InVia Fertility Specialists Blog

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.

Good eggs and a healthy embryo aren't enough to assure pregnancy during IVF. A receptive uterine lining (endometrium) is also critical for successful implantation after embryo transfer. A commonly used parameter for assessing the endometrium is to measure its thickness (endometrial thickness, EMT).

During the stimulation phase of IVF, EMT usually increases in response to estrogen released by the ovaries. EMT is now routinely measured using transvaginal ultrasound during in vitro fertilization (IVF). 

Marijuana is a drug derived from the hemp plant Cannabis sativa or Cannabis indica.  Its main psychoactive component is tetrahydrocannabinol (THC), which is linked to altered sensual perception, mood changes and impaired body movements.  Other components of cannabis (cannabinoids) have unique pharmacologic effects without the psychoactive effects of THC. 

There are only a few conditions where cannabinoids have been proved to be useful and approved by the US Food and Drug Administration (FDA). These include:

• Chemotherapy-induced nausea and vomiting
• Appetite stimulation in conditions that cause weight loss, such as AIDS
• Specific types of seizure disorders in children

Other indications that have been less well studied include chronic pain, muscle spasticity from multiple sclerosis, Parkinson's disease, post-traumatic stress disorder (PTSD) and Tourette syndrome.

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.

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”?

Now it is fairly common for women to achieve their educational goals and establish a career path before they consider having children. It often takes years to obtain these goals and this occurs during the most fertile period: ages 15 - 30. Often women will consider having a child between the ages of 35 – 45 and by then, her fertility has already starting to decline. In previous blogs, I have discussed the fact that after age 40, fertility declines precipitously, and have described treatment options for this age group. But what about women seeking pregnancy after 45? What are the treatment options available? How risky are these pregnancies?

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.

• InVia Fertility Specialists aims to expand fertility options and help improve access to care with the addition of the INVOCELL Intravaginal Culture (IVC) System
• The INVOCELL IVC System is a cost-conscious option that uses a woman’s own body as an incubator during fertilization and early embryo development

The time between your insemination or embryo transfer and the pregnancy test result can be stressful. Here are some tips that may help you get through this potentially challenging period.

ICSI is an acronym for intra-cytoplasmic sperm injection. In basic terms it means we are injecting a sperm into an egg. ICSI IVF differs from the conventional IVF process in that a single sperm is injected into an egg, instead of fertilization taking place in a dish where millions of sperm are placed near an egg.

Intrauterine insemination (IUI) is a reasonable first step in patients with unexplained infertility, minimal or mild endometriosis and mild male factor.

The pregnancy rate with IUI vs. intercourse in natural cycles is similar. Therefore, we will generally perform IUI along with fertility drugs (clomiphene citrate, letrozole or gonadotropins).

During intrauterine insemination, the semen sample is “washed” in a centrifuge so as to separate the sperm from the seminal plasma (which contains prostaglandins that can cause severe cramping). The motile sperm are then loaded in a tube (catheter) and deposited in the uterine cavity when the woman is ovulating.

Prior to IUI the total motile sperm count (TMSC) in the sample is usually estimated. Generally speaking, a post-wash TMSC greater than 10 million is considered optimal. The pregnancy rates with a TMSC are very low and these patients are generally considered unsuitable for IUI. But, is this really true?

One of the most difficult things IVF patients have to deal with is the fact that there are no external symptoms or signs of what's happening inside their bodies.

Are the follicles growing well? Is the uterine lining maturing properly? Are you responding well to the medications? Are the eggs of good quality? Are the embryos implanting?

An important marker of the reproductive cycle is bleeding - and this can become a major source of stress during IVF treatment. This post explains what kinds of bleeding can happen during IVF, and what (if anything) you should do about them.

Premature ovarian failure (POF) or premature menopause is diagnosed when a woman stops getting her periods due to cessation of ovarian function before the age of 40 years. The diagnosis is made based on elevated follicle stimulating hormone (FSH) levels (usually above 40 mIU/mL) detected on at least two occasions a few weeks apart. Approximately 1% of women will develop POF. In this blog, I will discuss some of the causes of POF.

 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.

You may be surprised to find out that in many cases, the first step in the IVF process is to take birth control pills. Though this seems to be counter-productive to your goal of getting pregnant, there are several reasons why they are used.

Polycystic ovary syndrome (PCOS) is a common cause of infertility. Women with PCOS often have irregular or absent periods and therefore ovulate infrequently or do not ovulate.

Polycystic ovary syndrome (PCOS)is the most common cause of infertility in women. PCOS is often associated with obesity. Obesity, however, is NOT a diagnostic criteria for PCOS, as it can also occur in normal weight women. 

At InVia Fertility Specialists, we often encourage our patients who are overweight for their height to lose weight prior to proceeding with fertility treatment. The resultant delay in treatment can be frustrating for patients. However, does pre-treatment weight loss improve outcomes?

This very question was addressed by researchers working with Penn State University's College of Medicine in a large, multi-center trial ("Benefit of Delayed Fertility Therapy With Preconception Weight Loss Over Immediate Therapy in Obese Women With PCOS." Legro, et al; J Clin Endocrinol Metab 2016 Jul;101(7):2658-66).

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.