According to this clock, my life is predicted to end some time after the year 2050. Please don’t misinterpret my sharing this as an example of morbidness and pessimism. On the contrary, I reflect on this from time to time to remind myself the importance of enjoying and appreciating each and every day with which we have been blessed.

Earlier this year, my father signed up with some plan from our local electric company to install energy regulators and shut-off devices on his air conditioning unit at home. As a reward for his contribution to energy conservation, they sent him a $20 gift card to Starbucks. You should understand that my father had never stepped foot into a Starbucks in his entire life, but ever since he received the gift card, it started burning a hole in his pocket. His thrifty upbringing (or dare I say, his traditional Chinese upbringing) will not allow him to let anything go to waste, especially if it is free. Every week, he has been calling regularly, asking if I will go with him to Starbucks on some Saturday to have a relaxing morning of father-son conversation. I finally was able to grant his wish this past week, which was especially nice because my sister was visiting with her family from Sacramento. So the three of us got to have some quality time as a family, reminiscing together over three cups of latte. It was an unbeatable experience, even if the coffee would not have been free.

This past year, many of my friends have had the misfortune of losing one of their parents. There’s not much one can say or do to change the fact that we all grow old and move on some day. However, one lesson I learned long ago keeps me inspired and focused. Because we can’t prevent the inevitable, we should focus on what we CAN control. Someday, when our loved ones are gone, rather than mull with regret over things we could have done, words we could have said or times we could have shared, why not seize the golden opportunities NOW, while we still can? My parents are amazing in that they both run at least a mile almost every day. Their health would predict that they will be around for quite a while, but I’m not taking any chances. I do my best to spend time with them on a regular basis, using the chance to build up great memories. Someday, these memories will be all I have left of them, so I’m greedily accumulating them now while I have the chance. If it’s not too late for you, I pray that you take the chance to enjoy the company of your loved ones now and make this a resolution for 2008!

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

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

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

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

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

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

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

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

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

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

It depends.

Inside a woman’s body, it doesn’t live long at all, if we’re referring to in the vaginal canal. Sperm that is in the vagina will leak out or die before a few hours. However, if the sperm makes it to the cervical mucus, then it can live for a day or two there. But some “top survivor” sperm will live even longer, beyond 4 days. Remember, we are talking about several millions of sperm, so they survive different durations. Because there are so many INDIVIDUAL sperm, the lifespan varies between the fastest to die and the slowest to die. It’s sort of like us asking the question “How many years can a car be driven before it needs a major repair” In general, that answer might be 1-5 years, but you can always have that one car that is still running after 10 years without a repair, even though that is an uncommon exception. So in a particular grouping of sperm, the wimpiest will die instantly, and each minute more die until after a few days, only the best survive. It’s not a scenario where the sperm all stay alive and then a biological alarm goes off and they all instantly die at the same time.

Inside the male’s body, the life span of sperm is 74 days. This means if a man does something bad for sperm (smokes marijuana or tobacco), then the sperm will be negatively affected for a long time.

Outside the body, sperm die very quickly (less than a few hours), unless of course, we are talking about sperm that is placed outside the body into a special laboratory environment. Then it can live several days. If that sperm is frozen properly, then it can live indefinitely until it is thawed.

My medical students often ask me how I decide what to post about. Usually, it’s just whatever pops into my head. Other times, like today, it’s on things that I have to explain over and over again to many different people. I realized that if something is inherently so confusing as to have the need to clarify it repeatedly, then it would do the world some good to put it down in words for everyone to read at their leisure.

Three different terms that are used in overlapping fashion are cyst, egg and follicle. The EGG is that all-important biological specimen that contains half a woman’s genetic information. In my simplified view of human reproduction, a woman randomly shuffles all her DNA (the stuff that influences her body to develop blue eyes, a cute little nose and a fondness for puppies) and packages exactly half of it into each egg. The goal then, is for the egg to unite with one of her husband’s sperm, which very coincidentally contains half of HIS genetic information. The final product is a baby, a tiny person with genetic information from both parents. We can’t see eggs on ultrasound, because eggs are smaller than a speck of dust. What we CAN see are FOLLICLES. Imagine a follicle to be like a water balloon with a speck of magic dust (the egg) inside it. A woman is born with about a million of these packed inside her ovaries. Each month after she reaches puberty, some of these follicles start to fill up with water like expanding water balloons. Most will grow just a little and then fizzle out. However, the biggest one, which gets crowned with the title of THE DOMINANT FOLLICLE will grow from microscopic size up to about 20mm, roughly half the diameter of a golf ball. Once it reaches that size, it should burst and let the egg fly out. Under ideal conditions, the egg gets slurped up into the Fallopian tubes where it can hopefully meet a nice eligible sperm and then off they go into the uterus to implant.

So when doing ultrasounds, I’ll often report to my patients, “Great news! You are growing two eggs in each ovary for a total of four, giving you four chances at pregnancy this month! Right now they are still a few days away from being ready.” When they ask how I know that, I answer “Based on the measurements.” This is where the patients naturally assume that by measurement, I am talking about the size of the eggs. But as you probably realize know after having paid attention to what I just wrote, I’m actually talking about the size of the follicles.

Now that we have clarified the relationship between an egg and a follicle, where does the term CYST come into all this? A cyst can be defined as a CLOSED SAC, sometimes filled with a substance like fluid, air or blood.. So actually, follicles are cysts. They happen to be GOOD cysts as opposed to bad cysts. So medically, CYST is the term we use to generically refer to many different sac-like structures, not just dust-filled water balloons. Cysts can be found in many places like in breasts, under the skin, in the cervix or in the brain. Furthermore, ovarian cysts can be the good kind (follicle) or bad kinds, such as endometriomas which are harmful cysts filled with fluid that looks like chocolate syrup.

Now here’s the tricky part. A follicle and a simple cyst look identical on ultrasound. So using just one single ultrasound, nobody can say for sure whether we see a good follicle or some other type of cystic structure. However, if you look again on ultrasound three days later and see that the water balloon has grown from 14mm to 19mm, then you get a pretty good idea that it is a growing follicle. If instead, your repeat ultrasound shows nothing, then it turns out that it was most likely a cyst which has gone away on its own.

The typical protocol for patients who are taking strong fertility drugs is to do a cyst check prior to starting the stimulation medications. This is an ultrasound done on about day #3 of the cycle. What we want to see is nothing. What we don’t want to see, but sometimes do, are cysts and if they are big enough, it tells us that this is not a good month to do a cycle, so we postpone things.

Finally, let’s go back to the idea of how it’s normal each month for a single healthy water balloon to grow to a mature size and ovulate its precious contents. Remember, I alluded to this being the dominant contender out of several contestants which start the race, meaning most women will start growing a lot of potential follicles each month, but without medications, they should just ovulate one (or occasionally two). The other follicles should quickly all fizzle out and not even grow to a visible size. However, there are some women with a common medical condition in which the ovulation process goes haywire. Instead of one dominant follicle emerging and the others all shrinking to nothingness, what happens is that a whole bunch of the follicles keep growing, but none really make it to mature size. So instead of seeing one large 20mm water balloon and nothing else, you see a whole bunch of 12mm follicles stagnated in their growth. Some of you have probably already guessed that this condition in which multiple small ungrowing non-ovulating follicles are seen in the ovary is called POLY-CYSTIC OVARY SYNDROME, but that’s a story for another day.

People are so different. I love it! There was one time when in the same week, I performed intrauterine insemination procedures in my office on two different patients of extreme attitudes with regards to the level of emotional involvement in the process.

“Mrs. Total Experience” requested the room lights be dimmed. She brought a CD player and headphones to play meditation music. She wanted to bring aromatherapy candles, which I said was probably OK, although if it were an IVF procedure with delicate air-particle-sensitive embryos involved instead of an IUI with just hearty sperm involved, I would have said no. She wound up not bringing it anyway. I’m glad, because I had an afterthought that it might violate some fire code in our office. After I placed the speculum and gently threaded the catheter into her cervix, she had pre-requested that I let her husband depress the plunger on the syringe. He did so with his left hand while he held her hand with his right. It was actually kind of touching. Having husbands inject the syringe is not uncommon, but this entire ritual was definitely the most elaborate I’ve seen.

In contrast, “Mrs. All-Business” was already waiting in stirrups and fully ready when my assistant and I came into the room. She was on her cell phone having a heated business conversation and I politely waited for her to finish. Instead, without the slightest pause in her conversation, she waved her hand in a “go right ahead” motion followed by the curved index-finger-touching-thumb gesture, which I immediately understood from my scuba diving days to indicate “A-OK”. So while she smilingly continued her conversation, I had to use some sign language myself. Waving both my gloved hands, I signaled “scoot down along the table a little”. Then “let your knees go apart a little”. Each time, I had to stand up from my exam stool so she could see me. I then held up the speculum for her to see and pointed towards the area where I would soon insert it. She nodded, all the while focusing on her conversation, which I couldn’t help but overhear. It apparently involved a transaction of more $$ than I would ever see in my lifetime. I did the insemination and stood up. Most other RE’s save time by not doing an ultrasound right after an insemination, but I do for several practical reasons. I confirmed that the sperm was in her uterine cavity. I was able to get a bonus image of her cavity to confirm the absence of polyps, sort of a no-cost poor-man’s saline-contrast ultrasound using the insemination fluid as distension medium. I also verified that her follicles had all ovulated. I adjusted our power exam table so that the patient was tilted head down at a 15 degree angle. She motioned for my assistant to give her her handbag which she had left on the chair on the other side of the room. As she pulled what looked like a small appointment book out her purse to write in, she smiled and casually waved to me as I left the room. I wondered if this superwoman will bring her laptop to work on while she is in labor pushing out her baby eight months from now.

I really enjoy my job. The day that I stop seeing things that surprise me is the day I will finally retire. I have a strong feeling that it won’t be any time soon.

• 6:30 am. I arrive at the surgery center. Two patients undergoing IVF procedures have been preparing for weeks to have their eggs harvested today. I greet the patients in the pre-op area and answer any last minute questions. I discuss any specific issues with the anesthesiologist and let her take over as she brings the patient into the OR. I finish some charting and then go scrub. The procedures are quick. Using ultrasound-guidance, I advance a needle through the vagina into each ovarian follicle. There is tubing hooked up with suction, so the follicular fluid flows into test tubes, which get handed off to the embryologist. He works quickly through the microscope, hunting for the eggs within each tube of follicular fluid. One patient (older) gets 5 eggs. The other patient gets 23 eggs. I make sure there is no bleeding and that each patient is doing well post-operatively. I discuss some matters with the embryologists.
• 7:40 am. I come back to my office and get an update from my staff. A pregnant patient called reporting having some spotting. Another patient is having bad morning sickness. We begin doing our scheduled ultrasounds. Each patient is in the middle of the ovulation stimulation process. Some of them have follicles that are almost mature. Others have only early ones. With each ultrasound, I measure the follicles and check the uterine lining. Some patients also have blood tests done. Using this information, I will make decisions on dosing changes and when to time the inseminations and egg retrievals. There are some inseminations this morning, as well. The husbands drop off the sperm that they produced at home, and one by one, their samples will be washed and processed. All in all, I do 16 ultrasounds and three inseminations and two mock embryo transfers this morning. In between seeing each patient, I go back to my desk and review the lab tests results that come in. I glance at the day’s news headlines online. I check Google Analytics to see how many hits my website got. I drink two glass of water. I compose treatment plans for the patients who will be doing cycles in the upcoming weeks. I return a few calls from referring doctors.
• 11:30 am. All the morning ultrasounds are done. The waiting room is empty. I go back to my desk and briefly check my fantasy basketball scores from last night. I hear my medical assistants screaming happily in the distance. I smile because this means the results of this morning’s pregnancy tests are finished running and the printouts are coming off the machines now. The happy cries from my clinical coordinators and medical assistants mean someone’s favorite patient with whom they especially bonded is now pregnant! I get the results. Five tests. Three pregnant. Two not. My staff fight over who gets to call the pregnant patients with the good news. The ones with the bad news will first be notified by my staff. Then, I will call them myself at the end of the day. I finish charting on the morning patients. I discuss all the patients with my staff to make sure we’re in sync with their treatment plans. No lunch today. I have a talk to give.
• 1:05 pm. I arrive at the medical school auditorium 5 minutes late for my lecture. The 3rd-year medical students are waiting to learn about infertility. I’ve given this type of lecture over 100 times, but each one is a little different because my lecture style consists of an interactive conversation, calling on students. So after covering the basic concepts, I never know where the rest of the talk will lead. This keeps it interesting for me. This is a particularly sharp and motivated group today. I stay a little later answering the many questions.
• 2:45 pm. I’m a little late getting to the radiology center to do a HSG test on my patient. It goes well. Good news. Her tubes are clear and her uterine cavity is normal.
• 3:20 pm. Back in my private office, I take a quick nap. With the help of advanced brain-wave technology, I have trained myself to be able to enter dream-state sleep very quickly. I wake up totally recharged after only 20 minutes, able to give my full alert attention to the next patient.
• 3:50 pm. One new patient to see. I love new patient visits. I never know what kind of interesting people with which types of interesting infertility problems I’ll see. This is a fairly routine case of a couple with suboptimal sperm. We discuss their situation, some tests we’ll be doing, their treatment options and what the next step is. We talk about their dogs and a little bit about my dogs as well. I do an ultrasound exam and go back to my office to dictate the consultation report. I call the two patients who had the negative pregnancy test. One failed her first insemination cycle. She is disappointed, but optimistic for the next time. The other one failed her first IVF cycle. Ouch. We’re both feeling devastated. They embryos had looked good, too. We schedule to talk in person next week. I review some more charts.
• 5:30 pm. Leave the office. Off to the gym before meeting some church friends for dinner. Hopefully, a big dinner.

In a perfect world, we would always make the right decisions all the time. We would always make the choices that best increase the odds of us getting what we want. If you want to know the secret of how to get pregnant, you have to first recognize that the right answer is not the same for everybody. Think back to the times in your life that you wanted something to change. You wanted a new car, but didn’t yet have enough money to afford one. You wanted a good job, but had not found one yet. You wanted that boy in your calculus class to notice you and ask you out, buy he hadn’t yet. Whenever we are faced with wanting things to be different from the way they are now, it comes down to two alternative choices:

• Continue doing things the way you are doing and wait for it to happen.
• Change the way you are doing things.

This applies to everything in life including the question of how best to get pregnant. For some people, the best answer is to just keep doing what you’re doing (going about your daily life, having regular sex without using contraception) and wait patiently until you eventually get pregnant. For other people, the best answer is go see a doctor right away and get started on ovulation medications or have surgery to remove that fibroid from inside your uterus or get medical help to treat your hormonal abnormality. So, how do you know which choice is the best one for you? Well, not only is the right answer different for different people, the right answer is different for the same person at different times. For example, if you and your husband decided in October to stop birth control and to try and get pregnant, the right thing to do would be to just have sex two to three times a week and wait for pregnancy to come. For about 80% of you, pregnancy will come within eight months. So if you were to ask me back then, in October “What should I do to get pregnant?”, my advice would be to do what human beings have done for hundreds of generations, just have sex. However, suppose you follow this plan and next August comes around (ten months later) and you’re still not pregnant. Now if you were to ask me again “What should I do to get pregnant, the answer would change from “just have sex” to “consider getting medical help”. So what factors should you consider when deciding whether you continue the “BE PATIENT KEEP TRYING” strategy or switch to the “TAKE ACTION DO SOMETHING.” strategy? There are FOUR important factors:

• AGE: Because the health of a woman’s eggs changes over time, it is more acceptable to take the slow patient approach when you’re younger than when you are older.
• DURATION: The more time that has passed without you getting pregnant, the more you should consider taking action, rather than continuing to try on your own.
• SUSPICION: If you have abnormal periods, or if you suspect your husband has a sperm problem or if you have a history of gynecological issues such as endometriosis or pelvic infections or anything that makes you suspect that your fertility is impaired, then you should probably seek help sooner than later.
• PRIORITIES AND PERSONAL BELIEFS: On one extreme, if you absolutely insist on getting pregnant “naturally” and have vowed that you would rather remain childless than step foot into a doctor’s office or take a single pill, then your decision would differ from that of another woman who’s mindset is that her life cannot go on unless she has a baby NOW, even if she has to sell a kidney to afford the world’s best treatment.

In future posts, we’ll look at each of these factors in greater detail. Remember. You are always making a decision. If you are choosing to keep trying on your own, rather than see a doctor, that choice is itself a decision. Your are choosing between sacrificing some of you hard-earned money to have a baby vs sacrificing one more month passing by from your limited fertile years.