Anti-mullerian hormone (AMH) level is now routinely used to evaluate ovarian reserve. AMH levels decrease with age and are a more consistent predictor of “ovarian age” than antral follicle count on ultrasound, inhibin b, or FSH levels. The ovary produces AMH and this is confirmed by the fact that AMH levels are undetectable after surgical removal of ovaries as well as menopause. It is therefore reasonable to ask, “Does AMH level predict age at menopause?”
Many patients who have been through an in vitro fertilization (IVF) cycle have blastocysts that have been frozen. These blastocysts are cryopreserved by a process known as vitrification, which is a highly successful method of cryopreservation, with survival rates of about 98%.
Once the embryos have been vitrified, they can stay in that state indefinitely until a patient is ready to try to achieve a pregnancy.
In many cases, patients with cryopreserved blastocysts have had a successful outcome with the fresh cycle. There are also instances where a pregnancy was achieved, however, the pregnancy resulted in a miscarriage. And unfortunately some patients, despite having embryos with a good morphological grade, do not achieve a pregnancy with the fresh cycle.
We use several blood tests to assess a woman's potential to respond to fertility treatment. Initial research on measuring anti-Mullerian hormone (AMH) levels, used for gauging assessing ovarian reserve, showed that they do not vary during and between menstrual cycles. A single blood test done at any time during the cycle was supposed to be diagnostic.
This was a huge improvement over FSH levels, which must be measured on cycle days 2, 3 or 4 and are known to vary widely from cycle to cycle.
At InVia, we have been measuring AMH levels for many years now. Our clinical experience was that repeat AMH levels did seem to vary in the same patient. We have therefore been careful not to base treatment protocols based on AMH alone. We do keep other relevant factors (age, day-3 FSH, AFC, previous ovarian response, BMI) in mind when planning an IVF treatment protocol. The basic question, however, remains “Do AMH levels vary”?
Endometriosis affects one in ten women in the United States, and can cause fertility problems.
At InVia Fertility, we have treated many women who have this condition over the years. Here are the top ten most common questions we've received about it:
One of the first steps in fertility testing for any male infertility issues is a semen analysis. A semen analysis gives a good representation of the male’s quantity and quality of sperm, as shown in this sample semen analysis. Sometimes even debris and cells can be found in the sample. Debris, such as epithelial cells, is commonly found in small quantities, as well as, white blood cells. White blood cells in semen is not an issue, unless there is the presence of more than 1 million white blood cells per milliliter of semen.
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?
Topics: Egg donation
Once a healthy, developing embryo is successfully transferred into your uterus, it has to attach itself to the uterine lining and then grow there, a process known as implantation.
For successful implantation, your uterine cavity must be "receptive". That means not compromised by inflammation, growths, or other problems, so that the embryo can "stick" and begin to grow.
In the fertility community, when we say "think sticky thoughts" after an IVF embryo transfer, this is what we're talking about. Lack of implantation or compromised implantation can lead to early miscarriage.
So, what kinds of issues can impact implantation, and how can your fertility team spot them?
Ovarian reserve is a term that is used to determine the capacity of the ovary to provide egg cells that are capable of fertilization resulting in a healthy and successful pregnancy. Cycle day-3 follicle stimulating hormone (FSH) and anti-mullerian hormone (AMH) levels are routinely used to evaluate ovarian reserve in infertile women.
FSH levels predict egg “quality” and increase (> 10 mIU/mL) in women with diminished ovarian reserve (DOR). AMH levels, on the other hand, predict the ”number” of eggs that a woman will produce during ovarian stimulation for in-vitro fertilization (IVF). An AMH level < 0.7 ng/mL is consistent with a diagnosis of DOR. A combination of FSH and AMH levels is an excellent measure of ovarian reserve in infertile patients.
Of late, women who are not planning to get pregnant have obtained tests to use these levels as a “fertility test”. For example, Mrs. Smith is a 32-year-old with a two-year-old son who is using barrier contraception. She is not quite ready to have another child, but requests ovarian reserve testing from her Ob-Gyn doctor based on something she has read on the internet.
The question is: Are ovarian reserve tests useful as a “fertility test” in women who are not planning to get pregnant? What should be done if Mrs. Smith has a low AMH level? Should she try to get pregnant immediately? Should she freeze her eggs?
Single people and same sex couples that would like to have children that are theirs, biologically, can use this blog as a guide to starting the single and same sex parenting process.
Fertility drugs are used to stimulate the ovaries to produce multiple follicles. Their use is associated with multiple ovulations and often with high estrogen levels. It would therefore be reasonable to ask, “Do fertility drugs cause cancer?”
This is an important issue as there are approximately one million IVF cycles reported per year worldwide. In addition, there are an unknown number of ovulation induction cycles.
There are often social challenges endured by LGBT families and parents. There is a lot of confusion and information to be sorted through, from friends, family members, Internet searches, and even from medical professionals. When choosing a fertility clinic, it's important to find a specialist that can guide you while providing a judgment free zone for you to feel safe and comfortable as you go through this very important step toward building your family.
For same-sex male couples, planning a family starts with a lot of questions—about getting an egg donor, surrogacy, and other fertility treatment options. Some of these questions can be answered by you, while others require input from professionals.
Topics: Egg donation
Most of us remember very little from our Biology 101 class we had to pass in order to finish high school or college. The terms were technical and the processes complex. However, now that reproduction has taken center stage in your life, you keep hearing some of these terms long since forgotten.
In this post, I'll clarify some of the mystery around one part of IVF, pre-implantation genetic screening (PGS). This testing looks at genes and chromosomes to determine an embryo's risk of miscarriage.
It is now more than 30 years since the first live birth after transfer of a frozen (cryopreserved) embryo (Zeilmaker et al., 1984). The ability to successfully freeze embryos had a profound impact on assisted reproductive technologies. It improved efficacy, encouraged the transfer of fewer embryos into the uterus and hence reduced complications arising from prematurity. Recent research indicated frozen embryo transfer babies do better than babies from fresh embryos.
One of our routine tests is to evaluate egg quality is a day-3 follicle stimulating hormone (FSH) level. A high FSH level indicates diminished quality of a woman's eggs (ovarian reserve).
Patients with high FSH often ask us if we can lower their FSH levels. Before answering this important question, let's start with a primer on the basics of FSH testing.
One of the most frustrating group of patients for IVF specialists are those with recurrent implantation failure. These are patients for whom we've done multiple IVF cycles but who still do not get pregnant.
These patients as labeled as having "repeated IVF failure" or "recurrent implantation failure". In reality, these are just bucket diagnoses which means we really do not know why the embryos we transfer do not implant for these women.
On an intellectual level, we understand that there are broadly only two groups of reasons for failure of implantation. One could be that the embryos are not of good quality. The other is that there is a problem with endometrial receptivity. Unfortunately, because it is still very difficult for us to pinpoint what the problem is in an individual patient, there is a lot of hocus-pocus and mystery surrounding the treatment options for these patients.
Embryo freezing has become common practice, and we have been doing it successfully for more than thirty years. Previously, the technique used for embryo freezing utilized computerized freezers with “slow freeze” technology. These were relatively inefficient, and a frozen embryo transfer cycle had lower success rate when compared to a “fresh” transfer, probably because of less than optimal embryo survival after slow freezing. The advent of vitrification and culturing embryos for 5 or 6 days before freezing (in the blastocyst stage) have changed things dramatically.
In a previous blog, I discussed data that showed a significantly reduced pregnancy rate in obese in vitro fertilization (IVF) patients.
This was in regular IVF patients attempting to conceive with their own eggs. However, what about donor egg cycles?
An endometrioma is a blood-filled "chocolate" cyst that can occur when endometriosis tissue develops in the ovary. In many but not all cases, endometriomas are treated with surgery.
When considering endometrioma surgery, it is helpful to know what the various types of surgery are and how they differ.
For more than a decade, we have been screening embryos for chromosomal number abnormalities (aneuploidy) at InVia Fertility Specialists. The technical term used for this process is preimplantation genetic screening (PGS) or pre-implantation genetic diagnosis (PGD). By screening out “abnormal” embryos we are now routinely able to achieve excellent pregnancy rates with transfer of single embryos and thus significantly reducing the incidence of multiple pregnancies. PGD or PGS, thus, is the smart thing to do so much that we have coined the term SMART IVF to describe them.
The number of people smoking has decreased significantly over the past 30 years. However, 30% of reproductive age women and 35% of reproductive age men in the United States still smoke cigarettes.
The available scientific data indicate that up to 13% of infertility may be attributable to cigarette smoking. The adverse effects of smoking on health are now well known. Most people, however, are NOT aware of the reproductive risks of smoking.
Recent studies have suggested a relationship between the diet of both partners and fertility, including the impact of obesity. Dietary supplements for fertility are one of a number of things that people incorporate into their lifestyle to increase chances of pregnancy.
Here is a list of dietary supplements that may increase your fertility. In particular, the roles of antioxidants, omega – 3 fatty acids, and co-enzyme Q-10 will be discussed in detail.
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.
A cycle day-3 follicle stimulating hormone (FSH) level and anti-mullerian hormone (AMH) level are commonly used to evaluate ovarian reserve. FSH level generally predicts pregnancy rates with in vitro fertilization (IVF) and a level < 10 mIU/mL is considered “reassuring”.
On the other hand, AMH levels predict the number of follicles (eggs) that the patient will produce during IVF and a level > 0.8 ng/mL is considered “reassuring”. (It is important to note that these cut-off levels can vary based on the assay used and can vary from lab to lab.)
A combination of reassuring FSH and AMH levels is generally considered “good” and a combination of concerning FSH (> 10 mIU/mL) and concerning AMH level (< 0.8 ng/mL) is generally considered “bad”.
But, what if there is discordance between FSH and AMH levels?
The first live birth after an IVF frozen embryo transfer was in 1983. Since then, there have been hundreds and thousands of babies born the world over with frozen embryos. A third of the babies born today with IVF are with frozen embryos. At InVia Fertility Specialists, currently, in about 40% of IVF cycles the embryos are frozen and transferred in a subsequent cycle.
Patients with polycystic ovary syndrome (PCOS) often do not ovulate, and thus getting pregnant with PCOS can be a challenge. The first line of treatment usually is the fertility drug clomiphene citrate (CC).
The starting dose of CC is usually 50 mg orally daily for 5 days. If ovulation does not begin, the dose is increased to 100 mg and then finally to 150 mg.
To detect ovulation, one can do serial blood tests and ultrasounds or measure an appropriately timed progesterone level. What are the treatment options for patients that do not respond to the highest dose of CC?
A failed IVF cycle causes a lot of heartache – for both patients and doctors. Aside from pain and grief, many of people start playing the blame game. Was the doctor negligent or incompetent? Did the patient fail to follow medical advice?
The truth is that we can learn much from a failed cycle, and this is why it's important to create a framework, so that we can analyze the failed cycle and increase the chances of success for the next attempt.
As a nurse doing consultations before IVF treatment, I'm often asked, "Does it hurt?"
The IVF process can be intimidating, and many patients naturally have a fear of the unknown. To help ease this anxiety, in this blog I'll review key parts of the IVF cycle and discuss how patients typically experience them in terms of physical sensation.
1) What is adenomyosis?
Adenomyosis is defined as the presence of endometrial tissue, which normally lines the uterus, which has grown into the muscular wall of the uterus. It can be diffuse or localized (focal) and the lesions can be solid or cystic.
2) Is it the same as endometriosis?
Adenomyosis differs from endometriosis — a condition in which the uterine lining becomes implanted outside the uterus — although women with adenomyosis often also have endometriosis.
In endometriosis, the “functional” part of the uterine lining is implanted – these implants respond to the (monthly) cyclical changes in your hormone levels. In adenomyosis the “basal” layer of the uterine lining grows within the uterine musculature. The basal lining is NOT responsive to cyclical changes in your hormone levels. The cause of adenomyosis remains unknown, but the disease typically disappears after menopause.
White blood cells in semen, detected in semen analysis, often causeconcern to infertile couples, those who are having trouble getting pregnant, and even their doctors. On the one hand, this makes sense, because pus cells or white blood cells in semen are commonly thought of in association with infectious diseases. However, the mere presence of white blood cells in the semen is not sufficient to make a diagnosis of a genital tract infection.
A hysterosalpingogram (hystero = uterus; salpingo = fallopian tubes; gram = X-ray) or HSG is a simple procedure where X-rays are used to evaluate the uterus and the fallopian tubes.
A HSG is a routine test done as part of an infertility work-up. It is to be done in the first half of the cycle so that we can be sure that the patient is not pregnant. In experienced hands, a HSG is quick, efficient and can be painless.
In this post, I explain why we might use HSG, how we administer it, what we can learn from it, and what its limitations are when it comes to helping us find out why you're having trouble getting pregnant..
A low sperm count is a common cause of male infertility. If a man ejaculates even the tiniest number of sperm, we can help the couple achieve pregnancy with in vitro fertilization and intracytoplasmic sperm injection (ICSI). But, what if there is no sperm in the ejaculate (azoospermia)?
There are two types of azoospermia . The first is obstructive azoospermia; where there is an obstruction in the reproductive tract. Obstructive azoopermia can be due to a vasectomy or a condition where the tube from the testes to the urethra (vas deferens) is absent (congenital absence of vas deferens). Congenital absence of vas deferens can be associated with cystic fibrosis.
The second type is non-obstructive azoospermia. This is a condition where sperm is produced in the testis but is not released into the ejaculate. In both these conditions, sperm can still be obtained surgically from the testes. The sperm obtained is usually immature and will fertilize an egg only with ICSI.
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.
Since many patients who have endometriosis are also infertile, they are not too sure about what they should do. Should the endometriosis be treated first or should the infertility be attended to first? In most instances, this advice can be very conflicting.
Intrauterine adhesions (scar tissue), also called Asherman syndrome, can cause infertility, menstrual irregularities (light or absent menses) and recurrent pregnancy losses. In a previous blog, I have discussed the causes of Intrauterine adhesions. In this blog, we will discuss the treatment of intrauterine adhesions.
As with smoking cigarettes, there's a connection between marijuana and fertility, and it's not a good one. Use of marijuana has a negative impact on trying to conceive, for both male and female users, for daily and occasional users alike.
While avoiding marijuana use is crucial if you're trying to get pregnant, you do not need to be using marijuana at the time you're trying to conceive in order for marijuana use to impact fertility. Using marijuana now can affect your ability to conceive in the future.
Endometriosis happens when the lining of the uterus (womb) grows outside of the uterus. It affects about 5 million American women. Endometriosis is especially common among women in their 30s and 40s; it can create difficulty getting pregnant and can cause infertility.
Pain is one of the most common symptoms of endometriosis. Endometriosis pain happens most often during your period, but it can also happen at other times.
Embryos have been successfully frozen (cryopreserved) since the early 1980’s. Worldwide literature has confirmed that there is no increase in birth defects in children born from frozen embryos. The pregnancy rates with frozen embryos have been increasing steadily. For the past few years, we have been freezing embryos at the blastocyst stage (5 or 6 days after egg retrieval) using a technique called vitrification.