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

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

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

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

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

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

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

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

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

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

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

What kind of fertility patient are you?

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

What happens when the beliefs of one group of people affect the freedom and rights of another group of people?

A month ago, I wrote Part 1 and Part 2 of this series on Georgia Senate Bill 169, a proposed legislation which slams into conflict two groups of people. The supporters of this bill view that laboratory embryos should be afforded the same rights and protections as a live-born child. The other group opposes the bill and believes that infertile couples who are trying to have a baby should not have their options overly restricted. So just what is this bill all about?

There are multiple components to this bill. The first part reads:

(a) It shall be unlawful for any person or entity to intentionally or knowingly create or attempt to create an in vitro human embryo by any means other than fertilization of a human egg by a human sperm.
(b) The creation of an in vitro human embryo shall be solely for the purpose of initiating a human pregnancy by means of transfer to the uterus of a human female for the treatment of human infertility. No person or entity shall intentionally or knowingly transfer or attempt to transfer an embryo into a human uterus that is not the product of fertilization of a human egg by a human sperm.

In our program, there’s only one way we know how to create embryos, namely by fertilizing human eggs with human sperm. I don’t know of any other programs that are doing it any differently, such as any using kangaroo eggs or hamster sperm, but if there are, I guess they’d be in trouble if this bill passes. Granted, this clause could also be interpreted to ban cloning. However, that would be redundant as there are already federal provisions in place aimed at banning cloning. This part of the bill doesn’t affect my patients, as we presently don’t do cloning.

The next section addresses financial compensation given for embryos or gametes. It reads:

No person or entity shall give or receive valuable consideration, offer to give or receive valuable consideration, or advertise for the giving or receiving of valuable consideration for the provision of gametes or in vitro human embryos. This Code section shall not apply to regulate or prohibit the procurement of gametes for the treatment of infertility being experienced by the patient from whom the gametes are being derived.

In a free society, people enter into agreements based on mutual benefit. Infertile couples sometimes need help from other people in the form of donor sperm or donor eggs in order to fulfill their dreams of parenthood. As a way of thanking the donors, financial compensation is routinely offered. To do away with this option would be disastrous if we look to the UK as an example. Over there, paying for donors is forbidden. This all but eliminates anyone from wanting to participate, leading to a loss of options for most couples, unless they are willing to resort to drastic risky behavior. For some of them, there is the option of coming to the US. In the past two years, I’ve had the chance to help four couples from countries in which paid egg donation is banned. After they got pregnant, they vented their anger at the unfair restrictions in their home countries which compelled them to come to the US. Well, if this happens in the US, I’m not sure where patients would go for their treatment, maybe Mexico?

The next section reads:

The in vitro human embryo shall be given an identification by the facility for use within the medical facility. Records shall be maintained that identify the donors associated with the in vitro human embryo, and the confidentiality of such records shall be maintained as required by law.

This is just plain meddlesome and seeks to slap a regulation onto something that is already routinely done out of common sense. We already document and label meticulously, so again, this would not affect us much.

Going on, the next paragraph reads:

19-7-64. (a) A living in vitro human embryo is a biological human being who is not the property of any person or entity. The fertility physician and the medical facility that employs the physician owe a high duty of care to the living in vitro human embryo. Any contractual provision identifying the living in vitro embryo as the property of any party shall be null and void. The in vitro human embryo shall not be intentionally destroyed for any purpose by any person or entity or through the actions of such person or entity. (b) An in vitro human embryo that fails to show any sign of life over a 36 hour period outside a state of cryopreservation shall be considered no longer living.

Here’s where it starts to get a little annoying. This vague statement suggests that the writers of this bill are not familiar with what actually happens in an embryology lab. When we put the sperm and egg together from a husband and wife couple, we have to assign somebody the power to determine what is done with that embryo — whether it is transferred back into the wife, transferred into someone else or frozen for the future. Whether or not it is labeled as the “property” of anyone, we have to give someone the legal authority to make the call of what happens to the embryo. This is like passing a law stating that a child can not be labeled as the property of his parents. That’s fine and dandy, but then is it OK for someone to grab a baby out of a stroller at the mall and take the baby home because it wasn’t the “property” of the parents? Very silly. Whether or not you label it a property, there HAS to be some legal designation, enforced by contract, to confer rights to certain people regarding the embryos, because you know what? The embryos can’t make decisions on their own.

The next clause appears redundant because it states:

Only medical facilities meeting the standards of the American Society for Reproductive Medicine and the American College of Obstetricians and Gynecologists shall cause the fertilization of an in vitro human embryo. A person who engages in the creation of in vitro human embryos shall be qualified as a medical doctor licensed to practice medicine in this state and shall possess specialized training and skill in artificial reproductive technology in conformity with the standards established by the American Society for Reproductive Medicine or the American College of Obstetricians and Gynecologists.

IVF is a medical procedure and as such, can only be done by medical doctors. There is no real need to restate it. Again, this is verbose, but not really changing anything that we already do.

The next section is where it starts to get really intrusive:

In the interest of reducing the risk of complications for both the mother and the transferred in vitro human embryos, including the risk of preterm birth associated with higher-order multiple gestations, a person or entity performing in vitro fertilization shall limit the number of in vitro human embryos created in a single cycle to the number to be transferred in that cycle in accord with Code Section 19-7-67.

In order to grasp the impact of this intrusion, let’s review how IVF works. When a couple make the decision to do IVF,  our goal is to help the couple create some healthy embryos that will grow into healthy babies. We help do this by putting their eggs and sperm together. The procedure take a lot of dedicated work from a team of many people. The main labor is the surgery involved in extracting the eggs. The good thing is that each additional sperm or each additional egg does not add all that much cost to the process.  Therefore, it would be highly wasteful to do IVF with just one egg and one sperm. We can’t know for sure how many of the eggs we get will successfully fertilize. Out of those that do, we can’t know for sure which will continue to survive until the day of transfer. Can you imagine a lawmaker telling you that you can’t put more gasoline in our car than you’re going to use each day?

On the day of an IVF egg retrieval, we surgically remove all the eggs that stimulated for that month. We try our best to fertilize every one of them, because we know that most of them will not end up capable of becoming a healthy baby. By attempting to fertilize all of them, we get the best chance that at least one or some of them will end up being good. In a good scenario, we get enough healthy embryos to transfer as well as some additional ones to freeze for future attempts. For many couples who fail IVF in the first fresh attempt, those frozen embryos are the difference between their ending up with a baby in their home vs. remaining sadly childless.

The rest of the bill piles on further restrictions by telling us how many embryos we can transfer. This issue of embryo number is such a loaded issue that I’m going to save it for the next post.

Nadya S. is NOT in any way, representative of the hundreds of thousands of genuine loving inferile couples in the US, whose only wish is to have a child to love. She is now applying for a trademark on the term “Octomom”. If you ever see her picture and/or name on T-shirts, mugs, ovulation kits or stripper attire, I urge you to boycott the product.

It would be a shame if overreactive legislation were passed to further impede the hopes of infertile couples all because of this one case.

By the way, there is no truth to the rumors that Dr. K has applied for a trademark on the term “OctoDoc”, although he HAS been heard to have jokingly referred to himself as that during a conversation at a recent pharmaceutical company-sponsored event that he attended this past month.

Planning ahead can really pay off.

A teenager diagnosed with leukemia was advised to save his sperm before undergoing his cancer treatment. Now, 22 years later, he and his wife are parents thanks to this forethought. For patients newly diagnosed with cancer, there is an organization which provides information regarding fertility options.

Many patients are referred to me for guidance after finding out they have cancer. Often, after learning about their options, they end up saving their sperm or embryos so that they can have children in the future. While some patients will need these preparations in order to conceive, there have been other patients who make these arrangements, but then end up getting pregnant on their own afterwards.

Can the sperm of a dead man be used to create babies? A recent news story brings up this controversial topic once again. The concept of posthumous sperm utilization is not a new one and there have been many cases of babies being born to deceased men.

I have been involved in such a case myself. I can only share the basics without divulging the details. This was a couple who were in the middle of infertility treatment when suddenly the husband took ill. He went to the doctor and was diagnosed with cancer. The couple halted their treatment, but deliberately took action to freeze many vials of sperm. The husband did not survive his disease, but made it clear that he wishes to give his wife the option of using his sperm. She came back after a time and did just that. Now she is successfully raising happy healthy children conceived from her deceased husband’s sperm.

The difference in the case of Nikolas Colton Evans is that he never explicitly expressed his permission to do this. In fact, he never even went to the trouble of saving sperm ahead of time. So this is not just a case of using posthumous sperm, it’s a case of harvesting posthumous sperm.

Instead of arguing the merits of doing it, one might present the counterargument of why NOT do it, as long as the mother wishes to. Well there is the question of the rights of the deceased. Do dead men have the right to not have their sperm taken and used? What about the rights of the future children? Do future children have the right not to be conceived if their biological father is already deceased?

By comparison, this woman and this woman make Nadya look like Mother of the Year. I haven’t decided yet what is the solution for preventing grossly irresponsible women from becoming mothers. Any ideas, besides withholding welfare handouts to women until they can prove they are practicing safe contraception? So sad.

I’m OK. Thanks for asking.

It’s good to know that my two-week absence from blogging has elicited such caring inquiries from many of you, asking about my well-being. Now I need to be a bit more honest. I’m actually NOT OK.

Well, to be more precise, I’m just about as OK as anybody else who lives in the United States, or even more specifically, in the state of California, which at the moment, is not that great. For the first time since perhaps the 9/11 incident, I am questioning the security of our way of life. To put things in perspective, if you were to ask me any time in the past five years this question: “How sure are you that in the next year, you, your friends and your neighbors will continue to have adequate food, water, electricity, lines of communication and safety from people with criminal intent?”, I would have thought “Huh? What kind of silly question is that?” and then answered 99%+ sure. After all, we live in modern-day America, not some impoverished third-world country and not in medieval times. However, if you ask me that same question today, I would say that I am only maybe 70% sure. The significance of this difference to me is HUGE.

We have grown to take for granted that we will always have access to food, water and emergency medical care and that we will always be able to count on the police to protect us from criminals. But reality reminds us that we can’t always do that. The two most glaring examples that come to mind are New Orleans during Katrina and LA during the riots. I learned a lot about the reality of life during Katrina during my trip to New Orleans for the ASRM meeting a few years ago. I befriended a taxi driver and some other locals and learned their war stories firsthand. The tales were surreal, giving me a grim reminder of how quickly life as we know it can revert back to the barbaric conditions of the Middle Ages. I’m also reading a fictional book, “The Tin Roof Blowdown“, which contains some of the most gory graphic descriptions of the chaos that occurred during Katrina.

Just as I went into medicine partially out of a burning curiosity about how our bodies work, I love to regularly research psychology, sociology, history and politics to satiate my desire of knowing how the world works, and I am now of the opinion that there is uncertainty, enough uncertainty that I am officially “concerned”.

Bear in mind that I look with amusement upon the globing warning alarmists or the religious zealots who predict the Apocalypse is coming this week or that week. But I am not fanatically ranting that the world will end tomorrow, or even next year. However, let’s just say that based on my own research AND based on what my own eyes see happening in the real world all around me, I know in my heart that this country is headed in the wrong direction.

Prior to this recent revelation, the life for my staff and me consisted of working our hardest for our patients, which for me, meant willingly giving up around 60 hours per week (including many weekends and some late nights) seeing patients, talking to patients, reading up on new advances and blogging. Some friends would feel bad that I worked so hard, but I reminded them that this was my calling in life. The reward of helping people have babies makes it intrinsically fun for me. Also, as a very important added component, in return for my sacrifices, I was shown gratitude by patients, who paid fair financial compensation so that I was now empowered to accomplish my many other goals and leisurely pursuits. It was a very fair system and is basically the American way, or at least, the American way that was originally laid out by the writers of the Constitution. Equally fitting, my patients were out there productively working their hardest using whatever their own talents were to make life better for THEIR customers, patients and clients. And as a result, they were paid adequate compensation so that they could pursue their goals for happiness, which just so happened to include doing medical treatment to have babies. In this system, everybody had the freedom to choose how hard they worked, with the corresponding reward in return.

However, as I mentioned earlier, things are changing for the worse. Now, I, for one, was  glad to see George W. Bush leave office. I disagreed with his specific policies which led to a further shift in the balance from individual freedom to excessive government power. I was optimistically open-minded (but cautiously skeptical) that maybe Obama’s promises of a “change” were more than empty political promises. But, BAM! Out of the gate, like a slap in the face, the new president showed his true self. My friends tire of me reminding them time and time again that we should judge people by their actions and not by their words. Well, the president’s first major action, deceptively called a “stimulus” package, is what he should be judged by, not by his sweet words of promising to make the country a better place for the people. No, I have not read the entire word-by-word rendition of the package. But then again, neither have any of the politicians who voted for it. However, I have studied it enough to render my strong opinion that it has little to do with helping people and more to do with increasing the massively growing domination of political power.

I have an interest in discussing these details in future posts and I plan to do so, even at the risk of you readers eventually telling me “Enough politics already! Get back to writing about fertility!”, but for now, I just wanted to share with you why I have been absent from blogging these past few weeks. I compare my recent world view to that of a not-entirely-unsuspecting New Orleans resident in the few days before Katrina. Sure, the news keeps warning us something bad MIGHT happen. Sure, we can see the wind and skies outside ourselves. But we don’t really know if, when or how hard it will hit. Meanwhile, though, we’re getting ready stockpiling food, setting up emergency generators, boarding up our windows and making contingency plans to get out of New Orleans. So, in this instance, how am I getting ready for a future collapse of this country? By researching and learning so that I can share information with others. Because, unlike a hurricane descending upon us, the upcoming social and economic disaster IS potentially preventable. I am hopeful that we, as a people can wake up and reverse the ever-growing shift from government dominance to individual freedom. We’ll see.

But don’t worry, I’m still practicing medicine. In fact, things have been busy and pregnancies have been coming in bunches (little bunches, not 8-fold bunches) and I still have lots of good stories and insights to share in future posts. I just realize now that we all have to prepare for a potential disaster that I hope will never come.

This bizarre story illustrates how time and time again, turkey basters and alcohol don’t mix.

In the previous post, we introduced the setting, describing what’s going on in Georgia. A trio of politicians are pushing for the adoption of new laws governing what people can do with regards to in-vitro fertilization. Today, we’ll begin dissecting the actual meat of this proposed legislation to see if it really is the best way to prevent cases like the octuplets from ever happening again.

I tried to be open-minded. I really did. But, right away, looking at the very name made me fight with every ounce of energy to avoid rolling my eyes. This act is cited as the “Ethical Treatment of Human Embryos Act”. Ethical treatment of a microscopic cell? I do understand that physical size is not the sole criterion of how significant something is, but it does lead to some amusing perspective to imagine cruelty being done against something that can’t even be seen. A human embryo is smaller than the specks of particles that you stir up when you blow on a dusty old countertop. In fact, you can’t even see an embryo with the naked eye. I can visualize images of torture against human beings in North Korea. I can even imagine people being cruel to a kitten. And of course, there is a tiny part of my humanity that mourns for the life of the little ants, right after I blast them with Raid. But my limited imagination falls short when I try to conjure up images of evil scientists in the lab inflicting pain and suffering on macroscopically invisible entities.

OK OK. So size isn’t everything. One can argue that an embryo can become a golden-haired blue-eyed little girl some day. That’s certainly true. But it’s still a huge fallacy to compare the humanity of an embryo with the humanity of a baby. A sperm CAN become a person someday, if it meets the right egg, but most of them don’t. An egg CAN become a person someday, if it meets the right sperm, but most of them don’t. An embryo (union of sperm and egg) CAN become a person someday, if it is normal and encounters the right environment, but most of them don’t. As somebody who works with this day in and day out, I do not think of an embryo as having constitutional rights. And I take issue with the people who scream, “Eggs, sperm and embryos can’t defend their own dignity, so we have to do it for them.”

OK OK. I know. These people are not screaming for the rights of eggs and sperm (gametes) — only for the embryos that form after the two combine. So if you present these esteemed politicians with a culture dish with an egg in it, I understand they’ll just yawn and say “oh that’s just a fleck of biological dust”. If you then show them a droplet of sperm, they’ll likewise agree “move on, move on, nothing to see here”. However……..(drumroll)…..the moment that the droplet of sperm is added to the dish with the egg in it, these politicians begin having heart palpitations and start drooling and dancing around the dish, ranting about preserving the dignity of the contents of that dish.

OK OK. So maybe I should be a little more serious. Again, I work with this day in and day out. I fully agree with the sanctity of family and of human life. People rely on my labor to help them have little babies. This thrills me without end and gives meaning to my existence. I respect that out of the bodies of the husbands and wives we can take tiny tiny biological cells and put things in motion so that maybe, possibly, one of these combinations MIGHT end up causing a baby to start growing inside the womb (or so we hope), which is why, I immediately become protective when someone starts to impede our mission, and for what? For the purpose of preserving the dignity of an embryo.

The utter ludicrousness of this might be more evident when you consider that were this bill to become law, it would be illegal and punishable, for you to put an embryo dish on the counter at room temperature and allow it to sit long enough to become nonviable. But, (now this is just mind-boggling), if the embryo were transferred into a woman’s uterus and it happened to implant (most of them won’t by the way) and if this implanted embryo were to grow and grow to become a moving fetus with heartbeat and everything. OK, THEN, in the state of Georgia, it would be completely legal to terminate it. How can you argue to give rights of embryos that supercede the rights even of successfully implanted fetuses? Whether we agree with it or not, we live in a country where first trimester terminations are not illegal.

OK OK. I am aware it is very likely that the same people who want to make it illegal to treat embryos “unethically” are also in favor of banning abortion, which raises the obvious question of what’s going on here with this bill. Is it to improve the quality of life for people as a whole? Or is it an indirect way to advance a political agenda? You be the judge. Now many of you may be curious as to my view on abortion. I do have a view. There is a 99%+ chance that no matter what I say about it, somebody from either side of the debate will egregiously misinterpret what I say, and twist it around, so I’ll choose my words judiciously in asserting that I am emphatically OPPOSED to abortion, specifically to the concept of aborting a known healthy fetus that is very likely to be born normal, just for the sole purpose of not having it be born. However, there is a difference between being opposed to something and necessarily thinking that it absolutely must be made illegal. The question is will making abortions illegal stop them from happening, or even lessen their occurrence? What is the tradeoff in harm, if any? I am opposed to murder, rape and abortion (as defined earlier in this paragraph). And I agree that murder and rape should be fully punishable, because if we were to make murder and rape no longer criminal, life would suffer greatly as a whole. The laws against murder and rape don’t prevent them 100%. Every day, these horrible crimes occur. BUT, to make it legal is not only silly, but also would result in things being much much worse. This concept is not as clear-cut when it comes to the matter of making abortion illegal. Criminalizing abortion might make the number of abortions go down somewhat, but cases of deaths or reproductive injury to young women would very likely go up from horrid back-alley procedures. This is more than just a theoretical argument. My beliefs about human behavior along with historical observations convince me of this. So before I get too off topic, I would assert that if I were a politician, I would vigorously enact changes that could lead to fewer abortions. But for me, those changes would be targeted at changing the mindsets of people regarding how much risk they are willing to take when subjecting themselves to the chance of an unwanted pregnancy. In other words, I greatly favor doing what we can to prevent abortions, which I feel could best be done at the level of preventing unwanted pregnancies in the first place. Now as to what policy changes I think would lead to fewer unwanted pregnancies? That’s a whole other lengthy post, maybe for another day.

So after taking this entire post to address the very title of this proposed bill, I’m guessing this is going to take more than two posts to address. Stay tuned as we dissect this further.