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?
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.
Anti-mullerian hormone (AMH) levels are now routinely used clinically to assess ovarian reserve. AMH levels are believed to reflect the pool of oocytes (eggs) that remain in the ovary (ies). Low AMH level are associated with a reduced number of eggs that are available and will often predict low ovarian response during IVF. AMH levels are therefore believed to reflect the quantity of eggs that remain. The question is, do AMH levels also reflect egg quality and therefore pregnancy rates with IVF?
We have always done everything we can to ensure you receive the best possible fertility care when you trust InVia Fertility Specialists to help you on your pathway to pregnancy. Now, we’re proud to announce that our high standard of care has received national recognition: Blue Cross Blue Shield Illinois has named us one of Illinois’ first Blue Distinction® Centers+ for Fertility Care.
My husband and I met at the young age of 19. We met one night in Philadelphia through a mutual friend and essentially fell in love. I know it’s extremely cheesy, but it’s the truth. We were both in college—I attended the University of Iowa while he was at Rowan University in southern New Jersey. Our relationship was long distance, established over the phone—you’d be amazed how much you can learn about someone after six months of talking on the phone.
I often get questions from patients with low sperm morphology (shape) during semen analysis. A typical question is “My sperm morphology is only 3% normal forms; what can I do?” or “What is the best treatment in this situation?” "Do I need in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI)?"
It seems intuitive that if 97% of the sperm have abnormal shape, then the chances are the couple does need IVF + ICSI. But, is that really true? What, if any, is the relationship between low sperm morphology and IUI pregnancy rates?
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.
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:
My husband Kevin and I met in 2000 and got married in 2008. We knew we always wanted children but were in no rush. When the time came to start trying, our mentality was “whatever happens, happens”. After almost a year of trying, at my annual OB-GYN appointment, the discussion came up about starting a family. How long had we been trying, my OB-GYN wanted to know?
After answering a bunch of questions and based on my answers, I was asked to give blood for a few tests. At that appointment, I remember being so carefree and felt that the doctors were more concerned about me not getting pregnant than we were - we honestly never gave it much thought.
After waiting a few days, my results came back. Tears flooded my eyes when I heard the nurse tell me that my levels were so low, we’d go straight to IVF. So many emotions came to mind, but what upset me most was that my body wasn’t capable of having children the “natural” way. Plus, Kevin and I did not know one thing about infertility.
I went onto so many websites to try to educate myself. I talked to a couple of friends who have gone through the infertility treatment process. No matter what journey was ahead of us, Kevin and I knew we were ready.
10 days!? 12 days!? I have to wait how long to find out if I’m pregnant or not!? While patients engaged in IVF are scheduled as early as possible for their serum (blood) hCG level (pregnancy test), many women cannot resist the urge to "cheat" and take a home pregnancy test with IVF.
Although in most cases this can be an accurate measurement of whether you are pregnant or not, it is not always a true reading.
What is polycystic ovary syndrome?
Polycystic ovary syndrome (PCOS) is a common cause of infertility. Briefly, its diagnosis is based on presence of two of the following three criteria:
“My doctor said that my embryos looked picture-perfect, yet they failed to implant – why did this happen?”
This is the question in the minds of women who undergo IVF failure, and this becomes a particularly nagging doubt when they face multiple IVF failures. Many women naturally think that their uterus is defective or their body is not good enough to accept the embryo-- that their uterus is rejecting the transferred embryo, or their own body is killing it. After all, fertilization happened in the lab, the embryo grew well in vitro, and they even saw their embryo (remember, you must always see your embryos and ask for photos before embryo transfer!).
The embryologist assured them that they looked perfect, and they’ve read lots of IVF success stories of women who got pregnant with such good embryos. As a result, they naturally come to the conclusion that good embryos are meant to implant – and if they didn’t, this clearly means there’s a problem with their uterus or their body.
Letrozole is an oral non-steroidal aromatase inhibitor approved for the treatment of hormonally responsive breast cancer after surgery. It has been used (off-label) for ovulation induction as part of the IVF process since 2001.
So you're in the IVF process, and now you’ve waited the long 10-16 days for your first pregnancy test. Your hCG level comes back positive. Congratulations!
Then the panic sets in. Is my number too low? Is it too high? Does this mean I'm having twins? Triplets? At InVia Fertility, we often have patients ask us to interpret their hCG level from that first positive test—and the truth is, most of the time that's not possible.
Most IVF cycles fail after embryo transfer when the embryo fails to implant. The three factors that can cause implantation failure are:
- Problems with the embryo (e.g. embryo abnormalities, sub-optimal culture conditions in the embryology laboratory);
- Embryo transfer technique issues; and
- The lining of the uterus (endometrium) is not receptive.
Several studies have looked at various medical approaches to improve implantation. One such approach that has shown to improve implantation is a physical scratch on the endometrium in the cycle preceding IVF -- “endometrial scratch ”, or ES. We'll look at what ES is, how it's performed, and evidence about its effectiveness in this post.
The Ovarian Assessment Report from ReproSource Fertility Diagnostics is used by some fertility clinics—including InVia Fertility Specialists—for ovarian reserve testing in patients. According to ReproSource, the Ovarian Assessment Report is the most advanced ovarian reserve testing system available using a single blood sample to assess ovarian egg supply in women considering egg retrieval.
Endometriosis is a common cause of infertility. Findings associated with endometriosis include: painful periods that are getting progressively worse, pain with intercourse, infertility and ovarian cysts. Some patients may have bowel or bladder symptoms. A significant number will have no symptoms.
When endometriosis involves the ovary, it often manifests as cysts that are called endometrioma. These will have a typical “ground glass” appearance on ultrasound. Endometrioma may reduce fertility by causing focal inflammation in the outer shell of the ovary (ovarian cortex), which manifests as massive fibrosis and loss in the part of the ovary that maintains the eggs (cortex-specific stroma). This loss of eggs may may eventually result in loss of fertility.
Want to get pregnant in 2019? Maybe you have been trying on your own for a year (six months if you are more than 35 years old) and nothing has happened. You may have been keeping track of ovulation with an ovulation predictor kit, or using an app to time intercourse. You decide it is time for you seek help.
Here are some tips to help you choose a fertility doctor and suggestions to get the most from your initial consultation.
Embryo fragmentation is a fairly common occurance. It happens when there is an uneven division of the cells of the embryo.
It's as if you were breaking apart a piece of crusty bread. When you try to break the bread apart, crumbs or fragments are formed. These fragments are of no use to the embryo and are considered “junk” pieces of cytoplasm. The higher the degree of fragmentation, the lower the likelihood of pregnancy.
AMH or anti mullerian hormone level testing and ovarian reserve testing are frequent topics of questions from people who are having trouble getting pregnant. Since my last blog on this subject, a lot of new information has been released. Below are are five additional facts about anti mullerian hormone level (AMH) and ovarian reserve testing.
The male partner can sometimes be overlooked when couples try to conceive. Approximately 15% of couples pursuing a pregnancy experience infertility. Within these couples, a “male factor” is the sole cause in 30%, and both male and female factor issues are present in another 20% of couples. Collectively, 50% of couples have a male factor involved as a cause of their infertility.
Examining and evaluating the man is often invaluable in helping to optimize not only his reproductive potential, but also the reproductive potential of the couple. Here's what we look for when evaluating a man in a fertility clinic.
At InVia Fertility Specialists (InVia) we have been providing fertility services to our patients for the past 16 years. Our in vitro fertilization (IVF) program has been very successful and has been consistently reporting excellent success rates.
One of our goals has been to maintain high pregnancy rates and at the same time minimize the incidence of twin pregnancy. This is because of the increased risk of complications with twins. According to the Society for Assisted Reproductive Technologies (SART); compared to singletons, the risk of infant death is more than 4-fold higher with twins and 13-fold higher with triplets.
Anti-mullerian hormone (AMH) is now a well-established marker of ovarian reserve. AMH is released by the (granulosa) cells surrounding small (antral and pre-antral) follicles in the ovary. It prevents these follicles from becoming responsive to follicle stimulating hormone (FSH) and thus prevent them from growing into dominant follicles.
The highest values of AMH in women are attained after puberty and subsequently decrease with age, likely reflecting the age-related decline in ovarian reserve.
Vitamin D (25OH-D), is a regulator of calcium and phosphate metabolism, and also plays a crucial role in reproductive physiology. Vitamin D has been shown to interact with the AMH gene and increase its functionality (up-regulation).
So, the question is, does Vitamin D influence AMH levels?
1) It is generally accepted that as a woman ages, her ability to reproduce will diminish and she will begin having trouble getting pregnant. There, however, is a wide range as to the age at which a woman’s ovarian reserve (reproductive potential) will diminish. Some women progress through menopause in their early thirties, while others conceive readily at age 45. A basal (cycle day 2 – 4) follicle stimulating hormone (FSH) level is a useful screening test of ovarian reserve.
If you are having trouble getting pregnant and are a poor ovarian responder, you may have heard that ovarian response can be increased with testosterone during IVF.
The possibility of using testosterone supplements such as Androgel or DHEA for infertility raises many questions, including: