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Chat Transcript: Mark Bush, M.D. March 8, 2005
Page: 1Transcript of an INCIID Event/Chat with
Dr. Mark Bush, M.D.
March 8, 2005
Mark Bush M.D.
Conceptions Reproductive Associates
3434 47th Street Ste 101
Boulder, CO 80301
Phone: 303-449-1084
Fax: 303-449-1039Email Dr. Bush
http://www.conceptionsrepro.com
Stacey : My husband and I have been TTC for over 2 years. My husband has a daughter from a previous marriage and has been told that he is fine. I have had many tests done and they all have come back normal. So we are undiagnosed infertile. Is there anything that can be taken over the counter to help our chances of conception?
Mark Bush, M.D. : I am not aware of items over the counter that would be helpful in your situation. By many tests, have you had a clomiphene citrate challenge test?
Terri: How often do you recommend have sex during the ovulation period? I have heard several different things. Some say to wait and only do it every other day, and others recommend every day.
Mark Bush, M.D.RTP Nurses Study demonstrated that the highest pregnancy rate with intercourse occurred just before ovulation. Haney et al also had a study that demonstrated that in otherwise fecund couples, that every other day and every day had the same pregnancy rate.
Mary: How many IUI's and rounds of Clomid do you recommend before they probably aren't going to work?
Mark Bush, M.D.: For women that normally ovulate, studies have supported the use of clomid/IUI for three cycles, then moving on to IVF. Said another way, couples that will conceive with properly performed CC/IUI will do so by three cycles.
Harriet: My husband and I have been TTC for a little over one year. They haven't found anything wrong with either of us, except for my "extraordinarily retroflexed" uterus. My doctor thinks this may be involved, but when I try to read about it all I see is that this isn't known to cause infertility. What is the consensus on this?
Mark Bush, M.D.: A retroflexed uterus is found in about 20% of women. It is a normal anatomic variant. As long as the ejaculate is deposited on hospitable cervical mucus, the sperm have no idea which way the uterus is flexed. I am not being flip with this comment. I have no data to suggest that a retroflexed uterus is having a negative impact on your fertility. But again, your doctor has the whole picture in mind and there may be other elements in play here.
Ursula: What is a Clomiphene Citrate Challenge Test?
Mark Bush, M.D.: A Clomiphene Citrate Challenge Test is where a woman takes 100mg of clomid each day, days 5-9 of her cycle, and then gets her FSH and estradiol checked on day 10. It is an indirect test of inhibin secretion. There is a positive correlation between ovarian egg quantity and quality and inhibin secretion. Having said this, values need to be interpreted in the face of age, prior reproductive history, and concurrent diagnosis
Andrea: How do you know if you need a Clomiphene Citrate Challenge Test? How should I go about requesting one of those tests from my doctor?
Mark Bush, M.D.: I obtain a basal (day 2, 3 or 4) estradiol and FSH on all of my patients with unexplained infertility. And because one of the first therapeutic maneuvers is clomid/IUI, I will go ahead and combine the full CCCT (Clomid Challenge Test) with their first cycle of IUI to get the important day 10 data. Corson demonstrated in his study population a 50% increase in the diagnosis of decreased ovarian reserve when obtaining the full CCCT. In other words, women with normal day 3 values that had abnormal day 10 values. But FSH and E2 are not the whole story. As Toner mentioned in Fertility and Sterility, FSH is closely linked to egg quantity and age to egg quality
Eddie : I am the father of an 8 year old daughter, but I got divorced. Since I have been with my new wife we have been trying to have a baby. My sperm count is seriously low and I have tried everything to build it up including exercise and diet and even slowed down on the drinking. This is to no avail. I don’t know what the problem is but the count just keeps coming out low. I have had numerous tests done to check the count and my doctor suggested I take Sudafed during my partners ovulation period which helped a little but apparently not enough. Is there anything else I can try?
Mark Bush, M.D.: Alcohol does inhibit GnRH, which then affects the signals from your pituitary gland to your testicles, adversely affecting the production of sperm. That is a good first step, along with proper nutrition, diet, rest, exercise. Fertilization occurred eight years ago, but the age of your partner at that time and her concurrent issues (or lack thereof) had an impact. I would need to see the semen parameters that you currently have. Of those on light microscopy, morphology (Krueger strict) is most closely associated with fertilization. Subtle defects in count can be overcome with IUI.
Ethel: I have a question about LUFS and the relationship between that and Ibuprofen. Is there a definitive way to diagnose LUFS and is chronic Ibuprofen use (because of autoimmune issues enough to cause this problem)?
Mark Bush, M.D.: NSAIDs have been linked to both LUFS and implantation disturbance. Prostaglandin pathways are involved in both the release of the egg and subsequent implantation. Definitive diagnosis of LUFS is difficult. The often employed sonographic evidence is unreliable. If you currently carry this diagnosis, make certain other factors are being checked.
Laura: Dr. Bush, what is your definition of "unexplained", and at what point do you stop testing and "call it a day"?
Mark Bush, M.D.: Unexplained infertility really means undetected infertility. The fallopian tubes are open (often displayed by hysterosalpingogram), the sperm is adequate on light microscopy (normal semen parameters) and the woman ovulates. But within each of these areas, there may be further defects that are undetected by the above tests. While the hysterosalpingogram can document that the tubes are open, tubal function is still untested. The embryo spends the first three days of life in the tube. The inner lining, muscular function and the microenvironment needs to be normal. Another area that the HSG cannot fully test is the ability of the tube to catch the egg when it ovulates. Minimal spill from constriction at the end of the tube and loculations that can suggest adhesions may point to a problem which can be further defined and treated with laparoscopy. If conception has not occurred with properly timed intercourse in a couple where the woman ovulates, the man’s semen is OK on semen analysis, and the fallopian tubes are open, often times it is a subtle defect in either the egg or sperm, or both. The sperm’s job (function) is to find the egg and then fertilize it. While the semen analysis can give clues to whether there is sufficient number and motility to accomplish this, it is really not a functional test. The parameter that most closely correlates with fertilization is the shape. We often use the Kreuger strict analysis to triage between conventional co-culture and ICSI when performing IVF. The same logic can be applied when deciding to move to IVF. If the percent normal on Kreuger is low, or if the count and motility are severely depressed, then moving to ICSI-IVF is favored over repeated attempts at IUI.
Typically accepted numbers for a diagnosis of unexplained is 10-15% of couples. But I cannot stress enough the importance of age and ovarian reserve that may be embedded in the diagnosis of "unexplained". A large portion of a couple’s reproductive potential lies with the female egg. The importance of the age of a woman cannot be understated. But for a given patient, the CCCT and antral follicle count can offer important clues as to her individual reproductive potential. Normal values confer a prognosis of age alone. For instance, in a couple with unexplained infertility where the woman is 28 and her values are normal, therapies that utilize the fallopian tube, such as corrective pelvic surgery (resection of adhesions, endometriosis, tuboplasty) and IUI are appropriate considerations. But if that same woman had borderline values, she would best be served by moving forward with ART. Age is one of the most important factors affecting fertility. As women age, the quality and quantity of their eggs decline. This is called decreased ovarian reserve. Even if a woman regularly ovulates, has regular periods, and feels fine from adequate estrogen and progesterone secretion from the ovary, the eggs that the ovary produces as a woman ages have a decreased ability to establish a pregnancy. IVF can not only be therapeutic but further diagnostic of an egg issue. Response to stimulation (to include number of mature eggs), fertilization, and embryo progression are all important elements. Embryo progression is defined as temporal landmarks, morphologic criteria, and survival. For instance, are the embryos dividing on time, do the cells look healthy, and are the embryos healthy/surviving to d3 or blastocyst? These elements often validate the decision to go to IVF with unexplained because a pregnancy was established by transfer of the healthiest embryos after the natural attrition that occurs from egg retrieval, through fertilization, to embryo development that is more pronounced in women with diminished egg quality. It will also help determine whether a woman should attempt again with her own eggs or consider donor eggs.
Abigail: I received a copy of my radiology report for an ultrasound I had done last month. It states I have two complex cysts in my left ovary with heterogeneous echogenicity with fluid-fluid levels present. Can you explain to me what this means?
Mark Bush, M.D.: By your description, these are most likely either endometriomas or corpus luteum cysts. Relevant historical issues for the former would be cyclic pelvic pain and the latter would be recent use of clomid that may have produced more than one ovulatory event. Repeat ultrasound is important to follow progression or resolution. If persistent, causing pain, or the total complex is 5 cm or greater and last greater that 8 weeks, it is unlikely to go away and surgical evaluation may be warranted.
Mark Bush, M.D.: You apparently carry a surgical diagnosis of endometriosis. Have you had a return of symptoms (like cyclic pelvic pain with your menses) that may suggest endometriosis in your pelvis? If so, endometriosis can affect both endometrial implantation proteins and egg quality. Further, your prior laparotomy and the immune response to endometriosis can engender adhesions that can adversely affect tubo-ovarian capture. I do not think that your RE made a mistake; he/she has the whole picture.
Melly: Dr. Bush, do you think 2 months of lupron depot treatment for endometriosis before IVF makes any difference vs 3 months of Lupron Depot? I will be on Lupron Depot for 2 months.
Mark Bush, M.D.: The study I cited discussed this. Three months seems to be the maximum where you get a beneficial suppression of the endometriosis burden without the peritoneal environment becoming refractory. I have had successes with 2 months of therapy - but it is not a randomized trial - just longitudinal data. My judgment is that two months will provide benefit.
Mark Bush, M.D.These were great questions. I am sorry I could not answer them all. I'll be back soon. Good luck to all!
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