Fertility File

You can make this the year you get pregnant and deliver a healthy child.

With the proper actions, step-by-step, you could have an excellent chance of realizing your goal.

It starts with understanding the normal sequence.

Most couples start out on their fertility journey with the simple non-medical strategy of trying on their own. More than half of couples need go no further than this step and they will succeed, usually within a year.

For others, they will end up needing some sort of medical help, either basic and “low-tech” assistance or advanced “high-tech” assistance.

The keys are to decide how long you will stick with one method before advancing to the next and to set a concrete deadline for action.

If you want to get started getting pregnant without a fertility doctor, here’s a basic starting point.

Explore optimizing your lifestyle: The five pillars are food, sleep, exercise, mental calm and minimizing harmful habits.

Optimize timing around the peak fertility window.

Set a deadline at which time, if you’re still not pregnant, you will give up on the current strategy and try something new.

CASE #1:

MIKE and ASHLEY are both 34 years old and have been married for four years. In their first two years of marriage, they were not ready to have children yet, so they practiced careful contraception with birth control pills.

Two years ago, they made the decision that they were ready. They stopped the birth-control pills. They did not obsess about getting pregnant, but rather, they went about their lives with the attitude of “whatever happens, happens”. Neither of them had been involved with any pregnancy in their lives, but they thought themselves to be relatively healthy and did not expect any problem.

Six months after they stopped contraception, there was still no pregnancy.

Ashley began to explore information on the internet. Nothing obvious came to mind. She had regular menstruation every month. Their frequency of trying was 2-3x per week. She asked Michael’s opinion about whether or not they should seek help. His answer was no. They should just keep trying. After all, they had other pressing matters in their life, with her goal towards promotion in her job and his having to attend to an ailing mother whose health was deteriorating.

One very important thing they did was they SET A DEADLINE. They both agreed that if a year and a half passed without pregnancy, they would consider some options. By doing, so and making it clear and concrete going as far as both setting reminders on their calendars, they felt at peace.

After their 15th month of trying non-medically, about 3 months before their self-imposed deadline was up, Ashley was late and did a urine test which was positive. They went on 8 months later to deliver a healthy baby girl.

CASE #2

JESSICA and CHRISTOPHER met when they were 35 and 39 respectively. Three years later, they were married. They both felt an urgency to get pregnant because of their age. After the wedding, they never used any birth control and started proactively trying right away. This consisted of tracking her ovulation with an app and making sure to be extra active (every 2 days) surrounding the fertile period. They also set a deadline, but theirs was more ambitious. They decided that if they were not pregnant by six months, they would consider seeking professional help. This was partially due to their age and the fact that they both strongly wanted more than one children.

After six months had passed, there was still no pregnancy. They consulted a fertility doctor who came highly-recommended by Jessica’s best friend. They met with the physician and had a helpful half-hour conversation. One of the tasks was for Chris to get a sperm test. It was found that his count was 35 million per ml, which is low, but barely in the normal range. They were offered the chance to do inseminations and they agreed right away. On their first cycle of IUI (intrauterine insemination), they conceived and went on to delivery a healthy baby boy.

Could they have gotten pregnant on their own if they would have patiently persisted another six months? Perhaps. Perhaps not. They stuck to their deadline, took action and got a good result.

CASE #3

AMANDA and MATTHEW
At age 27, when they got married they didn’t have a strong preference for having a child, but they also didn’t have a strong wish NOT to have one. So they didn’t use overt birth control, but they also didn’t meticulously time things. They were having intercourse about twice a week based on when they were in the mood. After six month, Amanda realized that time had passed and they hadn’t gotten pregnant, and she learned about the concept of setting a deadline. Because their desire to be pregnant was not that desperate, she mentally set a deadline of one more year after which Matthew agreed to quit smoking and/or to get a sperm test.

Another year passed with no pregnancy. Matthew got a sperm test which showed less than 1 million count per ml. After speaking with a doctor, they realized they had been wasting their time all these years. Even though they still weren’t ready to proceed with medical treatment at least now, they had a clear answer on what their chances were. As a result they decided to accelerate their life plans so as to be able to afford and do treatment in two more years.

TAKE HOME MESSAGE:
Setting a concrete deadline can help lessen the sense of helplessness or confusion regarding trying to conceive.

Are your chance of success with IVF affected by the doctor you choose?

In theory, there are several ways that your choice of IVF doctor and IVF program can raise or lower your chance of success. The quality of the embryology lab is one indisputable factor. The management of the ovarian stimulation and the choice of protocol are also important. Now comes strong evidence that the doctor who performs your embryo transfer matters also.

This is an article from the February 2020 issue of HUMAN REPRODUCTION entitled “The human factor: does the operator performing the embryo transfer significantly impact the cycle outcome?” by F. Cirillo, P. Patrizio et al

This retrospective study looked at twenty years of fresh embryo transfers from the Humanitas Fertility program in Milan, Italy. The study looked at a total of 19,824 fresh embryo transfers performed by 32 different doctors. Unlike with a single-doctor practice, where patients are managed entirely by one physician, in a multi-doctor setting, a team approach is used so that each clinical encounter has the possibility of being managed by a different physician.

This study isolated only transfers that were done by the “doc of the day” system and excluded special cases where patients made special VIP requests to have their transfer performed by a particular doctor of their choosing. Furthermore, this study excluded from the analysis any doctor who did fewer than 20 transfers.

As someone who always does a mock transfer, I found it interesting that at this center, a practice or mock transfer was never routinely done. Also, all their transfers were performed under trans-abdominal ultrasound guidance, which is something I never do anymore, having switched exclusively to the trans-vaginal ultrasound guidance technique over twenty years ago.

The variable of outcome that was studied was the OPR ( Ongoing Pregnancy Rate) defined as a pregnancy that successfully survived to twelve weeks. The first part of the study aimed to answer the question: How much does the person doing the transfer affect the the outcome? Simply tallying each operator’s success rates is not the best way to answer this question, because there are so many confounding variables that could affect success rate. The study controlled for many of these variables such as age of the patient, her FSH value (which reflects her ovarian reserve), the number of eggs retrieved, the fertilization rate and the number and stage of the embryos transferred. Since this was a twenty year study, it was also important to account for the year that the transfer took place as technological advances improved IVF success rates at the center with each passing year, so that cycles in 2001 would not be expected to have as high a success rate as cycles done in 2014. This was taken into consideration.

So does the person performing the transfer affect the outcome? The answer was a clear YES. In general, the 32 operators worked for a mean of 162 months, performing a mean of 620 ± 887 ETs, and their overall unadjusted OPR was 21.36%. The doctor with the best OPR had 29% while the doctor with the lowest OPR had 8%. Bear in mind, this is the unadjusted OPR.

Using statistical techniques to adjust for the previously mentioned variables, the study authors were able to calculate that the odds ratio of the worst performer was 16% below the mean while the odds ratio of the best operator was 13% above the mean. If we think of this in terms of real life rather than just numbers in a journal article, it means that there are some babies in Italy who owe their life existence to the roll of the dice of which operator was on duty on the day of their transfer. Of course, this concept applies to all infertility treatment and is the burden that all reproductive endocrinologists bear on behalf of our beloved patients.

There are many potential different factors of how transfers could differ from one to the next. Some of these include the precision localization of the catheter tip in a particular spot, the ability to enter with minimal trauma so as not to agitate the uterus to contract and the ability to avoid the embryos from being sucked back into the catheter upon withdrawal.

The second part of the study came as a surprise to me. When they analyzed to see if the odds ratio for operators improved over time, the slope was close to zero. This would suggest that the skill level of operators did not improve over time overall. That’s not to say there weren’t individuals who got better over time. It just suggested that as a whole, operators don’t generally improve with increased experience.

I concede that knowledge of the findings in this study don’t necessarily translate to useful actionable information for patients. Even if you could choose the doctor to do their transfer within a multi-doctor practice, there isn’t reliable information as to whose track record is better or worse.

I enjoyed and appreciated this study. As a disclaimer, the second author, Dr. Patrizio, was my colleague for three years, one year ahead of me in my OB/Gyn residency. I have always had great respect for his expertise in our field.

People who get pregnant easily might not understand why anyone would possibly need a formal strategy when it comes to fertility. Doesn’t getting pregnant just happen? For some people, yes. But for the 10-20% of couples who suffer from infertility, having a strategy is a very useful thing. People in this situation often have two types of frustration. They have the obvious frustration of not achieving what they desire — a pregnancy. They may also have the frustration of feeling lost, of not knowing what to do next.

Having an actual strategy is helpful in two ways. It helps people make better decisions about what to do and when to do it. It also helps emotionally by bringing some clarity and guidance to an otherwise confusing situation.

I’m a board-certified MD, who has been practicing for over twenty years. As a reproductive endocrinologist, I have helped, at last count, in the conception of 2317 babies. When it comes to solving problems, I like to analyze things in terms of probability.

Some problems in this world are clearly binary. Take the case of a burnt-out light bulb. If you do nothing, the problem never solves itself. Conversely, if you do something and replace it with a fresh bulb, this solves the problem nearly 100% of the time. Even in medicine, there are some almost-binary situations. A patient has a bladder infection. After taking antibiotics, the problem goes away. Here, however, the process has a bit more uncertainty than the light bulb example. Sometimes, a bladder infection goes away on its own without the patient taking any action. Sometimes, even after taking first-line basic antibiotics, the infection persists.

More so than in any other field of medicine that I can think of, fertility treatment is non-binary and lends itself best to a paradigm of probability analysis.

The fundamental question for a fertility patient each month is this: Should I continue trying patiently in the same way or should I do something new instead? If you are trying to get pregnant naturally, you may eventually succeed without changing your strategy. On the other hand, trying something new can often change the monthly probability. A higher monthly probability can affect whether you ever get pregnant in your lifetime or if you run out of time. Even for a patient who ultimately gets pregnant naturally, being proactive can affect the promptness in which the pregnancy occurs. This has value in many ways, including affecting if they retain the option to have a second or third child.

EACH MONTH, A PERSON HAS A CERTAIN PROBABILITY OF GETTING PREGNANT. For someone who has zero sex that month, it is 0%. For someone doing everything humanly possible that month, utilizing the most advanced medical technology, it can often approach 80%, but it still can’t be 100% certain.

Here are some general rules:
The magic number that represents ones probability in a given month is not known precisely, but can be inferred.
It can change dynamically from month to month, year to year.
It is influenced by the characteristics of the players involved (the sperm provider and the egg provider) and it is influenced by what actions they take that month.

Let’s begin by classifying the ways people get pregnant into three categories.

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First, there is the natural way, which is the way everybody knows, namely by sexual intercourse. This is the way that most couples get pregnant, couples who have no fertility issues. Some infertility patients can also get pregnant naturally, either with some help from medications or other lifestyle interventions.

Second, there are low-tech medical procedures. This refers to IUI (intrauterine insemination), a procedure where the sperm is enhanced in the lab and then physically guided into the uterus using a catheter, so that it goes a lot farther and faster to the final destination.

Third, there are high-tech medical procedures. The most famous of these is In-Vitro-Fertilization, a procedure in which the eggs are surgically taken out of the body and allowed to fertilize in the laboratory. Subsequently, the developed embryo is placed directly into the uterus.

A common rational approach is to try the first method until sufficient attempts have failed. Then the second strategy is adopted until a sufficient number of attempts have all failed. Then, it’s time to move on to the third stage. Along the way, there are different variations of these three ways that can be done, but it still boils down to fundamentally one of these three ways.

In future posts, where there is discussion of specific cases, it will be helpful to come back and remember the fundamental framework discussed above.