When Terra and Miles (not their real names) first came to me, they confessed that they were unsure if they should be pursuing fertility treatment yet. After all, they had only been trying for one year and were both healthy. Terra was 30 and had never been pregnant before in her life. Miles was 33 and had never fathered a pregnancy. They had actually known each other way back in college, but had not started dating until five years ago. They have been married for four years. Miles enjoyed his job, working for the police department in an administrative capacity, not out there in the field chasing bad guys. Terra worked in the HR department of a large company. Her job was quite stressful, but she had developed a good attitude about handling it. Terra said that her brother and his wife had been our patients and his persistent influence was the main reason why they were here. Terra gave me a quick update on how cute her new baby niece was and we started working on their case.

I started out by exploring what they meant when they said they had been trying for only one year. Hadn’t they been married for four years? “Well, yes,” Terra replied, “But in the past year, I read this book about taking charge of my fertility and I started doing cervical mucus checks, charting temperature and using ovulation sticks to time when to get together.” After further questioning, it was revealed that for their entire marriage (with the exception of the first three months), they had not used any contraception. They also reported having sex three times/week even when before they started tracking temperature. I explained to them that “trying” does not refer to actively doing things to track ones ovulation. In the true sense, “trying” refers to any time period when you are having regular sex (at least twice a week) and not using contraception. Using that as the proper definition, they had been infertile for well over three years, and that certainly was not normal.

SPERM ISSUES: Miles had no medical problems, no past surgery and led quite a healthy life. He appeared very lean and fit and rarely drank and never smoked. He was the shining example of someone healthy who was not expected to have any sperm issues. But as we all know, there is no way to absolutely guarantee normal sperm just by looking at someone. Therefore, we needed to start by doing a semen analysis. Plan: Semen analysis.

OVULATION ISSUES: Before I could ask her about her ovulation, Terra took charge and whipped out her checkbook. She did not write a check, but rather showed me the BACK of it, where there was that condensed three-year calendar. On it were circles of the first date of her period for the past 2 years. She proudly proclaimed that her periods were like clockwork and she had the evidence to back that up. She had no medical problems and was 5’ 6” and weighed 137# for an excellent BMI of 22. Her ovulation testing was consistently normal for the past year. Based on this detailed information, I told her that I was over 95% sure she was ovulating normally. We could always get a mid-luteal progesterone to check further, but as for now, I didn’t think it was a priority. Plan: No action at this time.

ANATOMICAL ISSUES: Starting from bottom to top (cervix to uterus to tubes to pelvis), Terra once had surgery on her cervix to remove some precancerous tissue. From her internet research, she already knew that something like that could compromise her cervical mucus. She said she is unsure whether she made a lot of mucus before the surgery, but she knows that she makes very little now, even right before ovulation. Further suspicion of an anatomical problem was raised when she shared that her periods were so painful that she would often leave work if the cramps got too bad. I told her that I would recommend an HSG right away to rule out a tubal problem. I shared with her my concern that she might have endometriosis. I would not be surprised if she had tubal scarring or even complete blockage. She disagreed with me at first, saying that she was more worried about a cervical mucus issue. She insisted on getting a post-coital test. Even after I explained that those tests were rarely done any more, she expressed that she really wanted one. We eventually compromised and made the plan to spend one month doing a post-coital test and an HSG. She agreed to call us on the first day of her next period (expected in a week or so) and get set up for both tests. PLAN: Natural evaluation cycle with PCT and HSG.

Terra and Miles impressed me as being a much more cheerful and optimistic couple than average. While it was still unknown what the reason or reasons were for their infertility of three years, we were soon to learn if the sperm had any issue and we were soon to learn if the tubes were blocked. An ovulation problem was lower on our list of suspects.

Click here for episode #2

Gabriela and Ross (they asked me not to use their real names) came in to see me for help in conceiving. They had discovered me quite randomly, having been referred by Gabriela’s co-worker’s brother’s wife, who had been our patient and who had successfully given birth to twins conceived by IVF. Gabriela was 36-years-old and described her work managing a business as being very stressful. Ross, who was 41, described his engineering job as being laid-back and interesting. The two of them got married a little over a year ago, after having met at a relative’s wedding one year before that. They described their lives as being secure and happy, other than for their being childless still. They never used any contraception after their marriage and while they didn’t predict for themselves to get pregnant instantly, because of their age, they didn’t really expect that they would still be childless a year later. They were resigned to keep patiently trying on their own, until fate intervened and Gabriela struck up a conversation with her coworker who was happily sharing the story of his brother’s newborn twin baby girls. Gabriela says she took it as a sign and had excitedly gone home that day and told Ross they were going to go see a fertility doctor ASAP.

INITIAL CONSULTATION: They came together for their first visit. After getting acquainted, we got to work gathering clues to help solve their problem. I began, as I usually do, by tackling the three primary areas where fertility problems could lurk - the husband’s genetic contribution (the sperm), the wife’s genetic contribution (the eggs) and the playing field where the two meet (the wife’s cervix, uterus, Fallopian tubes and pelvic cavity).

SPERM ISSUES: Ross had never been involved in any pregnancies in his life. This was not a surprise, as this was his first marriage and he had not had any situations in his past where he could have fathered a pregnancy. He was healthy, other than for having a BMI of 29, which he described as being typical of how heavy he had been for the past 10 years. There was nothing new or different lately with regards to his level of health. The couple described having sex once to twice a week. The sex was not painful nor difficult in any way. In the past few months, they had started charting Gabriela’s temperature and using ovulation kits to help with the timing. He was not on any medications. I told them it was good news that they didn’t have any risk factors for sperm problems. However, the next step would still be to check a semen analysis. They were reminded that any perfectly healthy male without any past record of having gotten anyone pregnant could still have a surprisingly bad semen analysis. The only way to know is to test. PLAN: Semen Analysis.

OVULATION ISSUES: The next question to address was Gabriela’s ovulation status. She reported that all her adult life, she had regular periods that came every 28-32 days. There were three months in which she did ovulation kit testing. It showed positive each time. She answered no when asked if she ever noticed milk coming from her breasts. (This would be a warning sign for elevated prolactin hormone, another contributor to infertility). She reported a normal energy level and no symptoms that would be suspicious for an underactive thyroid, except for one. She reported gaining 20 pounds in the past three years. When questioned further, she expressed frustration and puzzlement about her weight. She was not eating any differently than when she was younger. She had not been more physically active in the past than she is now. So she was especially perplexed about the weight gain. I asked her if she had any diabetes in her family and she replied that her mother had been diagnosed with diabetes at age 40 and her sister had had diabetes of pregnancy.  I told her that she does not fit the classic description of PCOS, because she is having regular periods and having positive ovulation testing. However, there are many clues that point to her having the insulin resistance component of PCOS so I told her we would do some testing. PLAN: Check thyroid status. Check for insulin resistance.

ANATOMICAL ISSUES: On ultrasound exam, she had a normal uterus. It was not unusually large, nor were there any fibroids seen. The uterine lining was seen very clearly. Her ovaries were interesting in that they had a classic PCOS appearance, with many strings of cysts around the periphery. I told her that at some point, we might have to check if her tubes are clear, but since we have some easier things to address first, that we would put off the testing (with an HSG) for now. The plan might be different had she had any high risk factors for tubal problems, such as extremely painful periods, previous pelvic infection or previous pelvic surgery, but without those, given the rest of her situation, an HSG was not the first priority at this time. PLAN: Nothing at present.

So, to summarize at this point, we have a nice couple with no past pregnancy at all for either partner, who have been having regular unprotected sex for over a year, but yet, remain infertile. We explored the three basic areas of fertility problems and came up with a plan for further testing on two of them, while postponing any action on the third. The couple will have the proper tests and come back to discuss the results afterwards.

Click here for Episode #2

During the initial consultation visit, I ask my new patients (both husband and wife) what kind of work they do. First of all, this helps me form a clearer mental image of who they are. It also helps me screen for any unusual stress-filled situations in their lives that need to be addressed in order to help restore their fertility. Sometimes, I get a general answer that needs clarification such as “I work in computers”, “I do import/export” or “I’m a consultant”. They then can clarifiy for me by being more specific, “Well, I sit at a desk all day answering calls from angry impatient people who have just suffered a car accident and I work to process their insurance claims”, or “I fly around the country and evaluate a company’s computer software needs and then I assemble a team to customize a package for them and then we all go there and train them to use it as quickly as possible”

When people ask me what kind of work I do, I can answer their question many ways. I can answer very generally and say I’m a doctor. Or I could be a bit more specific and say I help people get pregnant. Or I could be even more specific still as describe my exact daily actions, as I did in a previous post.

However, if you really want an exact, analytical, more useful answer I would best reply by saying I work to achieve the general goal of helping people have babies and my work can be thought of as being organized into individual cycles. This last part is important to recognize and I will elaborate shortly, But before we go there, let’s discuss another example. If you were to ask what Kobe Bryant did for work, the general answer would be that he plays basketball. However, a more specific analytical answer would be that he works to get a basketball into a designated basket as often as possible while trying to prevent the same ball from going into the opponent’s designated basket. That is the defining concrete goal of his work. All the other stuff such as the passing, the rebounding, the dribbling, the shooting drills during practice, the conditioning, the strategy sessions with the coach studying game film are all just supporting actions that help modify the main task which is to drop the ball into the basket.

In a similar vein, my main work task is to do successful treatment cycles. All the other stuff, such as ordering diagnostic tests, counseling patients, training my staff, keeping my office infrastructure running, studying to keep up on the latest in my field and taking measures to avoid burnout for me and my staff are just supporting actions for the main agenda, which is to have a successful treatment cycle.
Below is a summary of the different types of treatment cycles we do:

• IUI CYCLES: The standard simple treatment cycle is an intrauterine insemination (IUI) cycle. This consists of purifying a husband’s sperm sample and transporting the final improved concentrated product deep into the wife’s uterus on the optimal day (or even at the optimal hour).
• IVF CYCLES: This is the gold standard most advanced form of treatment. This consists of taking the eggs out of the wife’s body and directly putting it together with her husband’s sperm to create embryos. Then, the best-looking of the embryos are selected and placed directly into the uterus.
• NATURAL CYCLES: While over 90% of the cycles we do are either IUI or IVF, there are some patients for whom we help get their eggs ready and monitor to tell them the optimal timing. Then they just proceed to have sex naturally and get pregnant that way.

As I said earler while the heart of what I do is centered around the above-mentioned cycles, I do a lot of supporting actions as well, actions that help improve the success of the actual cycles:

• CONSULTATION: One of the most important skills for an RE is to decide which type of cycle is best for each individual patient and when to perform them. Some patients are better off trying on their own for a little longer. Others should start by trying IUI. Others are best served by going directly to IVF. Sadly, still others are best advised to give up and look at alternatives such as adopting or quitting all together. Making the optimal decision regarding which option is best requires gathering information through interviewing the patients, examining them and ordering tests.
• SURGERY: Many times, the success of a cycle depends on critically improving the condition of the patient’s uterus, where the baby is destined to live. Some common crucial ways of doing this including removing any offending tumors or polyps from the cavity and removing any diseased Fallopian tubes that might have a tendency to leak embryotoxic fluid into the cavity and kill the embryos.
• MAINTAINING INFRASTRUCTURE: In order to conduct my treatment cycles, I need to have a physical location with propertly functioning equipment and well stocked supplies. More important, I need a team of top-notch staff. Much of my time is spent recruiting and training a great team and making sure that I can do my part to fulfill their needs and wishes as well, so that they can come to work every day with enthusiasm and happiness, ready to do their best for our patients.
• EDUCATION AND SELF-DEVELOPMENT: Since I am responsible for coordinating all this in the first place, I take on the burden of always learning more. This is not a minor point and is arguably one of the most important things a good reproductive endocrinologist does.

There you have it. So the next time someone asks me what kind of work I do, depending on my mood, I can give them the abbreviated “I’m a doctor” answer or I can direct them to this web page for the long detailed version.

Two of my core beliefs are currently having a knock-down drag-out war with each other. One belief is that if you correctly choose a career that is fun, stimulating, enjoyable and spiritually rewarding, then you will never really “work” a day in your life.  I still hold this to be true. The other belief is often known as the law of diminishing returns.  This law states that each additional unit of something valuable or desired is valued or desired a little bit less than the previous unit. If you give a boy who loves chocolate a large slice of cake, he’ll be happy. A second slice will still make him happy, but not as enthusiastically as the first one did, and so on. Giving him that 37th slice won’t make him much happier than receiving that 36th slice. You get the point. This is a fundamental law of life, so to say that this is one of my beliefs, is like saying I believe in the law of gravity or in the law of 3+6 = 9.

So why do I bring this up? Well, I love my work. I love solving mysteries as to why a certain couple is not getting pregnant. I love coming up with what I believe to be the best strategy to help them conceive. I enjoy reading and learning new developments because I know that my time spent studying can potentially make the difference between success or failure for one of my patients. I especially love sharing in the excitement of finding out a positive result!

However, as much as I love all this, there reaches a point where each additional consecutive hour doing it begins to bring a little less joy and satisfaction than the previous hour, especially as much as it robs from my opportunity to do something else. This past month, many more new patients came to the practice than would be expected given our usual monthly average. Now I was pretty sure that the reason for this was that it was January, when there is almost always a large rebound in activity after the holiday season lull. Plus, we also had some other unusual things to take care of, as I have mentioned in previous posts. This greatly added to the illusion of feeling like things were even busier. However, the pace seems to have let up only slightly in February. So yesterday, on President’s Day, when most of my friends are at home doing nothing, my staff and I saw about 30 patients. The sense of accomplishment we got after taking care of the #30 didn’t really feel as rewarding as it did for #20. No surprise.

So what’s the solution to this dilemma? I’ve been trying as much as feasible to take a long break during lunch to either nap, go to the gym or go home and play piano (I live less than 5 minutes from my office). Each of my staff also get a staggered 90 minute lunch break, although most times they don’t take it, preferring the option of working straight through. That doesn’t work well for me, though as the times that I’m forced to work straight through, I find my productivity slowing greatly by late afternoon.

There is a cost associated with taking a long lunch break. At least one night out of each week (like now) and a few hours each weekend, I have to come back to the office after hours to catch up things. This is when I will review the old medical records from patients who failed at other practices. This is when I will catch up on journal articles. This is when I blog. However, I can come and work for an hour, go have dinner with a friend, and come back and do another hour of work. For me at least, it’s definitely more painless breaking it up into chunks like this.

I often share a reminder about the law of diminishing returns with my patients by discussing the difference between the freedom of childlessness and the joy of parenthood. When a couple first gets married, they cherish the freedom of not having any children to burden them. However, each successive year of childlessness has decreasing appeal, until the couple begins to essentially wish for the chance to give up their freedom. Then the baby (or babies) come into the picture and life is completely different, because it seems every waking moment now belongs to your child. From time to time, you will find yourself longing for a brief taste of your past lifestyle. Trust me. Again, I’ve heard this time and time again from patients after their treatments succeed and their child-free years are a thing of the past, forever.

Here are some tips to consider:

• During this time while you are focusing on trying to conceive, make the most of your freedom. Have a date night. Enjoy your reading time. After your baby is here, you will look back and miss these chances.
• Make a conscious effort, even AFTER the baby arrives, to dedicate some time to yourself on a regular basis. This could take the form of one spouse taking the kids for half a day while the other gets his/her free time. Better yet, at least once every two weeks, leave the kids with someone you trust and rekindle the habit of having date night for just the two of you. I know babysitters are costly, but you’ll find it’s worth it.
• One interesting tip I hear over and over again from couples who have done repeated treatments and now have several children (including some twins maybe) is to arrange regular one-on-one “dates” with each child. So one weekend, dad takes the 6-year old boy to the baseball game and the other three kids stay with mom. The next weekend, mom takes one, and just one, of the 4-year-old twins to the zoo. There will be unique value gained from these experiences, so as to make it worth the added effort.

A few hours of a novel experience have much greater value than several hours of the same routine over and over. So, now all of you who find yourselves in a rut of diminishing returns, please go out there and do something different from whatever you’ve been doing over and over these past months.

This weekend, a friend invited me to play in a poker tournament on behalf of a charity that gives support to crime victims. It was organized by an exceptional group of women who regularly devote their time and energy to doing philanthropic activities. I didn’t do well in the tourney, but was glad to have participated. It gave me a chance to play poker again, — something I hadn’t done for almost a year. This morning, while trying to answer a question posed by one of my patients (who turned out to be a poker fan herself), the idea of cards was still fresh in my mind, so I was inspired to answer her question using a poker-related analogy.

“Julia” (the patient who asked me not to use her real name) is a 28-year-old software consultant who has been married and trying to conceive for two years now. She does not have regular periods and clearly does not grow eggs on her own. She came to see me for help. We agreed to start very conservatively with a monitored cycle of ovulation induction. Last month, on Clomid 50mg, she produced one lovely follicle and got together with her husband at the perfect time. As excited as she was that she finally ovulated, it was devastating when she she found out that she wasn’t pregnant. Her question was a common one. If there was an egg and if the sperm is normal and if they got together at the correct time and if her tubes are clear, then why didn’t she get pregnant? What went wrong?

Well nothing necessarily went wrong. The official medical answer is simply that conception is a probabilistically-determined event. What does that mean?

Let’s play a game. Imagine that you have a deck of cards which will be used to magically determine your fertility. Every month, this deck of cards is thoroughly shuffled and cut and you are asked to draw one card. If that card is a heart, then congratulations! You’re pregnant and it’s time to celebrate. However, if that card is anything other than a heart, then your period will come and you will have to wait until next month to try again. Actually, this is a fairly accurate mathematical representation because the monthly probability of conception for a normal fertile couple is very close to 25%. This means that when an egg is released and the couple have regular sex at random times about twice a week, the chance of them getting pregnant that month, if they are normally fertile, is 25%.

So month after month, women all across the country who are trying to conceive shuffle their decks and draw their cards. Some of them draw a heart on their first month. These are the lucky ones that go off the pill and get pregnant right away. Others have to play this game for 6 or 7 months before they finally draw their lucky heart. Remember that about 85% of normally fertile women will get pregnant within six months.

Pretty simple so far? OK. Let’s go on.

When you are playing poker in any semi-official capacity, the first thing you do before starting the night is to fan out the cards face up so that everyone can verify that we’re playing with a normal deck. There should be 13 spades, 13 diamonds, 13 clubs and 13 hearts. Real life is not so neat. Yes, it’s true that while a couple of NORMAL fertility does get to play with a standard deck, there are couples out there who have DECREASED fertility, so that instead of having 25% hearts in their deck, they might have to play with a rigged deck that has only 8% hearts. So what happens to these unfortunate couples who have a substandard deck of cards? Well, some of them will be lucky and totally beat the odds by drawing a heart on the first try, despite the chance being only 8%. Because all they know is that they got pregnant right away, they will falsely go through life believing that they have normal fertility. The only time that they begin to suspect otherwise is later, when they find themselves taking a long long time to conceive their SECOND child. Of course, not all couples will be so blessed as to hit on the first try. The rest of the couples with the 8% deck might take as long as 15 months to finally draw a lucky winner, especially if their luck is a little below average. By this time, most of them will have already started toying with the idea of seeing a doctor. In practice however, many couples with a 8% deck will conceive on their own. It will just take them longer than the usual easy six months.

A VERY UNFAVORABLE DECK

Let’s go on. There will be still other couples who are even less fortunate and they will have to play with only a single heart in the entire deck, thus giving them a 2% chance of conceiving. This can be for many reasons. Either the husband has a terrible sperm count (but still has SOME sperm), the wife has really poor egg quality (but still drops a normal egg on a rare occasion) or the pelvis is pretty scarred up with endometriosis (but not entirely scarred up). These couples with a 2% deck usually find themselves playing for several years before drawing their one lucky heart. Most of these couples will rightfully get impatient, tire of the game and come in to get medical help. But remember that over the years, with advancing age, your deck of cards will change to have fewer and fewer hearts. So some of these couples might tragically take so long to conceive that they no longer have any hearts in their deck and thereby wind up forever childless.

Before we talk about how fertility treatment can help increase your odds of drawing a heart, let’s discuss another group of patients, those who don’t ovulate at all. There are some couples who are POTENTIALLY very fertile. His sperm is great. She is young and her egg quality is wonderful. Her Fallopian tubes are stellar. These couples actually have a deck stacked in their favor, meaning they might even have 30% hearts in their deck. However, due to ovulation problems, they don’t release an egg consistenly every month. One common way to know this is if a woman describes her periods as being so irregular that she only has two periods per year. When periods are this irregular, you don’t know for sure if they are even ovulatory cycles or instead are completely anovulatory cycles that just happen to end up with some odd bleeding. So here we have a couple with a deck packed with hearts, but they are not allowed to draw a card at all because of the lack of ovulation. Well, maybe they might get to draw 1 or 2 cards per year if they can ovulate once or twice, but their good deck is not being utilized to its full potential because they don’t get a monthly draw the way other couples do. For these couples, it is especially dangerous if when getting treatment, they go from ovulating zero eggs per month to ovulating, let’s say, six eggs in one month. In that case we would be taking their supercharged deck that normally sits idle each month and then all of a sudden drawing six cards at one time. The danger is that you’ll get a hand that consists of three or more hearts, meaning you get triplets or more. Yikes. This is the reason that we are especially cautious with completely non-ovulating women. For them, when we start treatment, we like to begin with helping them make just one or two eggs. If after a few careful cycles, they demonstrate that they can make eggs, but still not get pregnant, then that calms our fears a bit about them having a super-charged deck of cards. Then, we slowly increase the number of eggs until they finally get pregnant.

WHAT KIND OF DECK IS YOUR DECK?

If you are still with me, let’s go on to discuss another commonly asked question. How can I know how fertile we are? In other words, how can we figure out if we have a great 30% deck or a bad 2% deck of cards? Is there a way to peek at our deck? The answer is no. We can’t determine for sure what your deck is like, but we can over time, make some pretty accurate assumptions. In science, there are two ways to conclude something. One is by logic and the other is by evidence, meaning we believe things that make sense and we believe things that we actually observe.  If you were to ask me to guess what your monthly odds of conceiving are, ie. what  your deck of cards is like, I would start out assuming a standard deck (because most average people are … well … average) and then I’d make an adjustment for age. If you are older, I would mentally imagine fewer hearts in your deck. If you are younger, I would mentally picture there being more hearts. Then we start the game and begin to gather the evidence. Let’s say the first month that you stop using any form of contraception, you fail to get pregnant. You have drawn a card and it’s not a heart. You put the card back. No big deal. Just a bit of bad luck. Then, next month, you shuffle the deck and draw another card. Still no heart. Mind you that you don’t get to actually look at the deck at any time. Your only actual knowledge about the contents of the deck is based on the cards you draw. In other words, your only information about your odds of getting pregnant comes from observing whether or not you get pregnant each month. Third month, you draw a card. Yay! A heart. Your assumption that your deck is a normal one is probably correct. In any case, you don’t care, because you’re now pregnant and have other things to start thinking about. But what if things happen differently? What if your third month is also negative, as are your 4th through 24th months? This means you have now gone two years without getting pregnant. Are people going to tell you that you’re deck is normal and you’re just unlucky or just not timing it properly or just stressing about it too much? Maybe. But they would be wrong. The most logical conclusion is that there is something wrong with your deck. If you go two years without conceiving, you must face the fact that you don’t have a normal 25% monthly chance. There might be very few hearts in your deck, or heaven-forbid, no hearts at all!

This nicely illustrates the principle of how I would estimate your chances of conceiving. First, I make certain estimates regarding your deck of cards based on your age, lab tests and whatever other clues I can gather. And then I study what your past history of card draws has been.

OK, enough for now. It’s time for me to take a very short break to play some online poker on Facebook. Next time, we’ll continue and describe the ways we can help you cheat and turn things to your advantage so you will be able to draw your first heart sooner.

I really admire some patients. I certainly admire those who bravely endure difficult infertility treatment followed many months later by enduring hours of painful labor in their difficult first delivery. Yet, there is another patient I admire even more who happened to have a super easy forty minutes of labor in her first pregnancy. But she earned it. Here is her story.

Ann is 28 and she and her husband were first referred to me by her OB after a year and a half of infertility. The cause of their problem was pretty obvious. Her husband had great sperm. The HSG said her tubes were clear. However, she had periods about two to three times per year. So the working diagnosis was Ovulatory Dysfunction. In fact, she had already been started on injectable ovulation medications by another doctor and had already been on a high dose of it (Bravelle 225 IU) for three days by the time that I first saw her. I quickly dropped her dose to 75IU, but it was still not enough to slow down her ovaries and she wound up making TOO MANY follicles, so her cycle was cancelled out of fear of triplets. It was disappointing to have to cancel, but it was encouraging to know that she COULD make a lot of eggs with the injectable medications. At this point, I suggested we take a step back and try to figure out better why she had ovulatory problems in the first place. It was tricky determining the reason for her ovulation problem, because she was already known to have thyroid disease, but it was well-regulated on medication, so that wasn’t the problem. Now, all RE’s know that someone who doesn’t ovulate on her own, but then produces a ton of eggs on injectable FSH is a big suspect for having PCOS. Ann had a trim figure and certainly didn’t look like a classic PCOS patient. However upon further questioning, she reported that she exercised an amazing amount!

Ann’s typical exercise regimen consisted of working out 3-4 times weekly, either taking classes at the gym or running 30-50 minutes. Right at the time when she first came to see me, she had just finished six months of training for the California International Marathon in Sacramento, during which time she ran 4-5 times each week for up to an hour with an extra long 2-3 hour run each weekend. By the way, I don’t know how she does it, but Ann also manages to maintain a very rewarding career. Still, she was frustrated, because despite all this, she wasn’t losing weight! Of note, Ann shared that she had a sister who also had the same history of irregular periods. Her sister walks every day, but does not do the same intense exercise that Ann does. (Her sister has kindly given us permission to share that she is not happy with her current weight and would like to lose about 40#.)

Based on this information, what struck me was this might be a case where someone born with an inherited problem of insulin metabolism was able to overcome the effects of it by the sheer will power to exercise like a superstar!

We ran some tests. Ann’s insulin testing showed that three hours after drinking the yucky sweet drink we gave, her blood glucose was 89 mg/dL and her insulin, which was expected to be below 20 by then, was more than double that at 43 uIU/mL. She was promptly started on metformin for a three week trial. She returned to report a tremendous difference. Whereas before she used to have low energy and have to brutally force herself to exercise as much as she did, now she felt great and had a much easier time maintaining her workouts! Her craving for carbs was markedly decreased and she went from 131# to 128# in 3 weeks with a noticeable decrease in her waistline. This was very encouraging. At this point, we had to make a decision whether to just be patient and see if her periods would also respond as well to the metformin as the rest of her body apparently did. Then if so, we could let her try on her own for a few months, at least. She and her husband opted to be more proactive, so we tried another round of injectable FSH and got a much better controlled cycle with just 2 mature follicles developing. However, she did not get pregnant. Then something not all that surprising happened. While we were waiting for her to resolve the cysts from her previous cycle, she reported that she did a pregnancy test and got a BFP! We monitored her for the first trimester and she graduated from our office back to her OB carrying a healthy single baby.

Fast forward to this week when she came visiting with her beautiful three-month old, a beautiful girl with the blondest hair I’ve ever seen in a while. She told me great stories about how she exercised throughout her entire pregnancy, including the funny stares she got from the other gym members while her bulging tummy rocked side to side on the elliptical machine at 37 weeks. I would tell you the story of her labor, but she and husband tell it so much better in their own words:

Saturday morning (@1AM) Ann started having contractions that were somewhat painful but she was still able to sleep around them.  Having never been through this before she wasn’t sure if this was “it” or just false labor so she continued to go back to sleep (priorities in order!).  Contractions came every hour until 4AM at which point Ann woke Matt up and told him she thought she might be in labor (contractions were 10-12 minutes apart).  He was up with a start and asked what we should do so we grabbed our trusty Bradley book and starting reading about the various stages of labor and determined that we were in “early first stage labor” and decided to hang out and try to sleep more.  At 5AM contractions were 8-10 minutes apart and we were thinking we should pack our bags and start our day.  Matt took a shower and went to help a good friend get ready for a garage sale while Ann took a shower and tried to nap again.  Contractions varied everywhere from 3-7 minutes apart and lasted about 45 seconds in duration.

At 8AM contractions were about 5-7 minutes apart but varied in length and intensity so Ann’s friend Laurinda came by to offer distraction.  Ann and Laurinda decided to take a short walk down the horse trails by the house at about 9:30AM…the walk usually takes Ann about 20 minutes but due to the contractions they ended up walking for an hour!  During the walk Ann started getting horrible back labor pains and did the “giant hula hoop” maneuver to move the baby around and off her spine….the Yorba Linda walkers weren’t ready for a pregnant, laboring, hula hooping lady walking down the trails!  Regardless, the hula hooping worked and the contractions were now 4 minutes apart and 45-60 seconds long.  Once they got home Ann was hungry and ate a bowl of Life cereal which evidently is a massive labor starting meal as her contractions were right on top of one another and too difficult to talk through.  (At one point Ann may have told Matt in a stern voice that he needed to focus his attention on her and not the college football games).

The Ollivier’s decided that since Ann’s contractions were causing her to make a “serious face” it was probably time to go the hospital.  They left the house at 11:07 and Matt drove mach-10 down the Toll Roads with Ann’s contractions coming right on top of each other.  Ann attempted to talk herself into relaxation by reciting her mantra “I am relaxed.  I can do this.”  While Matt responded “Yes honey, you are relaxed,” or “No you aren’t.  You need to relax.”  They pulled into the parking lot of Saddleback Memorial Hospital at 11:17 and Matt raced inside to find a wheelchair since Ann was now unable to walk.  He waited, and waited, and waited for what felt to Ann like hours and raced back to the car with….no wheelchair.  Seeing that she had no ability to talk, much less walk, he ran back inside and commandeered (aka stole) a wheelchair from a room and ran back outside to his screaming wife.  Matt pulled Ann into the wheelchair and ran (literally) her inside to the elevators.  Once inside the elevators Ann had a MASSIVE contraction and was screaming all the way to the second floor, down the hall and into the labor and delivery area.

The nurses asked Ann to walk into the area to check her status and she gave them an evil look and stated that she could not walk there under any circumstances (she was barely able to breathe!).  Once on the table Ann was declared 100% effaced, 6-7cm dilated and Baby O was at -2 station.  She was told by a nurse that since it was her first baby she would most likely dilate 1cm per hour and to relax.  Ann continued screaming and trying to relax.  The nurses asked her how much water she had been drinking and told her that 16 oz an hour wasn’t enough and she was dehydrated and started an IV for fluids.  In the middle of having the needle jabbed into her arm her water broke all over the place and she felt the need to push.  The nurses yelled at her not to push and that she was only 6cm dilated.  She yelled back at them to check her again and they decided to draw a vial of blood instead.  Once they had their “essential” vial of blood, they checked her again and she was 100% effaced, 10 cm dilated and +3 station (aka. ready to push).  They raced around to get the room ready for labor and paged the MD on call.  The nurses raced Ann into the labor room and told her to relax (duh) while they got the room completely set up.  Four contractions later and Baby Ollivier entered the world at 12:08PM.  (For those of you “non-math” types that was 11:25AM arrival at the hospital and 12:08PM delivery….43 minutes).  The nurses were amazed (as was Ann) and Baby O let out a solitary cry and they proceeded to look around while her APGAR score was calculated (1 minute score=8, 5 minute score=9).  She flew into the world at 5lbs 9oz and 17 inches long with a full head of blond hair and all her necessary parts.  Her parents think she is beautiful.

Sure, there is plenty of medical evidence that women who exercise regularly have easier labors and less complicated deliveries. And for many people, that is enough to convince them. While I am a believer in properly conducted research studies, I also like stories. . Thank you so much, Ann, for sharing this with our readers. We love happy stories like yours.

I came across your website and decided to contact you just to get a second opinion.  Hopefully you can help.  I am 25 yrs old, married for two years and have been trying to conceive for the past 5-6 months.  Once we decided to have a baby, I started reading a lot online and decided to see an obgyn while trying to conceive that way we weren’t just “wasting” our time.  (I know, I’m very impatient)!  My ovaries, uterus, etc have been checked and everything seems to be fine.  I believe I have ovulation issues.  Although I have ovulated on my own in the past (positive opk and confirmation from blood test), I do not believe I have ovulated in the past few months.  My obgyn wanted to do an endometrial biopsy but I didn’t agree with that for some reason.  She also stated that I don’t have PCOS.  The impatient person that I am, I decided to seek a fertility specialist since insurance covered it.  So last month I went to a very well known specialist here in New York.  After tests and consultation, she advised me to start on 50mg of Clomid (days 3-7) and monitoring of follicles.  I really liked the fact that I was being monitored.

Well I went for ultrasound on CD 10 and there were 4 follicles (3 on my left ovary, 1 on my right) ranging from 8-10mm and uterus lining was at 6.2.  Then I went again on CD 13 (yesterday) and found that the follicles have barely grown from last visit - not even 1mm.  My uterus lining was 7.5, which she said was good based on the size of the follicles…?  We also did bloodwork to check estrogen level which unfortunately indicated that it had decreased since last visit (from 67 to 55).  Right away my dr. decided to prescribe Provera and to start that right away rather than waiting for the follicles to mature which she didn’t think was happening.  Additionally, she wants me to start on 100mg (increased form 50mg) and start that next cycle…obviously depending on my next visit on cycle day 3.  She also stated that maybe we might consider Metformin (?) but the blood result will be available tomorrow (Monday).  I don’t have diabetes but I’m just afraid that all these medications might affect my body.

My questions to you are the following:

1.  Do you think I would have eventually ovulated?
2.  Do you think it’s already too soon to increase the dosage of Clomid?
3.  Is it true that Clomid on days 3-7 increases more follicles VS. Clomid on 5-9 gives mature follicles?  Should I be taking it on CD 5-9 since I didn’t have mature follicles?
4.  Would you have recommended an endometrial biopsy as my 1st obgyn did?
5.  How do you feel about the Metformin?
6.  Is there possibility that my tube(s) can be blocked at this age?  I’m very reluctant to do HSG at this point.  There wouldn’t be any connection b/w tubes and ovulation, right?
7.  Would you recommend something different after reading my story?

Also, just additional information…One of the main reasons I decided to go to a doctor initially in July 2007 was because I had abnormal 3 week bleeding.  This is the first time that’s ever happened and it wasn’t a miscarriage or anything.  That’s when my obgyn prescribed Provera to restart my cycle and then in August I did ovulate on my own.  She concluded that the bleeding might have been due to stress and travelling.  Also, from July to October, I have gained about 10 lbs.  Maybe because I’ve been stressing about this whole TTC thing…not sure.

I have been reading thru both of your websites and there’s helpful information that I really appreciate.  I’ve learned a lot from reading your articles and real stories.  I know you have an extremely busy schedule and this might be just another story but any advice would be greatly appreciated! 

I look forward to hearing from you soon.

Thank you kindly,
Sara

Thanks for the detailed email. I think our readers will benefit from many of the issues you raise. I will try to address most of the ones you mentioned if you promise not to take it as an official “second opinion” or as being specific medical advice to YOU only. Without knowing your medical situation in greater detail and without examining you, there’s no safe way I can advise what is right for you specifically. However, I’d have to say that your RE and I appear to have similar approaches. If you stick with her and discuss things with her, you’re probably going to be in good shape.

• CANCELLING CYCLES: I’m sorry that your cycle was cancelled. I can probably write an entire post on the topic of cancelling cycles. When an RE initiates a stimulation cycle and prescribes ovulation medications, it is with the good INTENTION of growing a suitable number of quality follicles that month. Just because it’s the right intention doesn’t mean the ovaries will necessarily cooperate. As you astutely noted, proper monitoring is very nice to do, because it gives you the peace of mind of knowing exactly what’s going on. And in your case, it tipped off your RE to the fact that your ovaries weren’t responding this month. Whenever the ovaries don’t respond quite the way we like, we have to make a decision. Should we push it and see if eventually something develops or should we cut our losses and regroup. It’s a judgment call! Pretend you started a business, for example. Let’s say you opened a restaurant with the intention of packing it in with happy diners every night. However, after a year, you still have very few patrons showing up each night. You have to decide whether to stick with it, despite losing more money every month and hope things turn around or you can throw in the towel. The same applies to cancelling a cycle. You can make two types of mistakes. You can give up on a cycle too early and miss out on eggs that would have eventually shown up the next visit. OR you can make the mistake of getting sucked into the never-ending void of a drawn-out eggless cycle, thereby wasting a fortune in medication. Now in the case described above, because it’s a Clomid cycle and not an injectable cycle, there is no additional expenditure of medications. But based on the fact that it was already day 13 and still nothing had grown to the critical threshold of 13mm (which is a rough cutoff I use to distinguish between follicles that will go on to do well vs those that will fizzle out) AND based on the additional clue that your E2 was actually dropping instead of rising, I likely would have cancelled you as well. Remember. Even though you weren’t wasting additional medication each day, you WERE wasting your precious time.
• INCREASING THE DOSAGE: The minimal starting dose of Clomid is usually 50mg daily. If someone fails to make eggs with that, it doesn’t usually faze me. There’s plenty of room for improvement. Bear in mind that with respect to a first time Clomid cycle, there is a difference between failing to get pregnant and failing to ovulate at all. If on 50mg, someone makes eggs, but fails to get pregnant, there is a reasonable for sticking with the same dosage and trying one more time. However, if they completely fail to ovulate (as can be determined best by doing close monitoring), then it makes less sense to do the same thing over again.
• STARTING CLOMID ON D3 VS D5: Even among RE’s, there is general disagreement regarding the concept that starting earlier gives more follicles and starting later gives better-quality follicles. I don’t think the answer is clear cut and in the grand scale of things, it is not a critical difference when we’re talking about a relatively low-level form of treatment like taking Clomid.
• ENDOMETRIAL BIOPSY: EMB’s are very useful when used to screen for endometrial cancer. When used for infertility, it’s just a way to inflict torture on patients you don’t like. (In case you have no sense of humor and can’t recognize a joke, please ignore the previous sentence). During one of our round table dinners this past year, I remember a joking discussion on EMB’s with the consensus that out of the RE’s present, none of us did EMB’s any more. I personally have never done an EMB in my practice other than to occasionally screen for cancer in older patients with abnormal bleeding.
• METFORMIN: When you ask me how I feel about metformin, I KNOW I can write 10+ pages about it. I am definitely going to be inspired to write volumes about it at some other time. Suffice it to say that there are many patients that I put on metformin and many patients that I don’t put on metformin. As for the suitability for you in particular, I leave that decision up to your RE. If you were my patient and we had a nice one-hour chat and I got to evaluate you more completely, then I could better render an opinion on your case. But even with what you have told me, I can’t say more for sure. Sorry .
• WHEN TO DO AN HSG: The answer to this question is similar to the metformin question. It depends. In some patients, I do an HSG right away. In others, I push it back for later. Without going into detail, some factors that influence how soon I do an HSG include risk factors for blocked tubes (previous surgery, previous STD’s, painful periods), the suspicion of other fertility factors, patient’s aversion to discomfort, costs, and the exact history of failed attempts at treatment. Bear in mind that nothing is a perfect predictor. You can have an patient with painful periods and previous Chlamydia and a previous ovarian cyst surgery who ends up with a pristinely clean HSG result, just as you can have a perfectly healthy patient with no risk factors who ends up showing blocked tubes on HSG. You mention your age as a factor, but in reality, that’s not a good predictor of someone’s tubal status. I will answer your other question and say you are correct, for the  most part, tubal status and ovulatory status are independent factors and don’t influence each other directly. You can have blocked tubes and ovulate great or you can have fantastic tubes and not make eggs. The two are separate issues.

Sara, thanks again for your well-written letter. I know that other readers appreciate your taking time to share. Good luck in your quest! Be thankful you have a good RE there in New York. Perhaps I know her.

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

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

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

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

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

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

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

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

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

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

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

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

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

I am doing fertility medicine with a doctor here in Jacksonville, FL.

I have done two rounds of insemination with Clomid and a shot of HCG of
which neither took.

I then had to take a month off because I had to have hand surgery.  The
next Cycle day three i started taking my Clomid, I went in on Day 12 and I
had a small 13mm follicle on my left ovary and a large 28mm. The doc said
that the larger one indicates it is probably left over from the previous
cycle and should go away for the next cycle. I said ok and he canceled me
after taking the Clomid.

Day three of my next cycle, last week, I went in to check for cysts and
there was the same round figure on my left ovary, approx 28mm and the
doctor, who was a substitute that day, said it could either be a cyst or a
left over follicle.

What happens on the cycle day 3 if that follicle/cyst is still there? How
can they tell?  How do you make a follicle/cyst absorb, without taking BCP.
I do not want my cycle to be postponed again.  I was just curious because I
saw your discussion on here about cysts and follicles.

Thanks for any information you can provide.

Stephanie

Hi, Stephanie. Thank you for your email. I think a lot of readers can benefit from the discussion of this topic. I’m going to address the reply to everyone in general, but there should be some food for thought in this discussion that you can toss around with your own RE.

Just a reminder for those of you who have decided to see RE’s — You are already getting the ultimate in specialist care, so take advantage of the chance to ask them questions, especially when something unexpected, like a cyst, occurs. You should expect to have your questions addressed to your satisfaction. If they don’t have time to answer in great detail at that very moment, they can always talk with you on the phone later in the day. Set a time to do so if you ever have nagging questions. Some of you have vented that you’re getting your treatment through an HMO, and citing that as a reason why your questions aren’t getting answered. The quality of HMO doctors is not necessarily any different. It’s just that they have many more patients with whom you will have to compete for their time and attention. The tradeoff is that your service is usually close to free, so it’s not all bad. =) But if this is the case, be vocal. You have a right to have your questions answered, regardless of whether you’re seeing an RE or not.

In a monitored cycle, one of the first things to do is to check for cysts prior to taking the Clomid. If you have already read the previous post on cysts, it might help give you some basic understanding of the terms used. There are many different ways to approach ultrasound monitoring of a clomiphene (Clomid) cycle. Some people opt to take Clomid with no monitoring at all. This is the cheaper way. However, keep in mind that the more diligent the monitoring, then the more information you have with which to make better decisions, so it is a tradeoff.

It is acceptable in most cases to take Clomid without monitoring. So starting around cycle day 3, 4 or 5, depending on your doctor’s preference or depending on your convenience factors, most doctors will prescribe five consecutive days of Clomid. Then you are on your own as far as having sex, either just every 2 days or by timing with assistance from ovulation kits. The downside to this is that you never know for sure if you are ovulating and you never know how many follicles you have.

ADVANTAGES OF MONITORED CYCLES: A monitored cycle is a more deluxe version of the standard Clomid cycle. It adds some inconvenience and cost in that you have to go to the doctor for ultrasounds, but it has some clear advantages:

• Ability to avoid cysts. For all women, there will be an occasional month in which things are “off”. You might end up with a leftover cyst which has not fully gone away yet from your previous cycle. Or you might have a fast-growing out-of-sync follicle that is growing much quicker than normal. These problems are more likely when the previous cycle was a medically-stimulated one. In either case, it would not be optimal to take Clomid that cycle because of decreased efficacy. There is also the slight concern of the cyst growing excessively large under the stimulation of the Clomid and causing other problems. By getting monitoring prior to starting the Clomid, you can catch these cycles and avoid taking the Clomid. I find these cysts at the start in about 5-15% of my patients’ cycles. In general, I use 12-13 mm as the cutoff size for postponing a stimulation cycle, but there are other several factors I take into account as well. In general, if the cysts are smaller than that, then we go ahead with the cycle.
• Assurance of follicular growth. Some times when you take Clomid, you don’t even make any mature follicles at all. Monitoring catches this problem early and avoids the scenario of you wasting time taking 3 or more cycles of Clomid when in fact there is no chance of pregnancy, due to complete failure of the Clomid at initiating ovulation. In this case, it’s time to switch strategies to something stronger or to do additional testing.
• Optimal timing of intercourse and/or insemination. The only 100% accurate way to document ovulation is with ultrasound monitoring. Theoretically, if you get your ultrasound done at precisely the right time, you can pinpoint ovulation to the exact second. That has only happend to me twice in over ten years. I was doing an ultrasound on a patient and we all clearly saw a large follicle on one side. I went to scan the other side and when I returned to the original side, the follicle was instantly gone and there was increased fluid in the pelvis, a sign of recent ovulation (follicular rupture). Temperature, mucus evaluation and urinary ovulation-kit testing can only give you a crude estimate. In fact, by adding the strategy of taking an injection of hCG to trigger your ovulation, you can actually control ovulation so that you can time insemination close to the exact hour.
• Assurance of ovulation. Sometimes, patients will have all the signs of ovulation (temperature change, positive ovulation kits, pain, rise in progesterone), but the follicles themselves do not actually physically burst, thereby causing the egg to remain trapped inside the follicle until it’s too late to be viably fertilized. Ultrasound monitoring will pick this up if this is the case and alert the need for different strategies. One way in which monitoring gives my patients peace-of-mind is by providing confirmation that their follicles have successfully ovulated.

So let’s go back to the issue of what to do when you DO see a cyst. There are two main options. One is just waiting for the cysts to go away on their own. Over 80% of the time, new simple cysts WILL just go away on their own by the start of the next menstrual cycle. The other option is to take birth control pills. This further raises the odds that the cyst will go away. It also serves to lower the chance of developing new cysts. You can imagine the frustration of my patients who have their cycle postponed because of a cyst on their right ovary only to come back next month and find a new cyst on their left ovary, even though the original cyst on the right had resolved successfully. The decision whether or not to take BCPs is one of personal preference between you and your doctor. I usually suggest my patients wait one month for the cysts to resolve naturally and if they’re not gone by then, we can start BCPs, but some more proactive patients opt to start BCP’s right away.

Now what happens if months and months go by and the cysts are still there, unchanged, neither growing nor shrinking? At some point, the option of doing surgery has to be considered. I usually don’t advise surgery for a cyst unless it is clearly persistent and not going away (over 4 months) or if it looks suspicious. By this, I mean that not all cysts are simple cysts as seen on ultrasound. Some cysts are echogenic meaning there are shadows on the inside. This might indicate that it is filled with blood, or with medically dangerous components, such as cancerous tissue. This is rare, but certainly not impossible.

One more general tip. There are some patients who consistently end up with cysts and consistently fail to ovulate their follicles. One area I explore in these patients is the remote possibility that they are taking high doses of aspirin, Motrin, Advil, Aleve or other related drugs known collectively as Non-Steroidal Anti-Inflammatory Drugs. This usually happens in patients with chronic back pain or migraine headaches. High dose aspirin or NSAID’s block prostaglandins, which are substances in the body that regulate many things, one of which is ovulation. I had a patient once who consistenly failed to ovulate, despite making many nice follicles each month. It turns out she was taking massive doses of Exedrin for her migraines. After taking her off those medications, she has gone on to have three babies with us through insemination.

So, in summary, the decision whether or not to have your cycles monitored is based on many factors. I hope this information was helpful.

Happy New Year! I’m looking forward to many new pregnancies in 2008!