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General Infertility FAQ

Last Updated: 10/2/2006

  1. What is Infertility?
  2. Why should I seek treatment from a Reproductive Endocrinologist rather than from my OB/GYN?
  3. Where do I start? What tests should I have? What can I expect in my first appointments?
  4. I live several hours from the nearest RE. What do I do?
  5. How long does it take to ovulate after the first positive result on the OPK (Ovulation Predictor Kit)?
  6. How long after HCG does ovulation occur and how do we know?
  7. How long do sperm live after timed intercourse or after IUI?
  8. How long are eggs able to be fertilized?
  9. How long does it take for fertilization to occur?
  10. How long does it take for implantation to occur?
  11. How soon can I take my Pregnancy Test (Beta HCG or Home Pregnancy Test)?
  12. How do you determine the first day of your cycle?
  13. What should my progesterone level be?
  14. What should E2 numbers ideally be during an injectables cycle?
  15. What should my uterine lining be at ovulation and at implantation?
  16. I have just had a 3-day FSH test taken, and I am concerned about the results.
  17. How do we know if the sperm count is adequate for IUI?
  18. I am concerned about the size of my follicles, and the timing of my HCG shot. How big should my lead follicle be before I take my HCG shot?
  19. How much do follicles grow each day?
  20. Will smaller follicles "catch up" in time to release eggs?
  21. I have leftover cysts on my ovaries. My doctor wants me to sit out this cycle. What causes these cysts?
  22. Will they go away?
  23. How big do they need to be to reduce chances of pregnancy?
  24. Why do they reduce my chances of pregnancy?
  25. If I have cysts of any size, should I be concerned?
  26. What exactly is an endometrial biopsy?
  27. How long should I use Clomid before I move to Injectables/IUI?
  28. How many times should I try IUI before moving on to IVF?
  29. What is the maximum recommended dosage for Clomid?
  30. Should I be taking Clomid on days 3-7 or on days 5-9?
  31. What are normal ranges in a semen analysis?
  32. Why would my physician mix my Clomid treatment with injectables?
  33. I have heard that Clomid is not recommended for women over 40. Why?
  34. I am on a cycle of injectables or Clomid/injectables. Should I use an Ovulation Predictor Kit? If I don't, how will they time the HCG shot?
  35. How long should my partner abstain before the IUI? His semen analysis is normal.
  36. What is a sample protocol for IUI?
  37. What tests should I have after my IUI?
  38. Why am I taking Lupron with my cycle?
  39. How should my IUIs be timed?
  40. What are the logistics of injectables? How many days will I take them? How big are the needles? Who administers the injection? Are they painful?
  41. What is the standard IVF protocol?
  42. I hear so much about taking baby aspirin. Should I be taking it, too?
  43. Should I take progesterone supplementation during treatment?
  44. Should we try a hamster test to determine if we have male factory infertility?
  45. Should I use a BBT chart?
  46. My RE wants to me to "coast" for a while on this cycle. Why is he slowing me down?
  47. I heard that multiple cycles with fertility drugs increase the chance of getting ovarian cancer. Is this true?
  48. My doctor has recommended a hysteroscopy, laparoscopy, or folloposcopy. Where can I get more information?
  49. Do your chances increase with each consecutive cycle?
  50. I am concerned about the nature of my discharge and/or my cervical mucous during this treatment cycle.
  51. I had my egg retrieval. I had more eggs/fewer eggs that I expected. What factors are at work in egg retrieval numbers?
  52. I have a yeast infection! Will this hurt my chances or affect my ovulation predictor kit test results?
  53. I am in treatment and I am sick! What should I do?
  54. Is it safe to take over the counter (OTC) drugs during treatment?
  55. I am afraid that I might have ovarian hyperstimulation. What can you tell me about this?
  56. My progesterone was very high. Does this mean I am pregnant?
  57. I have spotted, and it is not time for my period. Was it implantation spotting?
  58. My breasts are tender, or I have cramps, or am irritable, nauseated, or bloated, or, I am gaining a small amount of weight. It is not yet time for my pregnancy test. Could these be signs of pregnancy?
  59. I have questions about my symptoms or situations before or after a treatment cycle. My period has been usually light or heavy since my last cycle with Clomid or injectables. Or, I have not even gotten it yet, although my beta was negative. Is this normal?
  60. What constitutes early or late ovulation? Does late ovulation decrease fertility?
  61. My doctor says I am not ovulating regularly. How could I get my period if I do not ovulate?
  62. I am concerned that I may have poor egg quality. How can I determine my egg quality?
  63. What causes chemical pregnancies?
  64. I have questions about special precautions during treatment. Should I avoid exercise after ovulation?
  65. What about Hot Tubs?
  66. Should I avoid air travel or ground travel after my transfer?

What is Infertility?

Infertility is the inability to conceive after a year of unprotected intercourse in women under 35, or after six months in women over 35, or the inability to carry a pregnancy to term. Couples who have known barriers to fertility, such as endometriosis, polycystic ovarian syndrome, male factor infertility, irregular cycles, etc., do not need to sit out the traditional "waiting period" to seek expert care for infertility. See INCIID's glossary for more terms and definitions.

Why should I seek treatment from a Reproductive Endocrinologist rather than from my OB/GYN?

Picking a doctor is so very important. A board certified Reproductive Endocrinologist (RE) is an Obstetrician-Gynecologist with advanced education (a mandatory three year fellowship) and research in Reproductive Endocrinology. These highly trained and qualified physicians treat Reproductive Disorders that affect children, women, men, and the mature woman. (Portions of the above were taken from INCIID Glossary). They are certified with the American Board of Obstetrics and Gynecology in the Sub-Specialty of Reproductive Endocrinology and Infertility. It is important to find a doctor who responsive and well matched to your needs and diagnosis. Most importantly, a reproductive endocrinologist specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem than an OB/GYN who treats only a few infertility cases each year. It is ideal to have a clinic that is open 7 days a week, for optimal procedure timing. We hear a lot of "I wish I hadn't spent all that time and money with my OB/GYN." It can be a tremendous waste of time, and money that you could put toward treatment with a specialist who can get to the root of your problem. You may need evaluation from a Reproductive Endocrinologist if you meet the criteria for infertility defined above.

Where do I start? What tests should I have? What can I expect in my first appointments?

There is no better place to start learning about basic testing than the Basic Testing link at INCIID!

I live several hours from the nearest RE. What do I do?

Try to see if you can do some of your monitoring locally and save your travel only for the "big" appointments. Be sure and talk to the doctor to determine how much traveling would actually be involved. However, you may also decide being treated by an expert will be worth the extra time and travel.

How long does it take to ovulate after the first positive result on the OPK (Ovulation Predictor Kit)?

You will most likely ovulate 12-48 hours after the first positive result on your OPK, and usually within 24-36 hours. Also, you do not need to keep testing for your LH surge once you get the first positive result. It is the first positive result that you are after.

How long after HCG does ovulation occur and how do we know?

Ovulation occurs 36-40 hours after the HCG injection. We know this from IVF observation. Eggs will release in this timeframe if they have not been retrieved.

How long do sperm live after timed intercourse or after IUI?

Normal, healthy sperm live approximately 48-72 hours. (Abnormal sperm may have a shorter life, which may vary according to sperm health.) We do know that washed sperm can survive in the IVF incubator for up to 72 hours. That would be considered the upper practical limit.

How long are eggs able to be fertilized?

Eggs are able to be fertilized for about 12-24 hours after ovulation. The older the woman, the shorter this time becomes.

How long does it take for fertilization to occur?

Fertilization occurs within 24 hours after ovulation.

How long does it take for implantation to occur?

Implantation occurs about 5-10 days after ovulation.

How soon can I take my Pregnancy Test (Beta HCG or Home Pregnancy Test)?

The earliest that a sensitive blood test can pick up any HCG at all is 5-7 days after ovulation. Your quantitative serum beta test can be reliable about 10-12 days after ovulation, if you have not taken a HCG booster. Extremely sensitive home pregnancy tests might in some cases be reliable as soon as 12 dpo. If you have taken a HCG booster, then you may have a reliable test at 14 days past ovulation. The serum beta is the most reliable test. Any level over a 5 is generally considered a positive result, although having a second blood test two days later should show the numbers nearly doubling. The "average" level of hCG is about 25 at 10 dpo, 50 at 12 dpo, and 100 at 14 dpo. Note that there is a difference between a qualitative and a quantitative test. A qualitative test gives a yes or no answer. Your HCG level has to be above 50 units to get a positive result. Quantitative tests give a value to the amount of pregnancy hormone in your blood. It gives a specific number. Anything greater than 5 is considered positive. Considering that it is possible to implant as late as 10 dpo, a qualitative beta might produce a false negative if used for an early pregnancy test.

How do you determine the first day of your cycle?

CD1 is the first day you see a red flow, not just intermittent spotting. There is no universal rule for the cutoff time for that date. Some RE's use midnight, others use 5 p.m., but most often CD1 is considered the first day of full flow that begins before mid-afternoon. Again, spotting does not count unless it is a continuous (not intermittent) spotting. Continuous spotting does count as CD1. The fact that the rules of thumb for calculating CD1 are so arbitrary suggests that you've got a little bit of leeway for variation.

What should my progesterone level be?

Progesterone will be less than 1.5 Ng/ml until the LH surge. It peaks about seven days after ovulation, when it reaches 15 Ng/ml or more. But note, if you are above 10 in the luteal phase, your progesterone level is probably fine. When it drops between 2-4, menstruation begins. (This is why use of progesterone supplements can delay the start of your period). Additionally, you may get very high progesterone levels after IVF because so many follicles were created. (Progesterone is made by the corpus luteum, which is the site on the ovary from which the egg is released. The more eggs are produced, the more progesterone is produced.) Most doctors use a high level of progesterone supplementation in the luteal phase, which can also result in very high progesterone levels. There is no progesterone level that indicates pregnancy, only an hCG level over 5 determines that. It is also worth nothing that progesterone pulses, so the level varies throughout the day. Some doctors suggest testing first thing in the morning after fasting for the most accurate result. A high progesterone level gives more information than a low reading in that a "good" level indicates sufficient progesterone to carry a pregnancy; a lower level (in the 5-15 range) does not spell doom.

What should E2 numbers ideally be during an injectables cycle?

You should see 150-200 per mature follicle. (Note: E2 tends to be somewhat lower on pure FSH cycles. You may use this as a guideline, but your physician will be your best guide in this case.) It ideally should be 100 or over after three days of LH-containing injectables. It ideally should be 100 or over after 4-5 days of injectable recombinant FSH. No chart can show ideal E2 levels since E2 varies per number and size of the follicles.

What should my uterine lining be at ovulation and at implantation?

As you approach your LH surge, it should be above 6 mm, ideally between 8 and 12 mm. (If it is much more than that, it may be advisable to ask about a hysteroscopy or sonohysterogram to see if perhaps there is a polyp inside the uterus). You want to have a triple stripe pattern around the time of the LH surge and ovulation. Towards the time of implantation, you want to have a more integrated HH or IE pattern. The triple stripe occurs in response to estradiol; the HH/IE conversion is in response to progesterone. It should also be noted that, although most doctors prefer the above pattern of linings, there is no conclusive research on whether a better pattern actually results in higher pregnancy rates.

I have just had a 3-day FSH test taken, and I am concerned about the results.

One of the best starting points is the Dr. Sable's article on FSH: Good Eggs, FSH Levels and Ovarian Reserve. In addition, here's what Carolyn Coulam, M.D. has to say about follow up to FSH: If these bloods were drawn on day three of a cycle, the results would imply decreased ovarian reserve or eggs available. To confirm this we would draw blood for inhibin B. If the inhibin B is low consideration should be given to donor eggs. Inhibin B is a protein made by the granulosa cells that surround the eggs. FSH is more of an indirect measurement of ovarian reserve.

How do we know if the sperm count is adequate for IUI?

Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If the functional sperm count (number with normal morphology and rapid forward-progressive motility) exceeds 1 million; chances for pregnancy with well-timed IUI are excellent. See Semen Analysis fact sheet for more information.

I am concerned about the size of my follicles, and the timing of my HCG shot. How big should my lead follicle be before I take my HCG shot?

A lead follicle should be at least 16 mm on an hMG like Pergonal, it should be at least 18 mm on a recombinant FSH like Gonal-F, and should be about 22 mm on Clomid. Occasionally Gonal-F can produce mature eggs in smaller follicles, in which case other measurements such as E2 and progesterone should be used to indicate maturity. (The difference in ideal size is due to the difference in mechanisms by which the medications work. For example, the mechanism by which Clomid works often takes a bit longer because it is indirect. Therefore, the follicle has more time to grow before the egg is actually mature).

How much do follicles grow each day?

Follicles grow 1 to 2 mm a day both while taking ovulatory stimulants and after the HCG shot.

Will smaller follicles "catch up" in time to release eggs?

Follicles generally need to be at least 15-16 mm to contain fertilizable eggs (although it is possible in rare cases for follicles to be as small as 14 mm and still contain fertilizable eggs). If the smaller follicles are close in size to the lead, they may "catch up" and release. HCG will usually result in most mature follicles releasing eggs. Otherwise, most likely only the lead follicle will ovulate.

I have leftover cysts on my ovaries. My doctor wants me to sit out this cycle. What causes these cysts?

A corpus luteum, or functional cyst, is simply a leftover follicle that has outstayed its welcome. Some continue to produce progesterone and estrogen, which may delay the arrival of the next period.

Will they go away?

Functional cysts almost always go away with time. Birth Control Pills are sometimes prescribed to hasten their resolution.

How big do they need to be to reduce chances of pregnancy?

Research has shown that any cyst 10 mm or larger is associated with a lower chance of getting pregnant. In a study on women doing IVF, those that had a 10 mm cyst at the beginning of a cycle had half the pregnancy rate of those who had no cysts (and the groups were equal on all other relevant characteristics). So it does not eliminate your chances of pregnancy, but it does sharply decrease them.

Why do they reduce my chances of pregnancy?

Cysts do not eliminate the possibility of pregnancy in a cycle, but they do reduce it. They do this through two mechanisms. First, physically, they can crowd out the development of new follicles. Also, if the cyst is secreting hormones at the wrong time of the cycle, (for example, progesterone during the follicular phase), it interferes with the chemical balance required for good quality ovulation and drastically reduces the chances of pregnancy.

If I have cysts of any size, should I be concerned?

It is normal to have small cysts, which may be very small leftover follicles or follicles that are preparing for the next cycle. Anything under 10 mm shouldn't be cause for concern as long as your baseline hormone levels are in range.

What exactly is an endometrial biopsy?

In an endometrial biopsy (EMB), a small catheter is threaded into the uterus and a sample is taken of the lining, or endometrium, during the last week of your cycle. (It causes brief cramping for which Ibuprofen, taken ahead of the procedure, is helpful). Once the sample is obtained, it is rated according to the day of a 28-day cycle for which it would be typical. For example, a lining at the beginning of the luteal phase is different from a lining at mid luteal phase or during the follicular phase. An out-of-phase endometrium means that the endometrial appearance is typical of a time in the cycle other than the time it was taken. This biopsy does have the potential to disrupt a pregnancy in progress. Many doctors will test for pregnancy before doing the biopsy, to be on the safe side. An EMB may also be done to check for abnormal cells in the endometrium (hyperplasia). This is a concern when a woman has very infrequent periods (bleeding less than once per three months) or when ultrasound reveals a thick lining. For this purpose, the EMB can be done on any cycle day.

How long should I use Clomid before I move to Injectables/IUI?

The vast majority of Clomid pregnancies occur during the first 4-5 ovulatory cycles. Some physicians also indicate that of those pregnancies, the majority occur during the first 3 attempts. (Also, if you do not stimulate well on Clomid at a reasonably high dosage, you might consider moving on to Injectables earlier. The maximum dosage is 150 mg., according to the manufacturer, and it may be wise to move on if unsuccessful after two cycles at that dosage). The average number of cycles on Clomid before moving on is three to six.

How many times should I try IUI before moving on to IVF?

Once a patient has had 3-6 IUI cycles with injectables, they might consider moving to IVF as the chance of a successful IUI cycle is reduced.

What is the maximum recommended dosage for Clomid?

As mentioned about, the maximum dosage is 150 according to manufactures. It may be wise to move on if there is no response to 150 mg, as the risk of antiestrogenic side effects of Clomid increase sharply as the dosage goes up.

Should I be taking Clomid on days 3-7 or on days 5-9?

In theory, days 3-7 of Clomid lead to more follicles and fewer side effects on the lining and the mucus. Days 5-9 lead to better development of just a few follicles. It seems to make a difference for some women and does not make any difference in others. Little conclusive research on the issue exists.

What are normal ranges in a semen analysis?

Normal Ranges for a Semen Analysis* Parameter Normal Ranges Color Gray/Transluscent Coagulate? Yes Liquify? Yes If yes, time in minutes Less than or equal to 30 Volume (mL) 2 to 6 Viscosity (1,2,3,4) 1 pH 7.5 to 8.1 % Motility Greater than or equal to 50% % of 3-4 + Forward Motile Sperm Greater than or equal to 50% Sperm Concentration (x 1 Million per mL) 20-200 Total Sperm Count (x 1 Million per mL) Greater than or equal to 40 Total Motile Sperm (x 1 Million per mL) Greater than or equal to 20 White Blood Cells (x 1 Million per mL) Less than or equal to 1 Agglutination (0,1,2,3) Clumping of sperm to sperm 0 Clumping of sperm to round cells 0 % Normal Morphology Greater than or equal to 30% Penetrak Score (mm) Greater than or equal to 30 mL = milliliter mm=millimeter Based on World Heath Organization criteria, 1992. Table excerpted from Berger, G.S., Goldstein, M., and Fuerst, M. (1995). The Couple's Guide to Fertility. New York: Doubleday

Why would my physician mix my Clomid treatment with injectables?

Mixing injectables and Clomid is an attempt to get some of the stimulant, cervical mucous, and lining benefits of injectables without spending as much money as would be required by doing only injectables.

I have heard that Clomid is not recommended for women over 40. Why?

As women pass 35, many doctors do begin to be more cautious about using it for a couple of reasons. One, women approaching 40 tend to have more lining problems and Clomid can have deleterious effects on the lining. Secondly, if a woman is perimenopausal, the mechanism by which Clomid works is not always effective, because the body is somewhat inured to low Estradiol levels.

I am on a cycle of injectables or Clomid/injectables. Should I use an Ovulation Predictor Kit? If I don't, how will they time the HCG shot?

Some women don't get a positive OPK when they are on injectables or even a mix of Clomid and injectables. You have to base the timing of the HCG shot on the Estradiol levels and follicle sizes. The use of progesterone also helps determine when to give HCG. It is best, for an IUI, to administer HCG when the progesterone level rises over 1.5.

How long should my partner abstain before the IUI? His semen analysis is normal.

For most men, a 2-3 day break is ideal. That gives the "sample" an opportunity to regenerate. Too "old" of a sample raises the risk of poor motility, white cells, and other problems. (An "old" sample would be that which is taken after more than 7 days of abstinence).

What is a sample protocol for IUI?

The simplest protocol is Clomid 50-mg days 3-7 (or 5-9) of the cycle. Use a urine LH or ovulation detector kit daily starting day 11 of the cycle. Perform the IUI the day following the LH surge. With the addition of vaginal ultrasound monitoring on the day of the LH surge or by day 14 if no LH surge, you may be given an HCG injection and IUI performed 36 hours later. Adjustments in the ovulation induction protocol can be made in subsequent cycles depending upon your response (as measured by LH kit and ultrasound).

What tests should I have after my IUI?

You should at least have a 7-dpo-progesterone test. Your RE may also check the pattern and thickness of the uterine lining via ultrasound at the same time.

Why am I taking Lupron with my cycle?

Most commonly, Lupron is given to IUI patients because they have a history of surging prematurely, before it was time to administer the hCG shot. Lupron greatly reduces the chance that this will happen. It is also sometimes used for patients who have a tendency to develop only one dominant follicle, even on ovulatory stimulants. Normally Lupron is only used in conjunction with injectables.

How should my IUIs be timed?

In most cases, doctors who do two IUI's do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective. However, some recent research suggests that higher pregnancy rates may be achieved by doing two IUI's, one at 12 hours past the hCG shot and one at 34 hours.

What are the logistics of injectables? How many days will I take them? How big are the needles? Who administers the injection? Are they painful?

Typically, they are taken daily for 7-12 days (although it is possible to take them as long as 14 days). If you are taking subcutaneous injections, they are administered in the stomach, upper arm or thigh, with a 1/2- or 5/8 inch needle. If they are intramuscular, they are given in the hip/buttocks area using a 1.5-inch needle. The partner usually administers the IM shots. You can also give the IM injection to yourself in the thigh. They feel like a flu shot or vaccine.

What is the standard IVF protocol?

There are several variations on the IVF protocol. Described below is a sample "down regulation" protocol. This is an example of one which doctors commonly start with when the patient is under 35 and has a history of good response to stimulation. In the down regulation protocol, you start the cycle before your stimulation and retrieval cycle. On CD3 of that cycle, your FSH level is measured. On CD21, you do a progesterone test to see if you have ovulated. (If you are annovulatory, they will often put you on a BCP regimen to give you a predictable cycle). If you have ovulated, then you start Lupron shots once a day. The dosage varies from doctor to doctor to some extent. You may start out on 20 units and then drop down to 10 units after five days. Your period should arrive close to its due date. On CD1 or 2, you are tested to ensure that Lupron has shut down your own hormone system, so that they can use drugs for stimulation and have a more predictable cycle. Suppression is determined primarily by your estrogen level, but your doctor may also check progesterone and LH. If you are adequately suppressed and an ovarian scan shows no cysts, you will usually start injectables on CD3 or so. Your Lupron dose may be lowered to 5 units at this time. Your medication dosage depends on your diagnosis, age, and response history if you have taken injectables before. You might take two amps in the morning and two in the evening. After three days of ovulatory stimulants, your follicles and Estradiol levels will be checked. It is good to see the E2 levels above 100 after three days of stimulation. There will not be a great deal of follicle development yet. If needed, your medications will be adjusted. You will go in a few days later for a second round of blood work and a follicle check. After that, you might report to your clinic daily for blood work and ultrasounds. Once your follicles have reached an appropriate size and your E2 levels are good, you stop the stims and Lupron, and are given the hCG shot. This is about 34 hours before the retrieval is scheduled. The cut-off for the hCG shot, again, varies. Some clinics check for good blood flow to the uterus and a triple layer pattern in the uterus before retrieval as well. They might use this as a determining factor on whether to order baby aspirin. Retrieval is generally an out patient procedure. It can be done with a local anesthetic or an IV anesthetic. The IV anesthetic is much like the IV sedation used in dental procedures, and is very comfortable. The eggs are retrieved using an ultrasound probe that has a needle at the end of it. They put the needle through the vaginal wall and aspirate the follicles. You will generally start progesterone immediately following the retrieval. The post-retrieval events vary according to whether you are doing a day 3 or day 5 transfer, but you will generally receive updates about the number of eggs retrieved, the number fertilized, and the progress of the embryos. The transfer itself is much like an IUI, although most doctors use u/s to guide the catheter in, because placement is so critical. Pregnancy tests are generally done somewhere between 12 and 14 days after transfer. Two other variants on the down regulation protocol are used in women over 35 or women with a history of poor response. The "flare" protocol has you start Lupron around the same time you start your stims, rather than during the luteal phase of the previous cycle. A "stop" protocol means that you take Lupron for several days but then stop it at some point while you are still taking your stims. Each protocol has its plusses and minuses. Women on the down regulation protocol require a greater amount of stimulation, often over a longer period of time. However, women on stop and flare protocols are more likely to have a premature LH surge and are more likely to develop a single dominant follicle (not a good thing in IVF).

I hear so much about taking baby aspirin. Should I be taking it, too?

More and more RE's are using this as part of their protocol, especially for patients with histories of miscarriage and lining problems. See the Baby Aspirin fact sheet for the pros and cons of taking baby aspirin. Consult your RE before taking a regular regimen of any over-the-counter-drugs during your fertility treatment.

Should I take progesterone supplementation during treatment?

Some RE's put patients on progesterone during the luteal phase automatically. The underlying concept is that if you wait and find out if the progesterone is low, even at seven days past ovulation (7 dpo), it can be too late because the lining may not be receptive to implantation. Low progesterone can cause implantation failure, because its role is to vascularize and maintain the uterine lining, which is where implantation takes place. Sometimes women require more progesterone support in the luteal phase on injectables, even if they have a good progesterone level. This may have to do with the high levels of estrogen that occur during injectable cycles. There are four different common methods of progesterone supplementation: progesterone in oil shots (PIO), progesterone suppositories or vaginal capsules, Crinone (progesterone) vaginal gel, and oral progesterone. Also, hCG "boosters" given five days or so after the first dose, are commonly used to cause the Corpus Luteum to produce more progesterone. Progesterone, even in the form of over-the-counter creams, should not be taken before ovulation because it can block ovulation and make the cervical mucus hard for the sperm to penetrate. Crinone and suppositories deliver progesterone in a more effective manner than oral supplementation. Oral progesterone is not used by some RE's due to ineffective absorption. Crinone is quite expensive and progesterone suppositories can be messy. Vaginal capsules (identical in appearance to a capsule used for oral medication, but inserted into the vagina) may be a little hard to place, but are quite inexpensive and available in a variety of doses in the same manner as suppositories. PIO shots can be uncomfortable, but they are effective. Discuss the best medication method and dosage with your doctor.

Should we try a hamster test to determine if we have male factory infertility?

Most clinical studies have failed to show a significant correlation between hamster egg penetration and human fertility. A Mannose Receptor Binding Assay of sperm is more useful.

Should I use a BBT chart?

A Basal Body Temperature chart is not a very reliable way to predict ovulation. Although the temperature shift associated with ovulation can be detected on a basal thermometer, it can sometimes take as long as two days before this shift shows up on a BBT. This generally means that by the time a temperature shift is detected, it is too late to time intercourse effectively. Further, there are many things that can negatively affect the reliability of BBT monitoring: A change in sleep patterns, getting up to go to the bathroom in the night, a cold or flu, etc., can all skew the results. Often, couples devote a great deal of unwarranted energy and concern over these tests, which are of very questionable value. The one value in a BBT is to provide a piece of retrospective evidence of ovulation during the past cycle. The presumptive evidence of ovulation is a rise in body temperature for eight days. BBT charts can give your practitioner an idea of your ovulatory history, but remain a dubious tool for timing intercourse. The most reliable method to effectively time intercourse is to test for the LH surge with an ovulation predictor kit. This is a chemical test for the presence of luteinizing hormone (LH), which is released about 24 to 36 hours before ovulation and triggers the final maturation process. Because women generally have the most fertile cervical mucus on or about the day of LH surge, and because sperm can survive for up to 72 hours in the woman's reproductive tract, it is often advised to time intercourse for the day of LH surge.

My RE wants to me to "coast" for a while on this cycle. Why is he slowing me down?

The idea of coasting is either to get a too-high level of Estradiol to drop a bit or to slow down development -- generally eggs are of better quality if the patient has at least 7-8 days of stims. In addition, they may possibly want to slow down some of the lead follicles and get some of the smaller follicles to catch up a little. Several studies have shown that coasting does not reduce success rates for a cycle, and it can also reduce the risk of ovarian hyperstimulation syndrome (OHSS).

I heard that multiple cycles with fertility drugs increase the chance of getting ovarian cancer. Is this true?

No. There is no evidence that shows a statistically significant increase in the ovarian cancer risk.

My doctor has recommended a hysteroscopy, laparoscopy, or folloposcopy. Where can I get more information?

INCIID has an excellent fact sheet on Reproductive Surgeries.

Do your chances increase with each consecutive cycle?

No, each cycle is independent. Your per-cycle chances do not increase.

I am concerned about the nature of my discharge and/or my cervical mucous during this treatment cycle.

You can get many types of discharge when you are on ovulatory stimulants. Usually, cervical mucous will be seen in injectable cycles after the E2 is greater than 200 or so. How much is observed varies very much from patient to patient. Fertile mucous is clear and very stretchy -- similar to egg whites. Often women are not even aware of it, as most of it tends to stay up by the opening of the cervix. You generally cannot predict ovulation, success, or lack of success based on cervical mucous or presence of a discharge when on ovulatory stimulants. Also, vaginal suppositories such as Crinone can create orange or brown discharge in normal situations. Any unusual spotting or discharge needs to be checked by your physician. Note that Clomid often degrades cervical mucous. This needs to be checked by your physician as well.

I had my egg retrieval. I had more eggs/fewer eggs that I expected. What factors are at work in egg retrieval numbers?

The number of eggs retrieved is largely a function of age, responsivity, stimulant/Lupron protocol, good monitoring, and a bit of luck.

I have a yeast infection! Will this hurt my chances or affect my ovulation predictor kit test results?

This will not affect your OPK results or your chances for pregnancy. Check with your doctor on what you use to treat it.

I am in treatment and I am sick! What should I do?

First, you need to consult with your doctor. In the meantime, a simple mild cold should not interfere with pregnancy. If you are running a low-grade fever, chances are it will not interfere with pregnancy. If you have had a fever of 101+ for sustained levels of time, that would be a sign of decreased chances of success. Your doctor may recommend Tylenol. He will also prescribe the best antibiotic for your situation, if you have a bacterial infection. Try to avoid OTC medications until you speak with your doctor, if possible.

Is it safe to take over the counter (OTC) drugs during treatment?

Over the counter drugs can have significant effects on various systems. It is extremely important that you consult your RE before taking an OTC drug during your treatment cycle. This includes herbal remedies and vitamins.

I am afraid that I might have ovarian hyperstimulation. What can you tell me about this?

First, if you are concerned about the possibility of OHSS you should call your clinic as soon as reasonably possible. OHSS (Ovarian HyperStimulation Syndrome) is when you have an unusually large number of mature follicles that release. When these follicles release, there is an unusually high concentration of estrogen-rich fluid in the peritoneal cavity, and the ovaries are generally enlarged far beyond their usual plum size - in some cases, they can swell to softball size. In milder cases, women experience bloating and some pain from the oversized ovaries. The treatment then is just a matter of rest and staying well hydrated. In more severe cases, the estrogen in the peritoneal cavity causes fluid to leak out of the circulatory system into the peritoneal cavity. This can cause marked discomfort and bloating, and can cause difficulty breathing due to pressure on the diaphragm. In the most severe cases, the leaking of the fluid will lead to hypovolemic shock and organ damage because of a lack of perfusion. Although there are exceptions, generally you do not see severe OHSS until the Estradiol gets into the 5000+ range. Mild hyperstimulation can occur at lower levels. As long as your doc keeps a close eye on your dosage and development, the chances of anything other than mild discomfort (especially on a non-IVF cycle) are minimal. The best pre-ovulation predictor of hyperstimulation is the E2 level, but it is not a perfect predictor. If you experience symptoms of OHSS, you should always play it safe and check with your doctor.

My progesterone was very high. Does this mean I am pregnant?

It does not mean you are pregnant. It doesn't even absolutely guarantee a good lining. Nevertheless, it is a good indicator. If you have good progesterone levels, that means that anything that is trying to implant will have a better chance of finding a hospitable place.

I have spotted, and it is not time for my period. Was it implantation spotting?

Implantation spotting is the exception rather than the rule. Sometimes the procedures themselves can irritate the cervix and cause light brown spotting afterwards. Sometimes when the uterus shifts from being estrogen to progesterone dominant you will get a little bit of spotting. Light spotting can be normal, but contact your physician with any concerns.

My breasts are tender, or I have cramps, or am irritable, nauseated, or bloated, or, I am gaining a small amount of weight. It is not yet time for my pregnancy test. Could these be signs of pregnancy?

You are probably feeling the effects of the hormones you are taking. It's really too early to be feeling anything as a result of a pregnancy. Implantation normally takes place about 5-10 dpo, but even after that it takes a couple of days for the hCG (which is what causes pregnancy symptoms) to build up in the blood stream. The presence of these symptoms does not indicate pregnancy, and the absence of them does not indicate a failed cycle.

I have questions about my symptoms or situations before or after a treatment cycle. My period has been usually light or heavy since my last cycle with Clomid or injectables. Or, I have not even gotten it yet, although my beta was negative. Is this normal?

Yes, it is normal for menses to be light, heavy, or simply different, due to the hormone levels being different. Also, progesterone supplements can delay the onset of menses. Most women don't start their periods until the progesterone level drops to somewhere between 2-4, which may take a few extra days.

What constitutes early or late ovulation? Does late ovulation decrease fertility?

There is not complete agreement on this. You might consider "too early" to be cycle day 10 and "too late" to be cycle day 20. There are two problems with late ovulation. The first point is that you obviously you have fewer chances (less ovulation) over a given time period. Second is the fact that with late ovulation you may be releasing eggs that have not been matured properly. It is also possible that the other parts of the reproductive system (hormone levels) are not in sync with the egg. That is not to say you cannot conceive if you ovulate late---it happens all the time. It is just that your chances are somewhat reduced.

My doctor says I am not ovulating regularly. How could I get my period if I do not ovulate?

Menstruation only requires development and shedding of the endometrium in response to alternating levels of estrogen then progesterone in the blood stream. These hormones can be produced by the ovary even when an egg does not mature or release.

I am concerned that I may have poor egg quality. How can I determine my egg quality?

You can get somewhat of an idea from the size of the egg and the estradiol level at midcycle. But other factors arise as you get further into your 30s, such as whether the outside covering is too thick to be penetrated easily by the sperm. You really can't diagnose egg quality until you get the eggs out of the follicles, put them under the microscope, and see how they behave. There are some less invasive screenings for ovarian reserve/egg quality such as the Clomid challenge, FSH, and Inhibin B, but they are also not as accurate as looking at the egg directly.

What causes chemical pregnancies?

Many early pregnancy failures are due to genetic abnormalities, mainly "trisomies" where an extra chromosome is present in what should be a pair. Some pathologists believe that the earlier the failure occurs after implantation, the more likely it is to be genetic. You can also have implantation problems that would cause chemical pregnancies such as hypercoagulation, failure to form the needed blood vessels, or autoimmune issues. (For more information read Immunology May be Key to Pregnancy Loss by Carolyn Coulam, M.D.) Note that chemical pregnancies are early miscarriages, not out of whack hormones as the name may imply.

I have questions about special precautions during treatment. Should I avoid exercise after ovulation?

Swimming and any other low impact exercise that doesn't overheat you is fine. It's best to avoid things like jogging and high impact aerobics. If you wanted to be on the cautious side, you might also avoid picking up anything too heavy during the waiting period (greater than 15 lbs.).

What about Hot Tubs?

If you are trying to become pregnant or are already pregnant, it is safest to avoid raising your core body temperature and therefore it is advisable to refrain from using the hot tub.

Should I avoid air travel or ground travel after my transfer?

Just don't overdo it. Air travel is fine as long as the pressure is maintained, which it generally is in commercial aircraft.





 
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