but a little bruising is normal. It’s not severe, right?
IRENE: Can I just show you? (raises the bottom of her blouse a little to expose some mild bruising on her abdomen)
ME: Yes, that looks fine. Anyway, as I said, we have this in place. You are on heparin and aspirin, which is intended to counteract the harmful effects of the clotting disorder. (I flip through the chart). Your first hCG level was 88. We then repeated it in two days and it was 169. This is an excellent rise. Then yesterday, we repeated it again. It was 625, which considering it was four days after the 169, is still a very good rise. At this point, all we can do is keep checking your hCG level every four days to give you the peace of mind that you need to know that everything is OK. At some time very shortly, I will do the first ultrasound. After that, we will do a second ultrasound in which we can see the heartbeat. I have a feeling you will feel a lot calmer after that. Meanwhile, we all just have to wait.
IRENE: Thank you. I feel a little better, but I know that when I get home, I’ll look around and be reminded of the places in the house where I experienced the other miscarriages and I’ll panic again. Is there anything safe for me to take that will calm me down?
ME: It’s best for you to avoid any tranquilizers or medicine. Unless you are feeling like hurting yourself or hurting Harold or you are totally unable to eat or to care for yourself, I would prefer not to prescribe anything. That’s not the case, right?
IRENE smiles.
HAROLD: Doctor, right now we are in your office and we feel safe, but I know that the moment we get home, it’s going to happen again. I have to get some sleep so I can do my work and I can’t spend every moment worried about this.
ME: Irene, what do you suggest? Do you have any ideas of what can make you more at peace, other than for us checking your levels and giving you reassurance with the results?
IRENE: In my mind, I trust what you are saying, but I can’t control my thoughts. Honestly, it just builds and  builds until I’m crying and ready to scream.
ME: I see. Well, let me think about this. I have two suggestions. One is for you to stay somewhere other than your home. It sounds to me that the environment is triggering bad memories because the rooms in your house are where you had the bleeding and the cramping that led to the bad outcomes. Can you stay with your parents or Harold’s parents or anyone?
IRENE: I see what you’re saying, but I’m not going to stay with Harold’s parents. His mom would drive me crazier and I don’t want her to force me to take that herbal stuff again.
ME: Hmm, OK. Well, I have another suggestion, but I have to warn you that it’s really silly.
IRENE: What is it? (almost smiling)
ME: It’s something that one of my patients taught me. She tried it and it helped her. Right now, you feel very safe in my office, right?
IRENE: Yes.
ME: What if I asked you to remember your miscarriages, to picture them in your mind right now, as vividly as you can? I know it sounds cruel and crazy, so you don’t have to if you don’t want to.
IRENE: I … I think I can do it right this moment, but how is this going to help?
ME: This is a little mind trick to help calm the association that you have between your memories and your emotions. Visualize your worst memories of the miscarriages and THEN I want you to replay the scenes over and over in your head like a movie, but I want you to shut out the sound and instead, insert a movie soundtrack. Choose music that is silly and happy, like something you would hear in the circus with clowns and animals running around. I bet you think I’m crazy, but maybe you could just try it.
IRENE: OK. It sounds so crazy I am thinking it might work, haha.
ME: OK, start now and do it over and over. You can do it too, Harold. Well, I’m going to go do some ultrasounds, but I’ll be back in 15 minutes to check on you.

When I came back, there was a sense that the tension in the room was greatly diminished. Both of them were smiling, although Irene was very obviously tearful. They left my office with hope.

My nurses checked on them the next day. Irene was still very anxious, but she admitted that things were a little bit better.

Click here for episode 9

Irene had started her injections on day 3 of her cycle. After five days of injections, it brought us to day 8 and she was here for her ultrasound. This is what we saw:

RIGHT OVARY: (14×13) (15×14) (13×13)
LEFT OVARY: (16×14)

Lining = 8mm Triple Layer

This was a great stimulation. There were enough follicles to give a good chance of pregnancy, but not so many that we needed to be concerned about quadruplets. The follicles were not quite ripe yet, but they were close. I continued her on the same dose and brought her back after two more days.

This is what we saw:

RIGHT OVARY: (16×16) (17×16) (13×13)
LEFT OVARY: (21×18)

Lining = 8mm Triple Layer

It was a tossup whether to trigger the ovulation today or to wait one more day. I decided to go ahead and trigger and bring her back two days later for the insemination. In general, for first time patients, I trigger at around 5PM in anticipation of ovulation in the morning two days later.

Irene came back two days later and had her insemination. She was started on progesterone supplementation.

Twelve days later, she came for her pregnancy test. It was positive! Her hCG level was 88 IU/L !

For most first time pregnant women, this would be a great moment of joy. For Irene who had four miscarriages in four pregnancies, this was the beginning of the scary time.

As planned, she was started on daily injections of heparin.

Click here for episode 8.