InVia Fertility Specialists Blog

The patient in the in vitro fertilization / IVF process who is a “poor ovarian responder” remains a challenge in clinical practice. The European Society for Human Reproduction and Embryology (ESHRE) working group on Poor Ovarian Response published a consensus definition of “poor ovarian response” after a meeting in Bologna, Italy around 2011. 9 – 24% of patients undergoing the IVF process are poor ovarian responders.

Given a choice, a majority of patients would prefer to take medications orally. So when it comes to progesterone, why do we prefer the intramuscular or the vaginal route? It's simple: the oral route doesn't work as well. Here’s why:

PCOS stands for polycystic ovary syndrome. It is a common condition related to an imbalance of hormones. It affects as many as 1 out of 15 women, and is a leading cause of infertility as well as other health problems. Getting pregnant with PCOS can be possible with the right diagnosis and treatment.

In many cases couples decide to cryopreserve their remaining embryos after an in vitro fertilization (IVF) treatment. They could freeze the embryos right after treatment before proceeding to a transfer due to concern of ovarian hyperstimulation syndrome or high progesterone. Others cryopreserve their embryos in case their first cycle is unsuccessful or for future use. Either way all the frozen embryos will have to be thawed in the same fashion for an FET cycle. With all the nerves and excitement come lots of questions about the thawing process.

During in vitro fertilization (IVF) in order for implantation and pregnancy to occur, the embryos must reach a stage of development known as ‘blastocyst’. Reaching the blastocyst stage is an integral part of the development of an embryo.

A failed IVF cycle is heart-wrenching.Your dreams of a pregnancy are shattered, your hard-earned money has gone down the tube, and you do not know what to do next! As humans we all need explanations for the failures we encounter.

If we get an answer, then we tend to have peace of mind, because we believe that we can achieve success the next time around if we can avoid past mistakes. But when an IVF cycle fails, unfortunately, often there's no good answer as to why. So much about human reproduction is still yet to be discovered, that often even the most experienced doctor may not understand what happened.

In a previous blog we discussed the expected ultrasound findings in a normal intrauterine pregnancy. Variations from the expected pattern of development are worrisome or, if major, definitive for early pregnancy failure or miscarriage. These were discussed in a recent review article by Doubilet et al. (N Engl J Med 2013;369:1443-51). Here is a summary:

Letrozole (marketed as Femara in the U.S.) is a drug that is approved for the treatment of breast cancer after surgery. It is also used (“off label”) for ovulation induction. I have discussed its mechanism of action and success rates in a previous blog, as well as use of Letrozole versus Clomid for patients with PCOS. Despite its obvious advantages, Letrozole is used infrequently by fertility specialists in the U.S. A major reason for this is a controversy about the use of Letrozole and birth defects in the resultant children.

An anti-mullerian hormone (AMH) level is a test now routinely used to evaluate ovarian reserve. AMH levels were believed to NOT vary during the menstrual cycle and can be drawn any time.

In a recent blog I had presented data which suggest that AMH levels in fact DO vary! AMH levels are also not supposed to be influenced by the use of birth control pills. A recent study from Finland suggests that this may not be true either.

A pregnancy test, in an IVF cycle, is generally scheduled approximately two weeks after an embryo transfer. This involves a blood test to measure the hormone of pregnancy - hCG (human chorionic gonadotropin). If positive (greater then 5 mIU/ml) the test is repeated two days later and it should rise appropriately. Initial studies had suggested that in naturally conceived pregnancies, the 2-day rise should be at least 66%. A slow rise was believed to be associated with an abnormal intrauterine pregnancy or a tubal pregnancy. More recent studies have shown that the rise could be as slow as 53% in 2 days and the pregnancy could still turn out to be normal.

Early pregnancy bleeding is fairly common and occurs in 20 – 30% of pregnancies. Vaginal bleeding in early pregnancy can be worrying, so it's only natural that if it happens to you, you're concerned about your baby, especially if you've had trouble getting pregnant and maintaining a pregnancy. It doesn't always mean that there's a problem, however, it can be a warning sign of a miscarriage or recurrent pregnancy loss. Here are the top five facts you should know about early pregnancy bleeding:

Human chorionic gonadotropin (hCG) is a hormone produced by the embryo after conception. Human embryos can produce hCG as early as 8 days after fertilization. During IVF, however, final egg maturation is triggered by an hCG injection (generally 10,000 units) given approximately 36 hours prior to egg retrieval, increasing hCG levels in the patient's body. It takes approximately 14 days for the hCG from the trigger shot to be cleared (metabolized).

The experience of feeling stress is part of our biological survival mechanism as human beings. It is a signal that danger is impending and action must be taken to seek safety. While it is a simple matter to obey traffic signals in order to cross a busy street safely, it is a much more complex matter to manage the chronic stress experienced in a situation where there is no simple solution. Infertility is just such a complex problem and requires effective stress management skills.

Polycystic ovary syndrome (PCOS) affects 6 – 8% of women and is a common cause of infertility. Women with PCOS often have absent or irregular menses. They therefore either do not ovulate or ovulate infrequently.

Getting pregnant with PCOS can be possible with the right diagnosis and treatment. For the past many decades, clomiphene citrate (Clomid, Serophene) has been the drug of choice for making PCOS patients ovulate. The ovulation rates with clomiphene citrate are good, however, the pregnancy rates are quite low.

1) Anti-mullerian hormone (AMH) is the substance that is responsible for destroying the mullerian ducts (female reproductive organs) in developing male embryos. An important discovery was the synthesis of AMH by granulosa cells (the cells surrounding a mature egg) and this was followed by the development of accurate blood tests to measure AMH. For the past 20 years the importance of AMH with regard to ovarian function has been extensively studied.

Bleeding during pregnancy is scary, particularly when you have been trying to get pregnant for a long time with the help of a fertility specialist. In this post, I’m going to look at different reasons why bleeding happens during early pregnancy—including reasons that DON’T involve miscarriage.

Please note that if you’re very worried about bleeding, especially heavy bleeding accompanied by pain, cramps, or clots, you should call your physician first and follow his or her advice.

For successful implantation to occur, an embryo needs a “receptive” uterine lining (endometrium). A thin endometrium can result in lower implantation of the embryo. In previous blogs, Katie Koss and Janet Chiarmonte have discussed the various pathologies that can prevent implantation and the three common techniques used to evaluate the uterine cavity. In this blog, the thickness of the endometrial lining and measurement of the lining during cycle monitoring will be discussed.

There are many choices to make in starting a family as a gay male couple. Let's say you've chosen a fertility clinic that has a track record of success serving same-sex couples, and you've secured an egg donor and surrogate. What’s next?

Women are born with all the eggs that they will ever have. In fact, when a female fetus is only 5 months along, she has approximately seven million eggs in her ovaries. By the time that baby girl is born, only 2 million eggs remain.

At the time of her first period, this number is further decreased to 300,000 eggs. Every month, a woman loses eggs. This process occurs even if she is on birth control pills or has irregular menstrual cycles.

I have previously written a blog on how to improve your chances of success with fertility treatment.

Improving your lifestyle is a big step in the right direction. Weight loss, regular exercise, quitting smoking tobacco and marijuana, drinking alcohol only in moderation are absolutely necessary to maximize chances of success.

You have had your egg retrieval and are now waiting for your embryo transfer. Instead of having your transfer 5 days later, you are told that the embryos are “dividing slowly” and the transfer is postponed or cancelled. On day 6 finally, blastocysts are formed and you are recommended to freeze the embryos instead of having a transfer.

It is natural to feel disappointed, and we do know how anxious you are to get pregnant. However, there is a very good reason why freezing slow developing embryos and transferring them in a subsequent programmed cycle makes sense.

If you're undergoing or researching IVF, you may have learned that not all embryos are able to implant, and therefore sometimes the decision is made not to transfer an embryo to the patient after an analysis is performed. The analysis used to make that determination is called blastocyst grading. What exactly is the embryology lab looking for when they perform blastocyst grading?

If you're having trouble getting pregnant, you've probably heard of anti-mullerian hormone or AMH. The level of the hormone's presence in the body is directly linked to the number of growing follicles able to produce eggs. Having a low AMH level is a hurdle many women face on the road to motherhood.

Anti-mullerian hormone (AMH) is a highly sensitive marker of ovarian reserve. It is released by the cells surrounding follicles in the ovary. AMH levels decrease with age and may be the most sensitive marker of ovarian aging. In fact, AMH levels have been shown to decrease earlier in life before other traditional markers, such as cycle day-3 follicle stimulating hormone (FSH).

Other advantages of measuring AMH levels include the fact they are not influenced by menstrual cycle timing or pregnancy. AMH levels are correlated with the number of antral follicles on ultrasound (small dark circles seen in the ovary which are usually 2 - 8 mm in diameter). AMH levels have been shown to predict the number of eggs retrieved during in vitro fertilization (IVF). AMH levels can also be predictive of pregnancy rates with IVF.

A uterine septum is a common anomoly of the uterus that is seen in 1 – 15 per 1,000 women (shown in the picture at right).  In this condition, the cavity of the uterus is separated by a long piece of tissue, while the outside of the uterus has a normal shape.

According to several studies, treating a uterine septum is associated with an improvement in live-birth rates for women with prior pregnancy loss, recurrent pregnancy loss, multiple miscarriages, or infertility.

I’m often asked by donors how many cycles they are allowed to do and the answer is always six. But where did that number come from? Did we make it up? Can they go somewhere else and do more?

In vitro fertilization (IVF) is now a fairly commonly used procedure and has resulted in the birth of tens of thousands of babies every year. According to the latest statistics available (2015, www.sart.org) there were 209,336 IVF cycles performed in the U.S. alone. This is an increase from 154,412 IVF cycles being performed in 2011.

In addition, the success rates with IVF have been steadily increasing with fewer embryos being transferred (details once again at www.sart.org). Initially, IVF was devised as a treatment for patients with diseased fallopian tubes (tubal factor). There have since been several other indications for IVF and a couple of brand new ones, which will be discussed in this blog.

I have by now answered several questions from readers who tell me they have a positive pregnancy test. They will often give me their pregnancy test result and ask me if the level is okay. On further enquiry, I often find out (and am furious) that these patients have been taking booster human chorionic gonadotropin (hCG) injections after the egg retrieval (luteal phase)! These injections result in a false positive pregnancy test since the patients are taking the same hormone (hCG) that the pregnancy test detects. This fools patients into thinking that they were pregnant when they really are not.

While all IVF patients understand that not every IVF cycle results in success, in their heart of hearts, every patient wants to get pregnant every cycle. After months or years of having trouble getting pregnant, the two weeks after the embryo transfer can seem like an eternity and can be very nerve-wracking.

Am I pregnant or not? Have the embryos implanted or not?

The suspense can be even worse than the pain of the IVF injections!

You've seen a fertility specialist, started IVF, and gotten through the first embryo transfer. You've spent a long time waiting for good news.

And finally you get it! The results of your pregnancy test, which measures hCG level, are positive. Congratulations!

Almost before you can celebrate, however, you start wondering, “Is my hCG level good?” Is the pregnancy going to progress normally? Here's what we can tell you about how hCG levels relate to a successful pregnancy.

“Should I lie down for a while after my embryo transfer to optimize our chances of success?”

That is a question we are asked on a daily basis. We've always advised our patients that bed rest after transfer was not going to increase the likelihood of success, but a new study has actually shown that bed rest following transfer might, in fact, actually DECREASE the likelihood of success. 

We often talk about follicles (affectionately called "follies") during the IVF process. But IVF patients often don’t understand the difference between follicles and eggs. If eggs aren't follicles, what are follicles, anyway?

After months or years of having trouble getting pregnant, all the action and the excitement of taking injections, going for scans, monitoring your blood test results and admiring your embryos is now over.

Your doctor has put your embryos back into your uterus, and now all you can do is wait for the final outcome, in order to find out whether the embryos have implanted or not. This wait is extremely frustrating: the outcome of the treatment is completely out of your hands, and there is no way of finding out what is happening to your precious embryos inside your body.

As any IVF patient will attest, the two-week wait after the embryo transfer is the longest fourteen days of your life. The symptoms after IVF embryo transfer-- physical and emotional-- can be hard to deal with.  Do any of these sound familiar?

Polycystic ovary syndrome (PCOS) is a relatively common hormonal disorder that is one of the leading causes of infertility. Some women who have PCOS develop insulin resistance. This occurs when the cells of the body don’t respond well to a hormone known as insulin. Insulin allows the cells to take sugar (glucose) from the blood. If the cells don’t take in this sugar it leads to higher levels of glucose and insulin circulating through the body in the bloodstream. This, in turn, leads to increased levels of androgens (male hormones) which cause the classic symptoms of PCOS such as excess hair growth and more importantly in terms of fertility – lack of ovulation. Getting pregnant with PCOS can be possible with the right diagnosis and treatment plan.

Many times women are concerned after experiencing failed IVF with a fresh embryo transfer if it is best to move right along into another cycle for a frozen embryo transfer. They wonder if there are any carryover effects from the ovarian stimulation and if they should wait to cycle to minimize any residual effects that could potentially impact endometrial receptivity. So, the question is, “Will waiting before performing my frozen embryo transfer cycle increase my chances to become pregnant?”

I have written previously on the role of progesterone (P) and the various methods of administering P. Historically, during the early days of IVF, P was administered exclusively via intramuscular (IM) injections. These involved a long needle that was used to deliver the medication in the buttocks.

Also, P only dissolves in oil (peanut, olive, ethyl-oleate etc) and repeated injections were painful and sometimes resulted in sterile abscesses. Patients also had allergic reactions to the oil. This was a nightmare for patients as these daily injections were sometimes continued for 8 – 10 weeks!

The treatment of male factor infertility was revolutionized in 1992 when Palermo and co-workers introduced intracytoplasmic sperm injection (ICSI). With ICSI, embryologists use a micromanipulator to inject sperm directly into the egg (that has been retrieved as part of an IVF cycle). It was now possible for men with severe male factor infertility to father a child. ICSI can be used even in cases where the wife produces more eggs than the husband produces sperm!

Using high magnification, an oval-appearing motile sperm is selected for ICSI. When a sperm is motile-- moving and swimming-- it indicates that it is viable and therefore is capable of fertilizing the egg.

1) What is adenomyosis?