The International Council on Infertility Information Dissemination, Inc

Chat Bytes: Acupuncture and Herbal Medicine Treatments for Infertility.

Webinar Weekly (Lunch Bytes Fridays starting up again November 20, 2020, 4:00 PM ET: REGISTER

Mike Berkley, L.Ac., FABORM is the founder and director of The Berkley Center for Reproductive Wellness. Mike is licensed and acupuncture board-certified in New York State and also certified in Chinese herbology by the National Certification Commission for Acupuncture and Oriental Medicine.

Mike graduated from The Pacific College of Oriental Medicine in New York in 1996, and he has been treating reproductive disorders since then. Berkley is the first acupuncturist/herbalist in the United States to work exclusively in the field of reproductive medicine.

He enjoys working in conjunction with some of New York’s most prestigious reproductive endocrinologists while delivering attention and treatments meeting fertility patients’ needs. Call (646) 832-4480 to schedule an initial appointment today.




Mike’s Personal Story

"I developed an interest in acupuncture and herbal medicine due to a very personal and difficult reason - infertility. My wife and I decided that we wanted to start a family soon after we got married. We tried and tried for two years before seeking the help of a reproductive endocrinologist. My wife was diagnosed with a bacterial infection and an autoimmune marker. At our follow-up examinations, we were “cleared” of all obstacles to conception and told to go home and “try.” We tried for another six months without success.

At this point, my wife sought out the help of an acupuncturist/herbalist who had some basic knowledge of reproductive issues. After treating with acupuncture and herbal medicine for six months my wife got nothing more than a regulated period. We were disappointed, then, the very next month, the miracle manifested! She was pregnant and she carried to term without a hitch. We had a beautiful 7.5-pound little tiger who is now a young man, healthy, happy, and productive! I was amazed, humbled, and enormously excited and gratified by the result which was yielded by what seemed like some hocus-pocus newfangled type of medicine, but it really worked.

It was then that I started to explore acupuncture and herbal medicine on my own. I had a curiosity to learn more. I couldn't believe it when I found out that this type of medicine had existed for 3,000 years and there are hundreds of medical texts dating back centuries on the subject of reproductive disorders and how to treat them.

I responded to an ad in the Village Voice for an open house at Pacific College of Oriental Medicine’s New York campus and left almost six years later with a degree in acupuncture and a National Board Certification in herbal medicine.

With license in hand, I devoted every free moment to studying Western medical and Chinese medical approaches to treating infertility. After years of study and clinical experience, I have been fortunate in that I have been able to develop my own unique acupuncture protocols and proprietary herbal formulas."

Chat Intro

Individual and ZOOM Chats Daily, or Weekly

INCIID added individual chat sessions to answer consumer questions, provide encouragement and support. These are difficult times for everyone but WITH INCIID YOU'RE NEVER ALONE.

Chat Transcript: Jacques Cohen, Ph.D.: World Famous Embryologist

[INCIID Moderator] : Good Evening, Dr. Cohen.
Sammie : I had my retrieval last week. We were able to get 12 eggs, 10 mature, 6 fertilized with ICSI. I had a 3 day transfer of two 8 cell grade A+ and A- embryos. Two of the remaining embryos made it to blastocyst and were frozen. Does the fact that those two made it to blastocyst stage in any way correlate to the 'hope' the two that were transferred might have made it to to blastocyst stage as well? 

Jacques Cohen, Ph.D.: There may be a positive correlation, but it differs from case to case. Anyhow - things look good thus far 
Ted : Do you recommend ICSI when using donor sperm?

Jacques Cohen, Ph.D.: Yes, although with some footnotes. Donor sperm is freeze-thawed and many sperm will be lost in the process. Sperm purification techniques can resolve that problem and only yield motile ones at the end of the process. IVF is not really a problem here, yet I would still opt for ICSI.
Mary: At 8:15 the morning of my 3 day transfer, I had two 8 cell embryos that were ready to go. By the time transfer rolled around at 1:30 pm, they had multiplied to 12 and 14 cells respectively. Is that growth too fast for day three embryos?
Jacques Cohen, Ph.D.: The embryos proceeded to the next division and that in itself is not so bad. It would have been possibly a different situation if your embryos were that fast at 8:15 AM;  Had it been  observed then it would have lowered the chance of conception by just a fraction.
Jerry : Is a 60% fertilization rate w/icsi and donor sperm normal? I'm 34. I was hoping for a higher fertilization rate.
Jacques Cohen, Ph.D.: Fertilization rate should be calculated for mature eggs only. I presume you knew the TOTAL number of eggs and calculated the fertilization rate from that. Yet, only 50-100% of the eggs are usually mature and these are used for ICSI. In other words 60% is really not so bad.
Janie: Hello, and thank you for this opportunity. I have undergone 3 IVF cycles to date, I made it to the retrieval stage on two of the three cycles. On both, I did ICSI with donor sperm. Of the 7 mature eggs over both cycles, none would fertilize. The embryologist said my eggs looked great, and she did not have a good reason for no fertilization. One suggestion was research showing there could be DNA problems with the sperm which causes it to break down in the egg. Have you heard of this? 

Jacques Cohen, Ph.D.: Yes I have heard of this, but it is an obscure situation. It is possible that your eggs lack factors that deondense sperm and make it ready for conception. There are experimental ways to overcome this. Also was the sperm donor the same? It may be better to have a more lengthy discussion regarding this. Please email me.
Susan : Dr. Cohen... could you comment on the opinion by some medical professionals that the eggs of women over 40 are 'too fragile' for IVF.
Jacques Cohen, Ph.D.: Yes I can. Provided the eggs and embryos are checked for an anomaly called aneuploidy. This anomaly is related to the number of chromosomes in the eggs and the anomaly occurs much more frequently in eggs from reproductively advanced women. The technique is called PGD for aneuploidy.
Pat : Is there a way to tell if a normal-looking egg is under or over-mature?
Jacques Cohen, Ph.D.: I think that I already hinted at this in my previous answer, yet there are many factors to consider. The rate of success in nature and after ART is entirely dependent on maternal age, but 'fragility' sounds like the issue is permanent and may be reflected in children. There is no evidence that it is. The only problem is obtaining an 'embryo that will take' and in many cases finding the right one for transfer. These are the two challenges. Yes - there are some tools that embryologists have available. Immature eggs lack a little cell called the polar body whereas over-mature eggs have light membranes, thin zona and so-called luteinized corona cells. There are other markers as well. 

Jacques Cohen, Ph.D.: Yes - there are some tools that embryologists have available. Immature eggs lack a little cell called the polar body whereas over-mature eggs have light membranes, thin zona and so-called luteinized corona cells. There are other markers as well.

Linda : I think that I've seen references on the INCIID Forums to something where research has found that IVF isn't any more effective than IUI in women over 40. Is that correct?

Jacques Cohen, Ph.D.: There have been no randomized trials to suggest this just sporadic experiences of practitioners. It is also dependent on success rates of both technologies in hands of individual practitioners. Overall, when reviewing all data, there is no evidence to support the contention that IUI is 'better' in any age group.
Carrie : I think I've seen something about maturing eggs in-vitro. Could this offer more hope for pinpointing exactly when an egg is mature enough for fertilization?
Jacques Cohen, Ph.D.: Well, they can probably do it but their results 'probably' have indicated that it is not as good as transferring them earlier. This issue is rather common, that is, clinics have different experiences depending on the patients they see and the techniques they use. ART is called ART for a good reason. Some of the technologies are quite exact and one can adhere to protocol, other technologies are 'soft' and depending on a myriad of factors. I would feel comfortable with their suggestions, because they base these on experience.
Mary Anne : My wife had surgery for endometriosis two years ago, since then we have had several IUI's with our endocrinologist with no successful pregnancies, he has now recommended IVF. My endometriosis was found to be moderate. What is your experience as far as IVF and success with endometriosis?

Jacques Cohen, Ph.D.: Many patients with endometriosis have undergone IVF with great success. The severity of endometriosis may determine the chance of IVF outcome, but things do not seem too bad in your case as far as prognosis is concerned.
Michelle:  I am going to have my first IVF in February using an Antagonist (Cetrocide). I had three children before having my tubes tied. I am 34 years old. I never had any problems conceiving my children. What do you think my chances are? I also would like your opinion because I heard he transferred a 2-cell embryo after 36 hours. Is that normal (he rated the embryo excellent)?

Jacques Cohen, Ph.D.: Your chances of success should be considerable. Comparing your own success with that of other patients or their experiences is not always a good idea. 

Delly:  I am 41 yr, have miscarried 5 times up to 9wks (3 natural & 2 IVF NYC); D&C tissue test 1X - genetically normal male Would PGD be useful? What is the PGD risk/reward? What would you recommend?  two vs. one cell - PGD? Are there risks sending samples from NYC to a PGD lab in California? Is a 5-day transfer better than a 3-day transfer?
Jacques Cohen, Ph.D.:  PGD is the way to go. One blastomere should suffice. Why Cailfornia? There are excellent PGD labs nearby! 

Jackie :  What are the benefits of going to 5 day blasts instead of 3 day? Is it possible embroys that were good at 3 day may not make it to 5 days, but could've made it if it was transferred on day 3 instead of 5? 

Jacques Cohen, Ph.D.: Good question! The answer is 'yes'. But it is not the norm. Excellent looking embryos on day 3 have a higher chance to become blastocysts, yet some fail. What is important also is how many good embryos there were on day 3.

Janice:  Dr. Cohen, I want to thank you for your decades of work in the field! I hope you know what a tremendous difference you have made - what changes you have wrought. Thank you!
Jacques Cohen, Ph.D.: My pleasure and thank you really so much for your comment.

Cecliia: What is the average rate of damage to the egg when ICSI is performed with IVF? How does the embryologist decide which sperm to choose for purposes of ICSI?

Jacques Cohen, Ph.D.: The average of damage should be lower than 5%. The spermatozoa in the final preparation for injection have come there after a long road of passages and hurdles both before sperm retrieval and afterwards. Usually this preparation contains motile sperm only and these are slowed down to visualize individual cell. Even if the embryologist would be pressed by time, he/she will 'automatically' opt for the one that is relatively fast, moves well and has the best morphology 'looks'. 

Shari:  I am planning to do a FET this spring - I have 8 day 5 blasts in the freezer. What is your opinion on nursing during a FET? I am currently nursing my 10month old.

Jacques Cohen, Ph.D.: This is a question for your RE. It is related to prolactin, oxytocin and E2 levels. I presume that it is not a good iea but I am not sure.

Maria : Hello, and thank you for being with us tonight. I am 32, no children, and after 5 years of infertility with recently diagnosed endometriosis (moderate), my endocrinologist has recommended IVF. Do you suggest any particular vitamins or therapies in preparation for this? I have read about acupuncture and massage. Thank you,

Jacques Cohen, Ph.D.: There are preparations already available regarding this that can be obtained over the counter. If you are interested I can obtain the names. Email me 

Jessie:  I am 41 yrs old, have had 5 miscarriages up to 9wks (3 natural & 2 IVF NYC). D&C tissue tested 1X - genetically normal male. 2nd IVF cycle in NYCI had 6 transferred (cells were 9,8,8,8,8,8) on day 3 & used 40 g. IVIg; Progesterone. and 30 mg Lovenox. I had a chemical pregnancy. Do you think it was an embryo issue or an implantation & environment issue?

Jacques Cohen, Ph.D.: All of the above. You may be frustrated by my answer, but so am I. This is so complex that it is rather rare that specialists can diagnose failure. An important aspect is your age: 41.... That is usually suggestive of an 'egg' problem but failure can be multi-factorial; with many causes.
Annie: At what size, does a follicle normally produce an over-mature egg?
Jacques Cohen, Ph.D.: It is not just size related but dependent on number of follicles as well. It is also dependent on days and types of stimulation. I would think that anything over 22mm has a good chance of over-maturity of some kind, but even this size does not mean that the egg would be always affected. Obviously we must exclude 'natural' eggs from these comparisons since these can be normal even from very large follicles.

mia : In general when using blastocyst in a thaw cycle how much information is known about the embryo prior to transfer if the embryo was frozen at the blast stage? Does transfer occur before the blast has a chance to expand?

Hopper : If cells are dividing too fast, what might that indicate?

Jacques Cohen, Ph.D.: Good question! There are too many aspiring scientists in this chat room! Answer: One can only speculate, after all the government does not allow any federal funds for embryological research, so what we know is quite little. It must be the cell cycle that is gone haywire. The cell cycle is a very complex mechanism studied by scientists mostly in somatic - non-embryonic cells. This can lead to loss of function. There are also genes that 'time' these events and these may not control the situation when embryos go to fast. Anyhow, all of it is speculative.

Laurie:  Can high STIM doses reduce significantly embryo quality ?

Jacques Cohen, Ph.D.: A loaded question! Overall, the dose is negatively related with INDIVIDUAL embryo quality, yet the high dose produces more embryos for selection and when this is done properly (and that is often a big if), the loss in quality should be made up for.  

Leslie : Can ICSI damage eggs?

Jacques Cohen, Ph.D.: Sure. Eggs can be damaged immediately and this can be seen microscopically. What is more relevant is whether ICSI could damage eggs in such a way that the children could be affected. Well, there is no evidence of this, although I am sure we will learn more with time. The same can be argued for embryo culture, IVF and freezing. Things look good thus far, but the true extent of the technology we will only know in generations to come.

Zippy:  Dr.Cohen, If embryos pass the PGD test (which I know only tests for about half the chromosomes), how likely is it that they still have some abnormality?

Jacques Cohen, Ph.D.: It is possible that some of the chromosomes are still affected but the percentage is much smaller than the chromosomes that are already tested. These chromosomes were selected based on their high incidence of abnormality in early embryos. In other words they account for the vast majority of problems.

Linda:  What is the expected rate of chromosomal aneuploidy for a 34-year-old woman ?

Jacques Cohen, Ph.D.: Do you mean in the embryo or after establishment of pregnancy? In the embryo the rate is higher than one would think; about 30-40% on average. After establishment of pregnancy (when most abnormal embryos are already lost in the reproductive tract often without leaving a trace of evidence) the rate is only a few percent for this age.

Lidia:  Is there actually a condition called 'empty follicle syndrome' or is this simply a mistimed retrieval? If empty follicle syndrome is valid are there any resolutions for it?

Jacques Cohen, Ph.D.: Empty follicle syndrome is one of these doubtful topics. We can only know if it exists if the follicles were excised and removed from the ovary rather than sucked empty. It can be very frustrating to obtain eggs from certain follicles and from certain women. Such findings should probably be characterized as problematic retrievals and not 'empty'.
Nora:  Can PGD biopsy be done to embryos with fewer than 8 cells on day 3?
Jacques Cohen, Ph.D.: Yes. The lowest number is usually 5, but sometimes 4. It depends on the experience of individual programs.
Veronica : How unusual is it for embryos to still be in morulas stage at five days then continue to blast on day six? How big of a concern is this slow development?

Jacques Cohen, Ph.D.: It is only a minor issue in most cases. The first blastocyst pregnancy was one of my patients in 1984. This was exactly such a case. The embryo was frozen on day six and replaced in a cycle after one more day (that is day 7) and she is now a happy 20 year old.

Another interesting question. You guys are good! It is all a matter of give and take. The longer one cultures embryos the more likely it is that even good ones stop growing. The earlier one transfers an embryo, the more likely it is that the selection process has not picked up the 'best' one. Those that defend the 'zygote' approach maybe would be in disagreement with me, but events such as mosiacism and development rate, are better observed later. Yet, in a perfect world, if we could find a better way of selecting zygotes and eggs, the earlier the transfer the better (and that would of course offend the 'blastocyst' proponents, so whatever the truth is - I can't win).

Brenda : Can PGD damage the embryo and cause to stop developing, even though it was healthy before PGD ?
Jacques Cohen, Ph.D.: It probably can, but I have little evidence for this. The scenario is plausible though for certain rare embryos. In general, embryos catch up pretty quickly after biopsy.
Betty:  How "portable" are frozen blastocysts from one lab to another. A friend is willing to donate her frozen blastocysts to me, but my RE's embryologist seems reluctant to work with "another embryologist's blastocysts." Is there such a wide variance in lab technique? Or just a matter of personal preference?

Jacques Cohen, Ph.D.: well, it is a matter of how and in what the embryos were frozen. In my opinion it is always better to have embryos thawed in the laboratory that performed the freezing process.
Jacques Cohen, Ph.D.: I like to say good night to my kids and to you all. Any further questions can be emailed to me at: Good luck to you all. Jacques Cohen



Chat Transcipt: Carolyn Coulam, M.D. Unlocking the Mystery to Pregnancy Loss and Implantation Failure

Chat Transcript
 Carolyn Coulam, MD 
Wed Jan 26, 9:00 PM Eastern Time

Jessie : How much of a factor does using frozen sperm with ICSI have on implantation rates.
Carolyn Coulam MD : Implantation rates depend on patient age and indication for IVF. In general the rate of implantation is the same for at least the first 3 cycles then decreases after that.
Markie : With a miscarriage at 10wks on the 1st IVF and no implantation on the 2nd IVF, are there any specific tests that you would recommend before doing a 3rd IVF cycle?
Jerri: How much of a factor does using frozen sperm with ICSI have on implantation rates.

Carolyn Coulam MD : Frozen sperm, if from a normal semen analysis, should not affect implantation rates. 
MaryKaye : With a miscarriage at 10wks on my 1st round of IVF and no implantation on the 2nd IVF, are there any specific tests that you would recommend before doing a 3rd IVF cy?
Carolyn Coulam, MD :If  we know the karyotype of the first miscarriage is normal we should look for both immunologic and thrombophilic risk factors

Mary Anne : Dr. Coulam, I recently miscarried at 8 weeks. The results of the chromosome testing showed Trisomy 7 and Turners Syndrome. I had a miscarriage 2 years ago but no studies done. I'm curious to know more about Trisomy 7.

Carolyn Coulam, MD : Trisomy 7 is lethal and should not be repetitive In other words "bad luck"
Frances : Can implantation failure be considered even if you had a pregnancy with heartbeat by detected by ultrasound, but then miscarried sometime afterward (especially in 1st trimester)?

Carolyn Coulam, MD : That is usually referred to as pregnancy loss rather than implantation failure.
Sara : Dr. Coulam, thank you for being here with us tonight.  How many IVF's are recommended for someone to have, for example I am 32 year old woman with mild to moderate endometriosis and have not had my initial IVF as of yet? This was a concern for us.
Carolyn Coulam, MD : How many would depends on why previous IVF cycles failed. If embryos are normal, then usually it takes 8 embryos transferred to get a 80% probability of pregnancy. 

Jennifer : A  friend of mine has had great difficulty stimulating and getting a pregnancy to go past 10 weeks. She is almost 40 at this point, with no specific issues determined. My friend has had all the standard testing is there anything you could recommend? Could the drug protocol she is on be affecting her egg quality?

Carolyn Coulam, MD : Egg quality is more likely related to age than stimulation protocol. She may want to consider PGD.

Carrie : What can be done for a patient who has experienced several IVF cycles with implantation but then experiences a spontaneous drop in HCG level after a few days and the pregnancy ends very early?
Carolyn Coulam, MD : These are referred to as chemical pregnancy losses. Chemical pregnancy losses can be the result of a problem within the embryo or within the uterus. To read more about the different kinds of reasons for loss look at this article: Immunology may be key to pregnancy loss 
Shelley : When should one consider immunologic testing and do failed IVF cycles with apparently good embryos count as pregnancy loss or implantation failure?

Carolyn Coulam, MD : Anything over 4 embryos transfered without success can be evaluated for risk factors for implantation failure.

Patti : Have there been any studies concerning the quality of embryos and use of ICSI? Are embryos created without ICSI of the same quality as embryos that left to be fertilized naturally?
Carolyn Coulam, MD : The results of the studies are conflicting, but the majority show no effect on implantation. There have been studies showing no effect with ICSI itself. There may be an effect if there is a male factor as the indication for the ICSI however.

Mary : do you recommend the use of low dose aspirin in helping to prevent miscarriage?
Carolyn Coulam, MD : Not routinely. Treatment depends on the risk factors present.
Linda : If one takes baby aspirin as part of the protocol, is heparin really necessary?
Carolyn Coulam, MD : Again it depends on the risk factor that we are treating. Read more about treatment options in this article: Immunology may be key to pregnancy loss  
Sharon : My Re has told us that those who get pg once are more likely to get pg again. Do you find this to be true?
Carolyn Coulam, MD : In general, yes this is true. 
Nell : Thank you, I was wondering what is typically a "safe" number of IVF cycles. I have never had an IVF as of yet, my endocrinologist stated I am a candidate for it.
Carolyn Coulam, MD : IVF is a widely used and safe procedure. You theoretically could have as many as it takes to get pregnant. 
Kaye : Does an abnormal post-coital test (all sperm dead) have any predictive value as to the possibility of an immune problem in the woman?
Carolyn Coulam, MD : It can be either anti-sperm antibodies in cervical mucous or a problem with the sperm. 
Pauline : Thank you so much for being here to answer questions tonight. When you use the term “chemical pregnancy losses”  and discuss them as a possible problem within the uterus, would this include having a large fibroid? Could a large fibroid cause a chemical pregnancy?

Carolyn Coulam, MD : Yes it could if it protrudes into the cavity but usually these sub-mucous fibroids are associated with implantation failure rather than chemical pregnancy loss.
Helen: I have immune issues that were treated with IVIg during my 3rd cycle of IVF and subsequently, I  miscarried at 8 weeks (with Trisomy 7 and Turners syndrome). Also had another pregnancy 2 years ago where I miscarried at 8 weeks (no studies done). My last IVF cycle went very well I have 4 frozen blasts (2 with the HLA embryo marker and all either grade 1 or 2). I would like to do a FET, but am of course concerned about another miscarriage. I'm 35 and had  unexplained infertility up until Dr. Sher diagnosed me 6 months ago with immune issues.
Carolyn Coulam, MD : It sounds as if FET is your next step. 

Perry : How strongly do you consider the presence of moderate to severe endometriosis as evidence alone to do immune testing (particulary NK cells)?
Carolyn Coulam, MD : Individuals with endometriosis have autoimmune risk factors 65% percent of the time.
Julia : If I had a Endometrial function test and it came back saying everything was fine, could ther be other things affecting implantation? I'm 38 have done 7 IVF/ICSI , have i child from the 3rd cycle done at 34, put back many embryos that looked good, no other implantation except a small sac that reabsorbed when I did get pregnant. We have severe male factor, I have 7.5 FSH but need a lot of FSH meds. Trying to determine if it makes sense to keep trying and what the main factor for it not working is.
Cindy: Usually how many miscarriages does a woman need to have before testing will be done to try to resolve the reason?

Carolyn Coulam, MD : We believe testing should be done after 2 consecutive miscarriages. 
Lillie:  Good evening Dr. Coulam. I have had two unsuccessful IVF cycles and two unsuccessful IUI’s. I am 34 and my diagnosis is "unexplained" with mild endometriosis. In both IVF cycles I had 4 embryos transferred. Both times on day 3 my embryos looked to be between "good and fair" quality. What tests are available for "implantation failure" and do you feel my success rate is reduced? 
Carolyn Coulam, MD 
: I would suggest you may want to be evaluated for both immunologic and thrombophilic risk factors contributing to the failure. For more information about the tests included for implantation failure and Thrombophilia Panels you may visit the material on Implantation Failure on the INCIID Website. You might also look at 
Nancy : Can a pregnancy loss trigger immune problems that might have not been there before? Carolyn Coulam, MD : Yes, it can.

Diane : I am  41 yrs old and have experienced  5 miscarriages with the longest lasting until 9 weeks gestation. I have been pregnant three times naturally and two others with IVF.  A D&C tissue test on one cycle showed a genetically normal male. We’ve done Kayotype and immune and blood disorders testing. However nothing comes back as abnormal. On my second IVF cycle, we transferred (cell 9,8,8,8,8,8) on day 3 used 40 grams of  IVIg; Prog. and 30 mg of Lovenox. We did not use PGD. I had a chemical pregnancy. Do you think it could have been an embryo issue or an implantation/environment issue? What would you suggest now?

Carolyn Coulam, MD : You should be evaluated for all of the risk factors contributing to failure  by both embryo and environment. For more information about all of the tests included in the evaluation, you may visit the material on Recurrent Pregnancy Loss on the INCIID website.
Barb: If an endometrial function test shows everything is fine and lining always looks good, could there be other implantation problems? 
Carolyn Coulam, MD 
: Yes, neither immunologic nor thrombophilic risk factors are measured by these tests. 
Karen:  Any tips on increasing the chances of implantation after IVF? 
Carolyn Coulam, MD 
: First we must identify the problem before we can recommend treatment. A thorough evaluation would be helpful.
Donna : Does stimulating the ovaries with gonadotropins again and again make you use your egg reserve faster? I know this may sound sill but I ask because my day 3 FSH went from 5.6 to 10.9 in 2 years after my first IVF cycle and I'm only 30 years old.
Carolyn Coulam, MD : No stimulation does not recruit more eggs to the cohort. It maintains growth of more eggs within the recruited cohort. 
Elizabeth :Are the autoimmune risk factors tested by through blood serum? 
Carolyn Coulam, MD 
: Yes, immune risk factors are tested in blood. Ready

Gwyndolyn: What tests are involved to confirm "autoimmune risk factor" for endometriosis? Carolyn Coulam, MD : Testing the following autoantibodies is recommended:

  • APA, (Antiphospholipids)                                  
  • ANA, (Antinuclear Antibodies)
  • ATA,  (Antithyroid Antibodies)
  • LA. (Lupus Anticoagulant)
  • Also NK (Natural Killer) cells and
  • Circulating Embryo Toxins 

Annie :  I am 41 years old and have experienced  5 miscarriages. The longest pregnancy lasted to 9 weeks. Three of them were naturally conceived and two were through IVF cycles.  I had a D&C tissue test with one. The finding with this pregnancy was of a genetically normal male. Karyotype Tests: Normal Female & Normal Male. Would PGD be useful? What is the PGD risk versus the reward? Do you recommend doing a two vs. one cell testing with PGD? 10 vs. 5 probe? 
Carolyn Coulam, MD 
: It depends on the number of embryos available. If sufficient number of embryos are available for selection, then PGD can be helpful. Usually 2 blastomeres are more accurate than one but not always available.

Betty : I tested positive for MTHFR (methylenetetrahydrofolate reductase) after I found out I was pregnant. I was put on Heparin twice a day. I have since miscarried due to chromosome abnormality. Going forward would it be important to start Heparin before getting pregnant? Also, I read about taking higher levels of Folic Acid (Folgard). What are your thoughts? 
Carolyn Coulam, MD : If MTHFR is your only risk factor then treatment with folic acid and vitamin B should be sufficient.
Harriet: Can you explain the triggered immune problems following a m/c?
Carolyn Coulam, MD : Sometimes, but certainly not always, the antigen that triggers the immune response if present in the pregnancy.
Tammy: How is the best way to go about finding a reproductive immunologist if my RE doesn't do much immune testing? I want to make sure based on my history, that the right tests are being ordered.
Carolyn Coulam, MD : It depends on where you live. If a reproductive immunologist is not available to you we can arrange a telephone consultation for you. (Editor’s note: If you are having problems finding a reproductive immunologist, please email us and we will try to help you find someone either in your area or through consultation. Email )

Zoe: I’ve put back 40 embryos over 7 IVF cycles, and only one became a baby. Are there other things to look at regarding implantation if the EFT was normal? Or is it more likely that the problem lies with our severe male factor or possibly ovarian reserve? I usually get 5-9 eggs and they almost all make it to blastocysts and look good.
Carolyn Coulam, MD : It could be either a sperm or egg contribution, but if you are transferring blastocysts and they are not implanting, we should really look at the environment (of the uterus). 

Joy:  I’ve been fully evaluated for immunologic and Thrombophic as well as Karyotype genetics. All have come back normal. We’ve experienced 5 miscarriages (two IVF cycles, one with IVIg abd three natural conceptions.) What would you suggest now?
Carolyn Coulam, MD : There are some new genetic tests for genes related to miscarriage such as HLA G mutation and  MYC/RPL from the sperm. Please visit the Millenova Immunology Laboratories website for more information about these tests: .

Roberta: How likely is a person with multiple living children to have anything of significance found on a recurrent pregnancy loss work-up.
Carolyn Coulam, MD : It depends on the history of the pregnancy losses, but in general not as likely as individuals with few children. 

Mary:  Thank you Dr. Coulam. I had problems with "unexplained brusing" a few years back and had much blood work done. Do you think this could have anything at all to do with my implantation problem? for your time. 
Carolyn Coulam, MD 
: Not really. Implantation failure is manifest by either negative pregnancy test of chemical pregnancy loss. Ready
Barri:  Hello Dr. Coulam.  I just turned 39 and have been trying to get pregnant for over a year and a half. We’ve done extensive testing in all areas and have had 4 pgs, (1 chemical) during this time. Right now  I am in the midst of an IUI cycle. I started with 6 follicles, looks like 3 may mature At what point do we do go to IVF with PGD? Or do we use a donor’s egg? I am concerned about waiting until my chances are worse and of course insurance doesn't cover IVF or Donor’s Eggs.

Carolyn Coulam, MD : How you proceed depends on the individual need and indication for IVF. You should really discuss this with your doctor who knows you condition. 

Sherry : We've tranfered many good looking blastocysts and all our immune testing and EFT came back fine. We do have severe male factor, and takes a lot of stimulation to get the eggs. I do not have endometriosis or anything noticeable from the lap, except "old looking" ovaries (sort of looks like a brain) I'm 38. Do you have any suggestions for me?
Carolyn Coulam, MD :  Regarding male factor, there are 10 gene mutations that we now check for. You may get this list from the website of Millenova Immunology Laboratories at

Melody:  What are the risks of IViG to mother as well as fetus?
Carolyn Coulam, MD : Side effects usually occur during the infusion and can be uncomfortable. Also one can experience migraine headaches for 1-4 days after infusion. There is a theorectical risk of transmittable disease but there has never been a report of HIV transmission. There appears to be no effect on the baby. 
Erin: What symptoms or history would suggest I may have immunological problems?

Carolyn Coulam, MD : A history of recurrent pregnancy loss or implantation failure after IVF. Or a history of blood clots.

Susan:  Is a Leukocyte Antibody supposed to be positve when you are pregnant? How does this work? 
Carolyn Coulam, MD 
: Mothers can develop antibodies to fathers leukocytes as a result of exposure from pregnancy. But these antibodies have no detrimental effects. 

Lisa: At what point does one go to IVF with PGD or donor egg? 
Carolyn Coulam, MD 
: Donor egg would be indicated if you could not generate normal embryos with your own eggs. 

Liz : Are you familiar with studies that show IVF with PGD in women over 36 is less reliable or successful for recurrent pregnancy loss? 
Carolyn Coulam, MD 
: No, When PGD is done for patients with a history of recurrent pregnancy loss more abnormalities have been found and hence less embryos transferred. 

Vera: What is the difference between antibodies and natural killer cells?

Carolyn Coulam, MD : APA, ANA, ATA and LA are all autoantibodies. NK cells are white blood cells that are involved in the first line of immunity. For more information about each of these tests, Read the INCIID fact sheet on immunological problems causing miscarriage and implantation failure:

Bobbie:  Besides eating a healthy diet are there any foods, vitamins, or minerals that have either a positive effect on implantation or a negative effect causing implantation failure. I have heard certain things such as peanuts may hinder implantation but how much of an effect do these things have? 
Carolyn Coulam, MD 
: I’m not aware of any foods that hinder implantation.


Carolyn Coulam, M.D. is an INCIID Advisory Board member and answers questions for consumers regularly on the IMMUNE ISSUES and MISCARRIAGE Forums here at INCIID.



Chat Transcript: Holiday Blues Chat with Alice Domar, Ph.D.

The Holiday Blues Live Chat Event with Alice Domar, Ph.D.

Alice Domar, Ph.D.: Thank you for inviting me to INCIID the Holidays

INCIID Moderator: Welcome Dr. Domar, we are thrilled to have you join us. Today is the beginning of l "INCIID the Holidays" , a series of events to help everyone navigate what can be a difficult season for many people. Please be sure to visit the  Mind Body Program .

Alice Domar, Ph.D.: Ok, I will be brave and be the first to speak! Let's talk about the holidays which can be so hard during infertility due both to the emphasis on children and the disappointment about not having a great time as we did when we were children.

Question: I was suppose to be due in Jan. We had to terminate. after amnio. I "pictured " myself very pg around the holidays. How do I get past that?

Alice Domar, Ph.D.: Try creating new traditions this year. Instead of the image of you waddling around the Christmas tree, think of fun things you can do this year. Even if it is a distraction, it can help. Try sledding, making hot buttered toddies, going caroling, etc
It won't make the pain of your loss go away, but distraction can make things easier. And if you find that some of these activities are enjoyable, you can make them part of your regular traditions as your family grows.

IndySarah: In our situation, we are adopting. I hope that's appropriate for this chat. We have received a referral and are waiting for our court date which could be next week. The holiday issue is going to be very difficult if we are, in fact, apart from our son after having met him.

Alice Domar, Ph.D.: How about saving what you like best about this season until after he arrives? You can then spend some of this waiting time preparing to do those things when he arrives.

IndySarah:: We have thought about purchasing a tree late in December, and then decorating it when we return home. And of course, there will be a later family Christmas this year as well.

Alice Domar, Ph.D.: That is a good idea. Can you go somewhere while waiting? Even if only for a weekend, it might make the time go faster Tell him it is doctor's orders!

IndySarah: I'll tell my husband that the doctor prescribed a getaway!

cemert: DH [Dear husband] and I are the only infertiles in our families, and are expected to do whatever his family has always done with the holidays. Last year was a nightmare, so now we are planning a getaway the weekend before Christmas, now the in-laws are upset. They think we are so selfish? Any suggestions for responses? Thanks!

Alice Domar, Ph.D.: This one comes up time and time again with my patients. When we marry and especially when we start families, however they are created, the pressure to follow our families' traditions goes up against the need to start the traditions of your own family.

cemert: Since we're the only ones without kids, we're expected to follow suit, I'm accused of controlling my DH, which is so untrue. I guess they'll get over it. Thanks!

Alice Domar, Ph.D.: This is a necessary part of the marriage process. You are not being selfish - the two of you are looking out for each other and your coupleness. Come up with some compromises if possible. Decide what you are and are not willing to do with them and stick by your needs and decisions

adorable67: Christmas Eve/day seems to be the hardest to cope with........and of course no one else doesn't have kids. we've been trying for 5 yrs now and are taking a break from infertility. Eveyone in my husband's extended famliy gaithers around and it's not like I can't go or change plans. My question is: how do you deal with family who don't understand how their indoendo hurts?

Alice Domar, Ph.D.: I was hoping you would ask a question since I really like your name! Why do you think you can not go or change plans? Maybe the two of you could suddenly "win" a christmas getaway, or tragically, you catch a horrible cold Christmas eve and can't possibly expose everyone else, especially those kids....

adorable67: but that seems rude and I'm already a yankee [living] in Oklahoma.

Alice Domar, Ph.D.: how is catching a cold rude? Women need to learn how to better care for themselves without feeling guilty about it. Infertility is a temporary crisis and you need to pamper yourself during this crisis

I Host DianneY: I have recently came upon the due date for my second trimester loss this year and would like to remember him/her during the holidays. Why don't others close to me understand that I will miss the baby that isn't here, especailly now?

Alice Domar, Ph.D.: Most people in this country are really uncomfortable with loss. Even if an adult dies, there seems to be this acceptable amount of time to mourn and after that, you better be back to normal. Losing a baby, especially during the second trimester, may not feel real to those around you. You may not have been really showing, they didn't feel the kicks, and they may just be uncomfortable since they don't know what to say to you. Think about what YOU need from each of them and let them know gently.
Buy everyone the normal nice gifts, maybe add an extra bow or two, but be aware that everyone has their own issues and you can't meet the needs of everyone else.

I Host DianneY: Thank you Dr. I know they don't understand that there was a bond and love between me an this little one already. I will use your sugesstion to let them know how I might be feeling. Thanks!

Alice Domar, Ph.D.: I recently wrote a chapter for a new book on miscarriage. I think the book is coming out in February, by Henry Lerner, MD. I think it is going to be called "After Miscarriage"

INCIID Moderator: For those of you who have experienced losses, please print out the The Miscarriage Manual: Coping with the Emotional Aspects of Pregnancy Loss. The Miscarriage Manual is A primary guide for parents who have experienced the death of a child through miscarriage, stillbirth or other perinatal loss. It was written by C. Elizabeth Carney, who experienced a stillbirth. This is an excellent document to give to friends and family to help them better understand the how you are feeling about the baby you have lost.

clara2: HI Dr Domar!! Thanks for coming!! Coping with IF is making me obsessed and sending my career to the toilet. I am with a therapist, taking PROZAC, nothing seems to help with my anxiety and obsession, how can I concentrate on my work?

Alice Domar, Ph.D.: I would suggest that you try a cognitive-behavioral therapy [CBT] approach, which helps you challenge and restructure the recurrent negative thought patterns. There are a number of good books (mine included!) but the bible is by David Burns, called the Feeling Good Handbook. Not on infertility, but a start. Ask your therapist if she does CBT and if not, maybe you could see a CBT therapist for a few sessions

clara2: I am in South America, difficult to get your books, how is this therapy?

Alice Domar, Ph.D.: All books are available on! I would guess there are cognitive therapists in South Africa. I have a patient who recently moved to Venezuala and she found good help there

clara2: Thanks a lot Dr Domar, Iwill try!!

BWC: My partner and I are really starting to direct our disappointment and anger at each other now. We have been ttcing [Trying to Conceive] for 3 yrs and have had a few losses and many failures. We just recently have started to really fight a lot and we can't seem to get out of it . We saw a counsellor but she wasn't experienced with infertility and donor egg stuff. Any suggestions? Thanks I read both of your books.

INCIID Moderator: Clara - you might try looking on the ASRM site to see if there are therapists listed in other countries

Alice Domar, Ph.D.: I would try to find a counselor who IS experienced in these areas! And one of the main reasons who couples fight during infertility is that naturally men and women respond differently to infertility and that can be really irritating. If only HE/SHE would respond the same was as I do, we would be ok.... 5

Alice Domar, Ph.D.: The Mental Health Professional Group has a new subgroup from Central and South America who offers support in spanish. Check out the web site under ASRM

Alice Domar, Ph.D.: de nada!

Michellej: Dr Domar- a question about dealing with the newest baby at a family function, when you've just lost one... I hate to resort to a smart aleck comment, but no one seems to get why it might be better to be in another room.... when everyone is insisting you gush over it, hold it, etc etc (UGH)

Alice Domar, Ph.D.: as I mentioned before, ....isn't it a shame that you suddenly caught a cold and can't possibly near anywhere near the new baby

I Host DianneY: That's a great suggestion!

Alice Domar, Ph.D.: and those people sound like idiots. I want to write a pamphlet of snappy comebacks...when someone insists you hold a baby, knowing full well you are going through inferitlity, it is like telling a diabetic obese person to count your ribs while they watch you eat cheesecake

Michellej: The thing is- I really DO like the family funcitions- except for that!

BWC: Do you know of anyone or any institution in toronto that uses the mind/body model?

Alice Domar, Ph.D.: There are actually are two sources in Toronto. Jan Silverman is a therapist there who does a variation of my program through the Infertility Network and I just trained a psychologist who wants to offer groups as well but is not up and running yet. Jan runs her own groups.

lauramc: My DH has been making noises about ttcing again and the thought of going through all that again sends me into near panic-attacks. How do you sort through the "other stuff" of IF and go on to building your family the way you wanted to before IF? DH is still in sort of denial about the emotional toll this took on me.

Alice Domar, Ph.D.: I believe in being honest with kids. you can say that you are doing everything you can, seeing the best doctors, but as he knows, we don't always get everything we want, even if we have been really really good


Alice Domar, Ph.D.: it sounds as if you need to go through some sort of healing process. Start a journal- the research on the cathartic process of writing aobut one's thoughts and feelings is powerful

lauramc: I have a journal...should I show it to DH?

Alice Domar, Ph.D.: Write about the most traumatic aspects of your infertility- write for 20 minutes per day for a minimum of 4 days. you may feel worse before you feel better but I would bet the end result would be a lot of relief . No, the journal should prbably be private, especially if you have some anger at him. don't write about events, write about thoughts and feelings.

lauramc: I think journaling is very cathartic for me...thank you

I Host DianneY: Is it just me or is there a baby boom going on out there? I would do anything to be pg and it is difficult to see pg women and babies everywhere. I wish that IF didn't effect moments that should be filled with the joy of a new life. I am hoping that as I move forward in life I will once again feel joy first and then regret.

Alice Domar, Ph.D.: You proabably notice babies because you want one...we notice food more when on a diet. the research shows that the pain of infertility does subside, no matter how it was resolved

Alice Domar, Ph.D.: Does anyone out there have some good holiday-stress reduction tips which have worked for you?

mickey11: Go shopping for gifts at the 24hr super stores at 3am to avoid long lines and crowds of kids/babies and pg gals...

Guest: I have stoic New Englander In-laws. They always want us there at Christmas -- (we have two small children) but after we get there, you can tell they don't want us there anymore. They have their own set of rules -- which no one really understands but them -- and they seem to want us always under their control -- if we go out it's too late when we come back - etc.

Alice Domar, Ph.D.: How about working out compromises? A lot of people,as they get older, may in theory want to be with the family but then quickly feel overwhelmed.

Guest: Any advice with dealing with them during the holidays.

Alice Domar, Ph.D.: Stay in a nearby motel or have them visit you! Then they have to follow YOUR rules. Maybe do the visits not during the holidays? Then there will be fewer expectations and disappointments. that will also allow the four of you to start your own traditions.

I Host DianneY: Sometimes I feel guilty about spending time trying again, especailly at 45, when I do have a miracle baby now. However a sibling would be wonderful for him. How does one decide the right balance between parenting and IF? My son is now 2 1/2..

Alice Domar, Ph.D.: A lot of post-infertility parents spend too much time and energy protecting their miracles. A sibling would be a good idea for some reasons and you spending time away from him is ok too

excel: How do you work through the negatives at the holidays...seems the last few years I've gotten my negatives just before Christmas and I am now debating about cycling now or waiting till the new year.

Alice Domar, Ph.D.: You need to figure out what is going to work for you. There are some advantages about can enjoy the egg nog, not worry about staying up late and running around, maybe even having a monent or two you enjoy. I am a big believer in postponing cycles until the time is right

I Host Songdancer: How do you deal with an EDD [Estimated due Date] for a stillbirth, another baby's birth date, and Thanksgiving all in the same week? Combine that with close relatives that never even acknowledged the stillbirth, and I find that Thanksgiving is really a time of emotions from both ends of the spectrum. Any tips?

Alice Domar, Ph.D.: I would suggest acknowledging them all. Whether or not you are a family that says a prayer before the meal. Ask for a moment of silence in memory of the baby you lost. And/or commenorate it with the planting of a tree, or reading of a poem.

mickey11: I have a rose bush for each baby lost....each time they bloom, I feel like my angels are saying hello to me. Plus I get to bring roses inside a lot to brighten up my home.

Alice Domar, Ph.D.: I like the idea of planting the rose bushes. We need to honor these souls.

excel: after multiple failed cycles (20 in my case) how does one get the enthusiasim generated to go through a new cycle with optimism. right now I feel like I am going through the motions but I can't believe that this will ever happen for me

Alice Domar, Ph.D.: Well, 20 is a lot of disappointments. I find that one goes through cycles when there is a least a bit of hope but at some point, there is a gut feeling that perhaps it is time to move on to Plan B. Hoepfully, your doctor wouldn't prescribe #21 if he/she didn't feel there was a decent chance. But after 20, I might ask for a second opinion

BWC: How do you find remain hopeful after so much loss?

I host Kaylie: Dr. Domar, my dh is a new clinical psychologist and starting a practice next year-any resources you recommend in IF or women's issues counseling?

Alice Domar, Ph.D.: The mental health professional group of ASRM is a good start

I Host Doe: Thank you all for coming to our chat with Dr. Alice Domar

Alice Domar, Ph.D.: Thanks for inviting me. As I am finding with my INCIID site this month, there is a lot of pain out there. Hope everyone learned at least a little something which will help...

I Host Doe: This has been a Holiday Blues chat with Dr. Alice Domar. Dr. Domar


Chat Transcript: Alternative and Complementary Medicine

Chat with Anca Sira, M.S., Dipl Ac, L.Ac
Wednesday January 5, 2005 9 PM ET


Anca Sira, M.S., Dipl Ac, L.Ac is a California Board Licensed and Nationally Certified Acupuncturist  She received her Masters of Science from Meiji College of Oriental Medicine, in Berkeley, California  She has 12 years experience in the healing profession and has studied extensively with some of the finest teachers in Oriental Medicine  Anca has a general practice of Oriental medicine treating many conditions and specializes in fertility and women's health issues  Using acupuncture, herbal medicine, Japanese healing modalities, and nutritional and lifestyle counseling, Anca Sira has helped improve the quality of life for her patients.

Judy: Hello Anca, Can you tell me what kidney yang deficiency means?
Anca Sira, LAc : Kidney yang deficiency is a term used in Chinese medicine that would in a nutshell describe a luteal phase defect  There would be other symptoms such as cold hands and feet, aversion to cold, frequent urination.

Anca Sira, LAc : I really want to stress that it's important to have a diagnosis and herbs customized to your individual needs and this will help you the most  Generally speaking blood building herbs help with lining and kidney yang herbs help with progesterone levels  Femoral massage can be used to help lining as well.

Anca Sira, LAc: Clots are usually indicative of blood stagnation and if you are not getting any herbs to address this then it will not change much  The best time to do this is during your menses.
Anca Sira, LAc: Femoral massage and electrostim to the lower back all help get blood to the area to nourish the ovaries  There are herbs that will help as well.


Anca Sira, LAc : You can have your partner do it for you or you can do it yourself  Find the femoral artery in your groin area and press on it till you feel no pulsating under your fingertips and hold for 30 seconds and do this 3 times on each side  It's easier when someone else does it as the pressure is hard to exert alone.


kc72: What kind of acupuncturist should I look for?
Anca Sira, LAc : It’s important to have an acupuncturist that has worked with RE's so that your RE is comfortable with that person giving you herbs  I never encourage self prescribing  Everyone I have worked with has done better on herbs than without to give you an idea.
kc72: how many months in advance of doing IVF should you be doing acupuncture?
Anca Sira, LAc : There is no specific number but the longer the better as this gives you more time to become balanced and respond well.

Mary: Would a gluten-free diet help with elevated natural killer cells/immunological implantation failure?

Anca Sira, LAc: Yes, Gluten is an allergen so you want to calm your immune system down and not aggravate it  So yes, eliminate gluten

Judy: Is there a difference between abdominal massage and femoral massage?

Anca Sira, LAc : Femoral massage cuts off the femoral artery and backs the blood into the uterus and ovaries  Abdominal massage can also improve blood flow to the area but not by the same mechanism  Both are excellent.
Jane : Hi, are there any specific foods that help with implantation?

Anca Sira, LAcAncaSiraLAc : I know that bromelain has been used by women thinking it helps with implantation as it is an anti inflammatory.  It wouldn't hurt but in my opinion, there are no real foods that help with implantation.
However, you might try to get on some supplements to help support your endocrine system  Like wheatgrass juice, Vitamin B6, Indole 3 carbinol, Selenium, Omega 3 with DHA, and flaxseed oil to start.

Anca Sira, LAc : Clotting generally doesn't impact implantation unless you have fibroids or scar tissue or adhesions  If it's just clotting you're referring to, no  But stagnation means the blood is not moving well and could affect blood flow to a developing baby so it's important to address it.


dlp : To follow up on my questions about trying to conceive over 40, you mentioned Indole 3 Carbinole  Haven’t heard of that one! Is it in tablet form alone or is it included with some other supplement. BTW, thanks for sharing information with us INCIIDers!

Anca Sira, LAc : Yes, my pleasure, Indole 3 carbinol helps the liver metabolize estrogen  It comes in a capsule form.



Judy : I have been very dry, and I am 30 years old.  Does this effect infertility? What should I take to balance my hormone in that matter?
Anca Sira, LAcAncaSiraLAc : This is a broad question that requires more history  Generally this indicates either blood deficiency and/or yin deficiency and you would address this with herbs.

kc72: How often do you see most of your patients to treat them for kidney yang, spleen and liver? My acupuncturist usually sees me right around time of ovulation and I am on customized herbs. Thank you very much Anca for your time and expertise!
Anca Sira, Lac: It depends on the severity of their symptoms, but generally 1 time per week. I've found over time that just at ovulation isn't really enough.

juliewi : Can a home stimulator like an RS 41 help?  I was given this to help my lower back pain but it has about 10 sticky pads which I put all over my lower back for stims ?  Can this help with follicles and different things we have been addressing here? Thank you very much for your help this evening..
Anca Sira, LAc : This sounds like a tens unit  You could try it. The worst that would happen would be that it didn't affect your follicles but your lower back feels good  I suggest my patients hook it up to UB 23, UB 32, UB 57 and Spleen 6.


Thank so much for joining us tonight. We hope you will come back and chat again.

Please visit Anca’s website here:  

She can also be reached by phone at: 415-456-7808

INCIID has an Alternative and Complementary Medicine Forum here:


Chat Transcript: Michael Doyle, M.D. Connecticut Fertility Associates

Auditorium Dr. Michael Doyle, M.D. on Wednesday Feb 2, at 9 PM ET

Harriet: Hello Dr. Doyle, I have a question regarding PGD and Antagonist for a poor responder. I'd like to know if you recommend it?
Michael Doyle, M.D. : For poor responders, I generally avoid Lupron, so that, yes, an Antagonist is one reasonable way to prevent premature ovulation before retrieval
Joyce: Hi Dr. Doyle. After two unsuccessful IVF attempts what is your opinion of testing for APA (Antiphospholipid Antibodies), Antinuclear Antibodies (ANA), Antithyroid Antibodies (ATA) and Lupus Anticoagulant (LA)?
Michael Doyle, M.D. : If there is history of miscarriage, or unexplained infertility, those tests can be useful, but maybe even before the first cycle !
(Editor’s Note: Please see the basic immunological fact sheet for more information on when to test and what the tests mean.)

Abigail : Dr. Doyle, my question is about immune treatments. I have come back with high ATA and elevated Thyroid Peroxidase levels. I understand that IVIg use is somewhat controversial, are their alternatives? What do you recommend?
Michael Doyle, M.D. : IVIg is controversial. Thyroid peroxidase levels themselves do not determine treatment. TFTs could be important to check also.

India:  What medication do you use with poor responders?

Michael Doyle, M.D. : I like Antagon or Cetrotide instead of Lupron in older patients and low or poor responders.
Barbara: Dr. Doyle, I had a normal lap done in 1998, since then the only pg was with my first IVF (in vitro fertilization) and it  ended in miscarriage at 10 weeks. We had another IVF that failed. Do you think that we should repeat the lap before attempting a third IVF cycle? Though no endometriosis was found at the time, it does run in my family. Thanks. (Editor’s Note: It is always wise to get and keep a copy of your medical records including the operative notes.)
Michael Doyle, M.D. : A laparosocpy would probably not improve the chances of an IVF cycle working in your case, since pelvic conditions are bypassed, and your pelvis is probably stil normal anyway. Unless you have a hydrosalpinx, which an HSG could detect.

Frances: What was your most successful IVF?

Michael Doyle, M.D. : Wow !! Tough question! I guess it would be the successful pregnancy from a case where there was only one sperm. But ALL successful IVF cases are amazing, even the "easy" ones.
Carrie : My DH (“Dear Husband”) has severe male factor. In our IVF cycle 10 out of 12 eggs fertilized My RE (reproductive endocrinologist) says that all 10 were excellent quality, the “HIGHEST QUALITY” . Four embryos were transferred and we were unsuccessful. What would you think our next step with 6 frozen embryos of high quality should be?

Michael Doyle, M.D. : Make sure your uterus is normal, and proceed with frozen embryo transfer. If they are day 3 embryos, consider thawing them ALL and transferring those that make it to day 5 (called blastocysts) , ideally transferring two of them. Good luck.
Michael Doyle, M.D. : There are various protocols, some begin with Lupron with your period, others a few weeks later after birth control, others a week after ovulation. Your doc will choose the one that's best for you.

Gerry : I have had 4 miscarriages in the past 2.5 years. In May I went to an RE and had all kinds of tests done. Structurally, hormonally and genetically, it would appear everything is ok. In May I tested positive for APA and ACA (anticardiolipin) antibodies. My levels were 90 for IGM AB Phophatidylserine and at 10 for IGM AB Cardiolipin. Since then I’ve lost another in August and one in October . My levels have now risen in Dec to 96 for Cardiolipin and 93 for APA. Do these get worse with each m/c?
Michael Doyle, M.D. : Not always, but more importantly, are you considering treatment with Aspirin, Prednisone, and Heparin or Lovenox?
Veronica : What are the chances of successful IVF at 40?
Michael Doyle, M.D. : It really depends on many factors, including egg quality, sperm quality, and fertility history 

Zelda : How concerned should I be with a day 3 FSH (Follicle Stimulating Hormone)  of 10.9. I am 30 years old and make 11-15 eggs during IVF stimulation.
Michael Doyle, M.D. : Probably not very concerned, if the quality of your eggs has been found to be good. But it may suggest that your ovarian reserve will probably become an issue at a younger age than you might have predicted.
Teresa : I am getting ready to do my third IVF using a donor's eggs. We have had 7 failed IUI's (Intrauterine inseminations) and 2 failed IVF cycles. I'm 38 and DH is 50, can you suggest we do anything different to assure success of this cycle?
Michael Doyle, M.D. : Egg donation sounds like a very good idea. Pick a great donor and just follow the protocols. As long as your uterus is functional, your chances should be very good. Try to relax, maybe even consider acupuncture.
Michelle: What constitutes a poor responder for a 35 year old woman?
Michael Doyle, M.D. : A poor responder might produce less than 4 follicles, and a have a relatively low Estradiol, level (i.e. <600, approximately).
Estelle: Dr. Doyle. Do you know if there is any difference between Repronex (Subcutaneous - SubQ) and the generic form which is an IM injection? Do you feel a difference in protocols using just Repronex vs. Gonal-F or Follistim.  I'm asking because of financial considerations. Thank you.
Michael Doyle, M.D. : There is no difference between IM (intramuscular) and SubQ (subcutaneous) Repronex, except that SubQ is reported to burn. I personally prefer the protocol include a significant amount of Follisitm or Gonal F, (i.e., the recombinant FSH) .
Norma : I'm afraid I was over suppressed with Lupron and Repronex and Gonal F. I didn't respond. I also have Hashimoto Thyroiditis. I'm concerned that I haven't cycled yet. I feel like I will any day now but it's been well over 28 days now. What could this mean?

Michael Doyle, M.D. : Your non-response was probably not caused by Repronex and Gonal F. Maybe you should recheck your baseline FSH, or even do a Clomid Challenge Test to assess your ovarian reserve.
Doe : Dr. Doyle, do you recommend low-carb lifestyles to your PCOS patients?
Michael Doyle, M.D. : Yes and EXERCISE if possible. Weight loss can be key to normalizing the high insulin and/or testosterone levels which are often associated with PCOS and which cause ovulation problems
Nellie : I am only 31 years old. How would I know if I was a low responder? My FSH was 4.5 today and e2 was 11
Michael Doyle, M.D. : Those are excellent numbers, so you probably need not worry. The way to know is to see how you respond to fertility drugs, but if you don't need to take them, you shouldn't!

Glenda : I've had 3 miscarriages and 1 successful pregnancy as a result of FET (Frozen Embryo Transfer). The last miscarriage was a chromosome normal female. I've had LAC, APA, and chromosome analysis done on me and husband. My only successful pregnancy was when I took Glucophage. I'm wondering if that might possibly be important to another successful pregnancy. I have started the Glucophage again and will do a FET next week. I am searching for answers as to why I keep losing pregnancies.
Michael Doyle, M.D. : Embryo quality can certainly be improved in women with PCOS and insulin resistance, so tests to determine insulin resistance could be very helpful.  i.e. Fasting Insulin or Glucose Tolerance Testing.
Donna : Dr. Doyle, can you compare the MDL to an Antagon protocol for low responders who are less than 35 years old?

Michael Doyle, M.D. : In general, MDL usually provides a bit more suppression, but as a flare, may also produce a few more follicles. Honestly, it is very difficult to predict which would be better in an individual case. You just have to try the one your doc feels is preferable based on previous stimulations... Good Luck!
Nora : My family appears to be cursed with PCOS as every woman has been diagnosed with it. Although each woman in my family (grandmother, mother, aunt, and two sisters) have been diagnosed with PCOS, I am the only one who has difficulty conceiving. My older sister has been pregnant three times in the four and a half years my husband and I have been trying to conceive (TTC). All blood tests and HSG are normal except for a slightly elevated testosterone level. Is this just likely a quirk of PCOS in me?

Michael Doyle, M.D. : PCOS can affect different people differently and remember, fertility depends not only on family connections but also on ovulation and eggs. Perhaps those other factors to consider – Has a Sperm Analysis been done? 

Barri : Good Evening Dr. Doyle. I’ve been through 4 IVF cycles with 1 pregnancy, ending in miscarriage. This was a few years ago. Now I am 40 and we very much want to try again, what are chances and what should be our first step??
Michael Doyle, M.D. : At 40 and following 4 IVF cycles your chances are starting to go down, but don't give up. You might start as a first step with a baseline FSH and E2, and perhaps a Clomid Challenge Test?

Denise : Dr. Doyle, another question for you, I've done Clomid Challenge (2003), Metformin (2003) and most recently Repronex and Gonal F in prep for IUI. I didn't respond to any of them. I've always had an irregular cycle, I have Hashimoto's and my mother has Lupus. Do you think any of these factors may be contributing to my lack of response or is it just age, I'm 42? Thanks!
Michael Doyle, M.D. : Honestly, it's probably almost all an age issue.
Cathy : I' am just in the early process of doing PGD (Preimplantation Genetics), I was wondering how long does an IVF cycle last and how long are you doing injections?

Michael Doyle, M.D. : An IVF cycle lasts up to 6 weeks, with injections comprising up to 4-5 of those weeks in some cases, NOT counting the progesterone. GOOD LUCK!

Dora : Other than a Saline Hysterosonogram , what is the best way to "make sure the uterus is normal"?
Michael Doyle, M.D. : Hysteroscopy
Mary : Hello Dr. Doyle. I have a question about use of Lupron vs. Antagon. I am 34 year old and a good responder. Fifteen (15) eggs were retrieved using Antagon and only 10 while using the Lupron protocol. I am going to do my third IVF cycle with Antagon again. Any guess why I do not respond well to Lupron? I have mild endometriosis and Unexplained Infertility. Thank you

Michael Doyle, M.D. : Lupron can sometimes suppress a bit more than we would like. Or perhaps it was unrelated, if there was not enough rest following your first cycle, you might have responded less because of that. 

Elizabeth : So acupuncture REALLY can increase/help implantation?
Michael Doyle, M.D. : honestly, thats out of my field, but if your center has a wellness group, ask them. or you can ask our team at .

Marilyn : I am on aspirin and that didn't work. My RE thinks these antibodies only affect a placenta at 2 months. She suggested Heparin after week 6 but my miscarriages usually occur before this point in the pregnancy. I went to a hematologist on my own and she thinks Lovenox given 1x daily will help my antibody situation. The RE is not convinced. I have read articles that suggests this affects implantation. When should I start Lovenox before or after ovulation?

Michael Doyle, M.D. : It is very debatable and there are different opinions on treatment. In cases like yours, I start Lovenox when the pregnancy test turns positive. (Editor’s Note: There are differing opinions among Reproductive Endocrinologists on starting antibody treatments pre or post conception. We also suggest you read the basic article on Immunology and then discuss this with your own doctor.)

Laurie : How many embryos do you transfer for a successful pregnancy for IVF patients?

Michael Doyle, M.D. : The number of embryos transferred is dependent on the age of the patient and the embryo quality. We usually transfer 2 or 3. ASRM (American Society for Reproductive Medicine) has guidelines for this which you can find on their website:
Liz : Is there any way to improve male sperm count with the use of vitamins herbs or other nutritional supplements? If so, do you recommend any particular one to assist with motility?  My husband’s sperm did not penetrate the egg on their own during our first IVF cycle. 
Michael Doyle, M.D. : I don’t know of any nutritional solution to this issue. Obviously with IVF ICSI (Intracytoplasmic Sperm Injection) (Editor’s Note – See the basic ICSI fact sheet) is performed. I think I would not predict how meaningful one cycle of IVF with failed fertilization is. I have certainly seen patients like this get pregnant later spontaneously!

Dana : I will begin a third IVF cycle and a three day transfer. What is the suggested number of blastocysts to put back at day three for a singleton pregnancy?
Michael Doyle, M.D. : If you really don’t want twins and you are transferring day 5 blastocysts, you probably should put back only ONE high quality embryo. 

Gloria : If on Lovenox therapy and carrying to term do I need to be induced? Can I  have an epidural safely?
Michael Doyle, M.D. : The Lovenox is stopped before labor and delivery, so epidurals are ok, and induction is not necessarily required. 

Martha : When should we start considering surrogacy?
Michael Doyle, M.D. : Surrogacy can be considered when it appears your uterus cannot carry a successful pregnancy. I would suggest you look at the Third Party Reproduction Forum on INCIID with Moderating Physician Joel Batzofin, M.D.

Margaret : I am considering the use of donor sperm. The donor I selected tests positive for CMV (Cytomegolovirus) antibodies, but not CMV.  Do I also have to test positive for CMV antibodies to use this donor to avoid complications should I become pregnant?

Michael Doyle, M.D. : No, his antibodies only suggest that he has been exposed in the past, not that he carries the risk of infecting you.
Mel : Hi Dr. Doyle, I'm 37 and have been trying to conceive for 12 years, I’ve had 10+ IUI's, 2 failed IVF cycles, 1 Failed FET and a diagnosis of PCOS annovulatory, and hyprolectimia. After all these years of trying should I give up?
Michael Doyle, M.D. : Wow, that's not my call. You and your partner should sit with your doctor and hash this out, see what options still remain and if they are right for you.... Good luck.

Lottie : I took Gonal-f four years ago and conceived our third daughter on the second round. I was doing twice daily injections of 150iu's each time. We are getting ready to try again and my RE wants to start me on 150iu's of Gonal-f. Is that too low of a dose? Especially since I got PG on 150iu's 2 x's daily. Would 225iu be more of a reasonable dose to try? This is not for an IVF cycle.

Michael Doyle, M.D. : Your doctor probably reviewed your prior response and might be maybe trying to reduce the risks of hyperstimulation or multiples? I would suggest you speak to him about your concerns.
Michael Doyle, M.D. : Thank you very much for your excellent questions. I wish you all the very best.... Good Night !

Visit the Connecticut Infertility Associates Website

Michael Doyle, M.D. is a reproductive endocrinologist from Connecticut Fertility Associates, 4920 Main Street, Bridgeport, CT 06606 He is an INCIID Professional Member and currently moderates the PCOS Forum on INCIID: 



Chat Transcript: Alice Domar Chat - Monday December 13, 2004 at 9 PM ET

Alice Domar, Ph.D.

Practical Tips for those stressed and struggling with Infertility and Pregnancy Loss


You are invited to spend some quality time with Alice Domar, Ph.D. and learn first-hand some of her tips for coping with the holidays.

Alice D. Domar, PhD is a pioneer in the application of mind/body medicine to women's health issues. She not only established the first Mind/Body Center for Women's Health, but also conducts ongoing ground-breaking research in the field. Her research focuses on the relationship between stress and different women's health conditions, and creating innovative programs to help women decrease physical and psychological symptoms.

She has conducted research on infertility, breast cancer, menopausal symptoms, ovarian cancer, and premenstrual syndrome. Dr. Domar has earned an international reputation as one of the country's top women's health experts. She is the founder and director of the Mind/Body Center for Women's Health at Boston IVF.

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Chat Transcript: Mark Bush, M.D. March 8, 2005

Transcript 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: 303-449-1039 Email Dr. Bush


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.

Martha: Thank you for answering all of our questions. I had a laproscopy and while they didn't find any endometriois, they found "filmy" adhesions. I have CONSTANT pelvic pain on the side where they found the adhesions. My tubes were clear and the adhesions were limited to the bowel area. Can adhesions by themselves be considered a cause of infertility? Is there any reason why I would have adhesions without any sign of endo?
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!



Chat Transcript: Attaching in Adoption: An Online chat with Deborah Gray

Attaching in Adoption:
An online chat with Deborah Gray

Ann Downie: Hello I wanted to say I really love your book, [Attaching in Adoption]. My question: Our 20 month old has been home 6 months. She is very jealous of her 7 year old brother. What do we (including brother) need to do to encourage attachment

Deborah Gray: She is still having trouble like many do because they have a hard time getting used to sharing attention.
Many of these children feel attention is scare because of where they came from.
Look at your little girl in the face, then clearly tell her we love our boy too so be nice to your brother. Please don't her bat at him. When she screams as he gets attention tell her firmly but kindly, "We love you both." Continue to give him attention in front of her but save your biggest reactions for when the two of them are interacting positively.

Robin E.: While in China should both my husband and myself feed her or me since I will stay at home with her.

Deborah Gray: It doesn't matter
Sometimes if the child has been fostered first they will reject the mother. Be prepared for this as it can feel devastating.
But after the intitial shock wears off you'll get your turn
Attachment between your child and you will take time. But you have lots of time. The first few days just concentrate on being as senstitive and soothing for her as much as possible.
Do whatever it takes to calm her down even if your husband does all the feeding.

lesliep29: We're having a lot of problems with our daughter who's 13. She says she wants to get removed from our family. We have regular blowups. How can we help her express her anger in a less damagi
Deborah Gray: This normal at this stage

She's grieving and has not accepted the finality of the loss of her birth parents. Support her grief and let her know that you're very sad with her that she didn't have the opportunity to live and stay with her birth mother. Be sure she understands that this isn't a choice she can make -- She can't reject you and go back to China.
Ask the caseworker who did the placement to visit
describing to your daughter the limitations of her options.
Get the caseworker to help her become reality based
Rather than arguing about it with her -- get the casewroker to come and do this as a post placement cap.
Children who have lived within institutions don't understand anything about the way the world works. They have no understanding of life except inside the instititution.
Many times they think someone is coming and when they finally are placed. They also think someday they will go back.
She needs to work with someone who is not a family member around these issues maybe with the help of an interpretor.

lesliep29: Deborah, thanks. I understand better now. I'll have to work on helping DH to understand it. He's the one who gets the brunt of the anger. Her English is actually very good. How honest she's being with her therapist is another matter.
Deborah Gray: Ask for some family sessions with the family therapist. It seems like she may be "stuck".

Robin E.: How do we help an infant grieve?
Deborah Gray: [9-16 months] These infants have alarms at leaving their care givers. Sooth them and calm them down.
It depends on the individual child with what the grief reaction will be . Children tend to lose their regulation when they lose their caregiver.
Do a lot of soothing and comforting in all areas of their daily life'

Nancy: I adopted my now 18 month old when she was 10 months, how do I know she is attached?
Deborah Gray:

  • Does she reach out for you
  • Does she try to stay close to you
  • Do yher eyes follow you around the room
  • Does she try to show you a toy or an accomplishment
  • Would she rather be with you then others almost all the time

There is a check list in my book "Attaching in Adoption"
At this long in the home you should see she's preferring the parent to others. This is where you should be able to begin to see it

keri: Please describe "high structure" parenting as you refer to it in your book
Deborah Gray: High Structure parenting is informed by knowing that children feel best if their enviroment is consistent highly nurturing and predictible. HSP only gives children the number of choices that they can really handle. As children grow into the ability to handle more choices then the structure is loosened. Initially the structure helps them tremendously in learning how to take advantage of a possitive environment rather than using control
or poor choices to gain attention or to gain priviledges.
The structure insures the positive choices, priviledges and attention.

Deborah Gray: It's been a pleasure to be with you this afternoon but I must leave now . I hope to be back in a few months to see how everyone is doing.

Deborah D. Gray, MSW, MPA author of the 2002 book Attaching in Adoption: Practical Tools for Today's Parents is a clinical social worker specializing in attachment, grief, and trauma. She enjoys helping children and their parents in situations where deprivation or attachment losses make attachment formation challenging. In her private practice with the Attachment Center Northwest, parents are usually present in the therapy sessions to provide comfort and safety for their children's trauma work, or to work with their children on attachment-related issues. Her philosophy empowers parents with information, offering new skills and techniques to meet the needs of their children.Deborah Gray lives in Washington state with her husband and their three children. Contact her at