FAQ – Polycystic Ovarian Syndrome (PCOS) – Ectopic Pregnancy

Laurence A. Jacobs, MD, Reproductive Endocrinologist, Fertility Clinics Chicago area

"Please know how much we appreciate your time and your help. We can’t thank you enough. Although we are hoping for a future miracle conception without your help, we know it is more realistic we will be seeing you soon! Our baby would love a brother or sister!"

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Frequently Asked Questions

Questions:

Click the question below to answer many common questions ...

Can anorexia cause long term infertility?
If I have polyps, even very small ones, should they be removed before seeing a reproductive endocrinologist for insemination?
What is polycystic ovarian syndrome (PCOS)?
What should I know about ectopic pregnancy?
Does male obesity play a role, in infertility?
Is laparoscopy needed to diagnose endometriosis?
Are there any survival strategies for coping with infertility ìduring the holidaysî?
Why consider genetic testing?
What should I expect during IVF treatment?
The State of Illinois mandates better insurance coverage for infertility treatment--what is that about?
Can you explain the sperm function testing process and what it will reveal?
What are the causes and solutions to miscarriages?
What are some sources of online support and information when dealing with infertility issues?
What are success rates? How do clinics define these rates and is this an important factor in selecting a reproductive endocrinologist?
When should I call a reproductive endocrinologist?
How is thyroid disease linked to infertility?
Is vigorous exercise during fertility therapy beneficial or harmful? There seem to be conflicting opinions
How do clinics define success rates and is this an important factor when selecting a physician and/or practice?
How do you determine the need to seek a fertility specialist?
How successful is a reversal of a tubal ligation?
Iím 39 years old and had a tubal ligation four years ago. Iíve decided to have another baby. Would I be better off having surgery to reverse the tubal ligation, or should I consider IVF?
What is the best way to find out when ovulation occurs?
Are there any risks associated with PGD (Preimplantation Diagnosis)? Do most patients have this screening done?
If you have blocked fallopian tubes, what are the surgical options and can the damage be reversed? How can you avoid having the tubes removed?
Does FCI do intrauterine insemination (IUI)? What is the approximate cost and does insurance cover this procedure?
Chlamydia is a vaginal infection? How can you find out if it has caused damage that would hurt your chances of getting pregnant?
If you have difficulty getting pregnant, and you have inconsistent menstrual cycles (32 days, 43 days, etc), how can you tell if you are ovulating? Should the partner/spouse have a sperm analysis?
What is premature ovarian failure (POF)?
What is vitrification (egg freezing)?
Will acupuncture improve fertility?
Is progesterone safe? I am supposed to start using Progesterone in oil injections during my upcoming IVF cycle. I believe this is a ënaturalí form of progesterone, but wanted to be sure. I have read that there may be a slight increase in birth defects associated with the ësyntheticí forms of progesterone (Progestins). I became a bit concerned upon reading the insert that accompanied the drug since it warns of potential risks associated with taking progesterone during the first trimester of pregnancy, including birth defects (genital deformities). I am assuming the FDA requires that the warnings be put in regardless of the type of progesterone, natural or synthetic, but would like some reassurance. Can you please help me to understand why we need to continue the use of the progesterone after implantation of a pregnancy? Are there other options such as Crinone (progesterone vaginal gel) which is approved by the FDA for use in assisted reproductive technology.

ANSWERS:

1. Can anorexia cause long term infertility?

If your periods are irregular and sporadic, you are most likely not ovulating or have anovulation. A series of blood tests can easily confirm anovulation and diagnose the causes. Your BMI body metabolic index can be calculated from you height and weight information. Women with low BMI, (less then 20) have suppression of their hypothalamic and pituitary gonadotropins hormones, which regulate normal, ovulation, and ovarian hormone production (estrogen and progesterone).

Your BMI (body metabolic index) can be calculated from your height and weight information. Women with low BMI (less than 20) have suppression of their hypothalamic and pituitary gonadotropins hormones, which regulate normal ovulation and ovarian hormone production (estrogen and progesterone).

Anorexia nervosa can cause long-term or permanent disruption of hypothalamic hormones. This type of hypothalamic anovulation can often be reversed.

For example: for underweight women with hypothalamic anovulation, weight gain may allow for resumption of normal menses and even ovulation on occasion. If weight gain does not improve hormone production, the use of injectible medications (gonadotropins) can successfully induce normal ovulation and lead to successful pregnancies.

2. If I have polyps, even very small ones, should they be removed before seeing a reproductive endocrinologist for insemination?

Any anatomical defect within the uterine cavity (polyps, sub mucous fibroids, adhesions or septum) may decrease the chance of pregnancy or increase the risk of miscarriage.

The uterine cavity can be evaluated by hysterosalpingogram (HSG - an x-ray using dye) or saline sonogram (saline flushed inside the cavity during an office ultrasound.) An outpatient surgical procedure, hysterectomy, allows for confirmation of the defect as well as treatment.

Uterine polyps are benign (99 percent) outgrowths of the endometrial lining. The polyp acting as a ìforeign bodyî in the cavity may cause chronic irritation and interfere with embryo implantation.

A recent study published in the respected Journal of Human Reproduction (6/2005) confirmed that regardless of size or location polyps could have a negative impact on reproductive outcomes. Hysteroscopic polypectomy (removal) improves pregnancy outcomes in infertile women and should be considered prior to undergoing IUI or In-Vitro Fertilization (IVF).

3. What is polycystic ovarian syndrome (PCOS)?

Since PCOS can have may variable and subtle symptoms, some doctors may overlook the diagnosis in young women not trying for pregnancy, especially if they are simply interested in regulating periods with medications, such as Provera or birth control pills. In addition, there is no single test to diagnose PCOS.

Symptoms may include:

Oligo-amenorrhea (irregular or absent periods).
Oligo-anovulation (infrequent or no ovulation)
Infertility
Hirsutis - excessive hair growth of face, chest, or abdomen; acne
Weight gain

Many experts agree that in order to diagnose PCOS, you must first rule out other endocrine conditions, such as thyroid and adrenal disease and the patient mush have 2 out of 3 of the following criteria:

History of irregular or absent menstrual cycles and or no ovulation since puberty
Hirsutism and/or high blood levels of male hormones - androgens
Ultrasound evidence of polycystic ovaries

Women with PCOS have irregular menstrual cycles and infertility because they usually donít ovulate. Researchers have determined that most women with PCOS have an endocrine imbalance known as insulin resistance. In which the body doesnít handle insulin normally. Insulin is the hormone produced in the pancreas that lowers blood glucose levels.

After eating a meal, blood glucose levels rise. The pancreas responds by releasing more insulin into the bloodstream. The insulin helps the liver, muscle, and fat store some of the energy as glucose and fat, thus keeping blood glucose levels in a normal range.

Women with insulin resistance may have normal blood glucose levels, but because the cells of their bodies are resistant to insulin, the body compensates by producing even higher levels of insulin to keep their blood glucose levels normal.

The resulting higher insulin levels lead to more fat storage (obesity) and also disrupt proper ovarian hormone production (increased male hormone), thus preventing ovulation. Insulin resistance ultimately can produce all the symptoms of PCOS anovulation, infertility obesity, and Hirsutism.

When women with PCOS are able to correct the insulin resistance with proper diet, exercise and/or insulin sensitizing drugs, such as metformin (Glucophage), normal ovarian function (ovulation and normal female hormone production often returns.

Use of metformin, regular exercise and or weight loss of 5 to 10 percent of body weight can each independently lead to spontaneous pregnancies as well as dramatically improve pregnancy rates with all fertility treatments.

To learn more about fertility enhancement for women with PCOS utilizing life style changes such as weigh loss and exercise, visit www.psostrategies.org.

4. What should I know about ectopic pregnancy?

Approximately 1 - 2% of all pregnancies are ectopic (outside the uterus, most commonly in the fallopian tube). The risk of death related to ectopic pregnancy has decreased by almost 90% over the past 20 years. However, ectopic pregnancy is still the leading cause of maternal death during the first trimester of pregnancy due to difficult or delayed diagnosis, tubal rupture and hemorrhage.

Risk factors for ectopic pregnancy include:

sexually transmitted infections (gonorrhea and Chlamydia primarily)
pelvic inflammatory disease
in utero diethylstilbestrol (DES) exposure
infertility and certain infertility treatments
previous tubal sterilization
previous tubal surgery as well as previous ectopic pregnancies. For example, previous tubal surgery increases the risk for ectopic pregnancy at least five-fold. Your previous pelvic infection with its associated tubal pathology increases your risk for ectopic pregnancies at least three-fold.

Ectopic pregnancy is associated with various symptoms: early known pregnancy or delayed menses, lower abdominal or pelvic pain, irregular vaginal bleeding or spotting. Ruptured ectopic pregnancies are less commonly seen today, primarily because modern diagnostic tests are more sensitive and allow for an earlier diagnosis. A greater knowledge of early symptoms and awareness of risk factors help to raise clinical suspicion for ectopic pregnancy and allows for earlier diagnosis. For most women, the combination of one or more serum hCG blood tests in conjunction with vaginal ultrasound(s) can often establish the diagnosis of ectopic pregnancy. The early diagnosis of ectopic pregnancy allows for early intervention and treatment options that may help minimize tubal damage.

There are a few therapy options available. Methotrexate medical therapy is now well established as an effective first line alternative to surgical treatment for ectopic pregnancy. An injection of Methotrexate will often stop the growth of the pregnancy tissue in the tube. Another option includes a conservative surgical procedure (laparoscopy for linear salpingostomy), which can be performed to remove the pregnancy and save the fallopian tube. The likelihood of the affected tube remaining open after successful medical treatment for an ectopic pregnancy is comparable to conservative laparoscopic surgery and ranges between 60-85%.

Conservative laparoscopic linear salpingostomy is successful in salvaging the fallopian tube in approximately 80% of women, but in the remainder, persistent bleeding or excessive damage to the fallopian tube may require removal of the tube (salpingectomy). Other possible reasons for removal of the tube may be related to the location of the pregnancy or delay/difficulty in diagnosis so that the pregnancy may be more advanced causing more tubal damage or tubal rupture with hemorrhage.

In general, approximately 60-85% of woman treated with either Methotrexate medical therapy or conservative laparoscopic surgery later achieve an intrauterine pregnancy while 10-20% will experience a recurrent ectopic pregnancy. Overall, subsequent intrauterine pregnancy rates after an ectopic pregnancy are significantly higher after conservative surgical treatment or Methotrexate therapy than after salpingectomy, emphasizing the benefit of earlier diagnosis and conservative management.

5. Does male obesity play a role in infertility?

Several studies have demonstrated a dramatic increase in sperm DNA fragmentation in obese men, leading to a significant reduction in sperm quality. In addition, there may also be an increase in the miscarriage rate for men with high-level fragmented DNA damage. Increased sperm DNA fragmentation due to oxidative stress may be due to several factors: men over age 50; possibly cigarette smoke, excessive exposure to heat; obesity and numerous environmental toxins. Some of this sperm DNA fragmentation may be reversed. We often recommend various antioxidants (such as Proxeed or Conception XR) to improve sperm counts, motility and possibly morphology before doing inseminations or in vitro fertilization. For more information regarding oxidative stress and sperm DNA fragmentation, look at the web site www.conceptionXR.com

6. Is laparoscopy needed to diagnose endometriosis?

Endometriosis is a condition where the endometrial tissue (uterine lining) is found in locations outside the uterus. This most commonly involves the lowest portion of the pelvis (cul-de-sac), surface of the fallopian tubes, surfaces of the ovaries, bowel or bladder. With more advanced disease, endometriosis can grow deeply within the ovaries, forming cysts called endometriomas (chocolate cysts). Endometriosis is most often associated with dysmenorrhea, chronic pelvic pain, and/or painful intercourse. It also may be completely asymptomatic.

The connection between endometriosis and infertility is unclear and may depend on the stage of the disease. The association with infertility seems obvious when severe adhesions distort the fallopian tubesí ability to pick up eggs or when large ovarian endometriomas interfere with ovulation and/or egg pickup by the fallopian tubes. However, when the pelvic anatomy remains intact with milder forms of endometriosis, the association with infertility is not so clear. Although a laparoscopy surgery is the only way to look inside the pelvis and diagnose endometriosis with certainty, I agree that it is not necessary in your situation. Your ovaries are normal on ultrasound and ovarian endometriomas (stage 3 or stage 4 advanced disease) were not seen on an ultrasound. Therefore, you may have mild endometriosis or you may have no endometriosis at all. Infertile women who do have documented endometriosis can be managed similarly to other infertile women. In your case, you may need various fertility drugs to help stimulate proper ovulation, and your husband needs to be evaluated as well. Ovulation induction with well-timed intercourse seems to be the appropriate first step. If that is not successful, then you should ask to be referred to a reproductive endocrinologist for intrauterine inseminations in conjunction with ovulation induction. As a last resort, even women who have advanced stage 3 or stage 4 endometriosis with severe pelvic adhesions and/or large ovarian endometriomas, do extremely well in getting pregnant with in vitro fertilization.

7. Are there any survival strategies for coping with infertility "during the holidays"?

The holidays can be stressful for anyone ... many people dread the holidays, but they can be particularly difficult for infertility couples. The holiday 'hype' is often focused on kids and family ... leaving you vulnerable to frustrating family dynamics. At holiday gatherings, well-meaning friends or family members often inquire about a coupleís plans for having children, not knowing about their fertility struggles. In other situations, if they are aware of a coupleís fertility problems, they are often at a loss as to how to behave or what to say. Honest discussion about your emotions and fertility problems may lessen some of the awkwardness.

Here are several coping strategies that may help:

One way to alleviate the stress of painful holiday family gatherings is to stay home ... don't go. Avoiding painful family situations may lead to other problems, but in fact may be the best solution under certain circumstances (i.e. a recent failed IVF attempt). Decline invitations if you think it will be too much of an emotional strain to be around someoneís new baby or obvious pregnancy. Protect yourself.
Or, take control over some of the celebration and limit the time you do spend ... decide when you want to go there and when you want to leave.
Communicate with your spouse about these decisions. Your spouse may have a different attitude and you need to try to be on the same page. Just talk about your feelings. Support each other. Talk and compromise ... be a team and make it work.
Plan some quality time with family and friends with whom you know you will feel comfortable. Or, better yet, plan a lovely vacation by yourselves ... away from everyone. Remember, the two of you are a family.
Prepare yourself ahead of time for the inevitable awkward questions, such as "When are you going to start a family?"; Have a comeback answer ready. For example, "Thanks for asking, but itís a painful subject and I donít feel like talking about it" ... will usually end the discussion.
Get information about dealing with the stress of holidays and infertility from well-respected support groups. National resources available: American Fertility Association (www.theafa.org) and Resolve (www.resolve.org).
Do something nice for other people. It will take your mind off your problems if you focus on helping others. Remember, there are always others less fortunate than you. Volunteer at a homeless shelter or visit the elderly in a nursing home or a veteran at a local VA hospital. For a truly heartwarming experience, visit Misericordia, Heart of Mercy, an organization/residence that supports children and adults with developmental disabilities in order to maximize their quality of life. (6300 N. Ridge, Chicago IL 60660, 773-973 6300 / www.Misericordia.org). Visit their retail gift shops, bakery or restaurant, or donate your time as a volunteer. Helping others will change you forever ... for the better.

8. Why consider genetic testing?

Your age and his severe male factor problem are major obstacles to a successful pregnancy. Unfortunately, for women ages 40-44, 50 -100% of their eggs may be genetically abnormal, causing infertility but also significantly increasing the risks for miscarriages and genetic birth defects. If you are going to use your eggs (instead of donor egg), IVF is your best option so your egg quality as well as embryo quality can be evaluated and then a few of the healthiest looking embryos can be transferred to your uterus. Furthermore, assessing many of the chromosomes of each normally developing embryo (Preimplantation Genetic Diagnosis, or PGD), allows the RE to be even more selective and transfer only genetically normal embryos. PGD can reduce the risk of miscarriage as well as the risk of many genetic birth defects. In addition, PGD may increase pregnancy success rates, but only when you end up with more embryos than you plan to transfer back to the uterus.

PGD was first developed in the early 1990s. The technique involves the microscopic removal of generally a single cell from a day 3 developing embryo. Most normal embryos on day 3 have 5-8 cells, so removal of one cell does not disrupt the embryo. The chromosomes chosen for testing (usually Chromosomes # 13 14 15 16 17 18 21 22 X and Y) account for over 90% of the genetic miscarriages and birth defects. For example, Down's syndrome is caused by an extra # 21 chromosome (Trisomy 21). Aneuploidy (any abnormal number of chromosomes ... missing or extra) increases dramatically as women age. If PGD is not performed, any transferred embryos demonstrating aneuploidy, will either not implant in the uterus, or result in a miscarriage or birth defect----no good outcome. PGD should not be looked at as a substitute for amniocentesis, but it markedly reduces the chances for genetic birth defects.

A newer technology, called MicroArray, will soon allow for the assessment of all 23 chromosome pairs instead of the 9 or 10 chromosomes currently tested.

The most common situations for recommending PGD include:

Women age 39 or older (although some women 35-38 ask for the procedure)
Severe male factor (especially when testicular biopsy is needed to obtain sperm)
Miscarriages (2 or more genetic or unexplained)
IVF failures (2 or more despite normal quality embryos)
Previous birth of a child with a single gene disorder (examples such as Cystic Fibrosis, Tay Sachs, Muscular Dystrophy, Hemophilia to name a few)

At Fertility Centers of Illinois (FCI), we use 2 excellent genetics labs for our PGD testing. For more information, you can review the rest of this web site or go to the web site of one of our genetics labs, www.PGDcenter.com.

9. What should I expect during IVF treatment?

In general, the entire IVF process takes approximately two months once a decision is made to proceed. The first month ('preparation cycle') involves diagnostic tests and evaluations of the couple, consultations, and 'preparation' of the ovaries. The second month ('stimulation cycle') involves the actual hormone stimulation of the ovaries, monitoring with frequent blood tests and ultrasound (US) exams, retrieval of the eggs, followed 3 - 5 days later by the transfer of embryos into the uterus.

The couple starts with a thorough IVF consultation with me in order to discuss the entire IVF process (diagnostic evaluations, ovarian hormone stimulation, egg retrieval technique, anesthesia, embryo transfer, risks, benefits and costs). Optional techniques such as cryopreservation of extra embryos and preimplantation genetic diagnosis (PGD) are also outlined. Questions are then answered and reading materials are provided to help the couple understand the process.

The 'preparation cycle' then starts with the next menstrual period. On cycle day 2, 3 or 4 several endocrine and infectious disease labs are drawn. Some of these endocrine lab tests (Estrogen and Follicle Stimulating Hormone) indicate the woman's "ovarian reserve" of eggs and determine the medication dosage and IVF protocol to be used for stimulation of the ovaries the next month. The labs for the man can be drawn at any time. The woman is often then placed on oral contraceptive pills (OCPs) or progesterone for the next several weeks in order to 'rest' the ovaries (by suppressing her pituitary hormones), making her more responsive to the fertility injections the following month. The uterine cavity is assessed for any abnormalities such as polyps, fibroids or adhesions (saline sonogram, hysterosalpingogram or office hysteroscopy) if it has not been checked within the previous 12 - 18 months. Next, an IVF nurse coordinator consultation takes place in order to help the couple understand the IVF process, schedule the actual IVF 'stimulation cycle,' sign consent forms and schedule an injection teaching session. Depending on the IVF protocol selected, many women begin Lupron injections later in the month (approximately cycle day 21) in order to prevent spontaneous ovulation during the subsequent 'stimulation cycle.'

Upon finishing the OCPs, a period begins, signaling the start of the 'stimulation cycle'. The fertility drug injections are usually started on cycle day 2, 3 or 4 and are given for an average of 10 - 12 days. During stimulation there may be 6 - 8 office visits needed for labs and ultrasounds in order to monitor the size and number of egg follicles developing and Estrogen levels. The fertility medication dosages are adjusted accordingly. When the largest follicles reach a certain size, another hormone injection is given to mature the eggs (within the follicles) and the retrieval is scheduled 36 hours later. The egg retrieval is done transvaginally with ultrasound guidance under anesthesia (conscious sedation) and takes approximately 20 minutes. The eggs are fertilized with the sperm in the IVF embryology lab. The development of the fertilized eggs (embryos) is carefully monitored by the embryologists for several days. Depending on the number and quality of the embryos, some are transferred into the uterus 3 or 5 days later. Extra normal appearing embryos may be cryo-preserved. The woman is instructed to rest at home (couch potato) for 1 - 2 days. Two weeks after the embryo transfer a pregnancy test is done and a consultation is scheduled.

10. The State of Illinois mandates better insurance coverage for infertility treatment - what is that about?

In 1992, the "Family Building Act" was passed which did indeed mandate better insurance coverage for infertility couples in the state of Illinois. This was a very controversial vote that initially ended in a tie in the Illinois Senate. Even though there is a fertility bill in place in Illinois, there are numerous exclusions, so that over 50% of our fertility couples have little or no fertility coverage for treatment. For example, if a corporation has less than 25 employees or over 250 employees, they are excluded from the Illinois State Mandate. Corporations that are self-insured are also excluded. In addition, some insurance companies that are registered outside the state of Illinois are also excluded.

On a more positive note, the overwhelming majority of HMO's that practice in the state of Illinois are mandated by State law to provide fertility benefits, including up to four in vitro fertilization attempts for your first IVF baby and then two subsequent attempts thereafter. You should follow-up with your company Human Resources department in order to determine which PPO and/or HMO options you have to gain the best insurance coverage for your future fertility needs.

11. Can you explain the sperm function testing process and what it will reveal?

The sperm function test you are referring to is called a "strict morphology" or a Kruger test for sperm function.Ý The "strict morphology" of the sperm helps predict a man's fertility potential (fertilizing capacity) even in cases where the man's sperm count, motility and/or regular morphology on a standard semen analysis are all normal. The strict morphology takes a critical look at many sperm according to a very strict set of criteria. Only a small number of specialized andrology laboratories have trained technicians who can analyze the sperm according to these strict criteria. The sperm are stained and microscopically examined under oil for normal size and shape of the head, mid piece and tail. According to the strict criteria, even a minor defect in any category rates the sperm as abnormal. Therefore, relatively few sperm are rated as normal or perfect utilizing the strict morphology test, as compared to the "estimated crude morphology" which is done during a regular semen analysis.

The strict morphology score is a result that indicates and predicts the spermís potential for fertilization. This evaluation can be very useful in guiding your reproductive endocrinologist with various treatment options including, intrauterine insemination and/or in vitro fertilization (IVF). For example, if the strict morphology score is very low, this indicates severe impairment and probable inability to fertilize without resorting to IVF where the healthiest appearing sperm can be inserted directly into the egg in order to fertilize the egg. On the other hand, if the strict morphology score is normal, indicating a large percentage of perfect sperm, then the likelihood of success with intercourse and/or intrauterine insemination is quite high.

12. What are the causes and solutions to miscarriages?

It is true that at 37, approximately 33% of all pregnancies may end in miscarriage simply due to 'older, poorer quality eggs' that predispose to genetic chromosomal abnormalities (aneuploidy - extra or missing chromosomes). However, there are many other treatable causes for miscarriages.

Hormonal abnormalities, such as low serum progesterone levels, diabetes or thyroid disease can easily be diagnosed and treated, and will reduce miscarriage risks.

Uterine anatomical defects can be evaluated by an x-ray (HSG-Hysterosalpingogram) or by ultrasound (saline sonogram). Uterine defects, such as submucous (protruding into the cavity), fibroids, polyps, intrauterine adhesions or septum (congenital shape deformity) or double uterus (bicornuate) account for 10 - 15% of recurrent miscarriages. All of these above defects can be repaired surgically.

Genetic chromosomal unbalanced translocations (portion of one chromosome stuck to another) make up only 1 - 2% of pregnancy losses. This abnormality can be diagnosed by doing a blood test (genetic karyotyping) on you and your husband. Just like miscarriages due to age-related chromosome abnormalities mentioned above (aneuploidy), miscarriages from chromosome translocations can be prevented by doing In-Vitro Fertilization (IVF) and Preimplantation Genetic Diagnosis (PGD). PDG involves evaluating the genetics of the embryos on Day 3 of development, so that on Day 5 of development, only a few genetically normal embryos are returned to the uterine cavity. PGD can dramatically reduce the incidence of miscarriages in older women (aneuploidy), as well as those couples with translocation abnormalities.

Another source of problems can involve an increased tendency to form blood clots (thrombophilia) in the small blood vessels of the developing placenta. Thrombophilia is the opposite of hemophilia (increased bleeding due to a lack of clotting factors). Thrombophilia may be congenital (born with), such as Leiden factor V, anti thrombin III, homocysteine, and protein C & S abnormalities. Thrombophilia may be acquired due to malfunction of the immune system producing antibodies, such as lupus anticoagulant or anticardiolipin antibodies. Most of these thrombophilias can be successfully treated with heparin/lovenox and baby aspirin or with prednisone and baby aspirin.

Some extremely controversial causes of miscarriage relating to increased NK (natural killer) cells will be mentioned and discouraged. Some unproven therapies involve administering Leukocyte Immune Therapy ("LIT" ñ white blood cells from your partner or 3rd party strangers) to stimulate the woman to make more 'blocking antibodies' to protect the fetus. "LIT" has been recently been banned by the FDA.Ý Intravenous immunoglobulin (IVIG) therapy is also very controversial since most doctors don't see any benefit; there's a lack of good controlled studies; it's very expensive and it involves using blood products from strangers so there is a small risk of transmission of hepatitis or HIV from the transfusions.

For a thorough assessment to investigate the possible causes of your miscarriages, see a fertility specialist (fellowship trained reproductive endocrinologist) or a regular OB/GYN who has interest and experience in evaluating for recurrent pregnancy loss. It will put your mind at ease and may increase your chances for success.

13. What are some sources of online support and information when dealing with infertility issues?

There are several reputable fertility resource organizations and websites that you and your spouse can turn to for support.

The Fertility Centers of Illinois (FCI) website (FCIonline.com) has a wealth of information about fertility treatment, physicians, in vitro fertilization, financial information, weekly educational seminars and topics on mind, body and stress.

FCI, for example, offers such programs as "Fertility 101" which gives patients who are new to infertility insight into the process. Other programs such as "Coping As a Couple", "Dealing with Family and Friends", and "Surviving Loss," are popular among couples.Ý Some very innovative centers offer classes that deal with the stress levels that one faces through holistic approaches that can impact many aspects of fertility. Some of these offerings usually include Yoga for Fertility, Acupuncture for Fertility, and Fertility Massage. For more information about holistic approaches, a good site to visit is www.pullingdownthemoon.com.

There are also links to the three major national infertility support groups:

The American Fertility Association (AFA) / www.theafa.org.
Resolve/ www.resolve.org.
International Council on Infertility Information Dissemination (INCIID) / www.inciid.org.

According to Pam Madsen, Executive Director, "The AFA wants to help make sure no one suffers the often unbearable emotional, social and economic strains unnecessarily". The AFA has a free quarterly newsletter full of excellent infertility articles, a recently launched public education campaign (www.focusonfertility.org) with free interactive tools and links, online educational seminars, and downloadable fact sheets for everyone dealing with reproduction.Ý For the past few years I have been a member of the AFA Medical Advisory Board and I highly recommend this organization for the best, most credible and current information about reproductive health and family building options.

I also recommend the Resolve website which contains a large amount of information on infertility, insurance coverage, adoption options, and several bulletin boards along with lists of meetings and events.Ý In fact, the local chapter, Resolve of Illinois, (www.resolveofillinois.org) has their annual symposium April 30, 2005 in Chicago. Several of my FCI partners are participating in the workshop (773-743-1623).

The INCIID site also contains medical articles, bulletin boards, lists of fertility clinics, current information on fertility treatments and a monthly newsletter.ÝOne of my FCI partners, John Rapisarda, M.D., is a physician advisor.

All three national organizations do an excellent job helping educate fertility couples and also offering guidance to those considering adoption or childfree lifestyles.

For some, a good source of information and emotional support comes from various chat rooms and bulletin boards. The benefit of the Internet is the wealth of available information and the ability to chat with others facing the same fertility problems. In cyberspace you are never alone. However, beware that the opinions or experiences of others may or may not be accurate.

14. What are success rates? How do clinics define these rates and is this an important factor in selecting a reproductive endocrinologist?

There are many factors when selecting the right physician and practice. IVF success rates are an important factor to consider when making your decision. Although looking at the "stats" is helpful in assessing the general success of a program, it is also critical to look beyond the numbers.

It's helpful to know that IVF success depends on two factors. The first is the coupleís chance of conception. This will be influenced by many factors including age, diagnosis, years of infertility, ability to produce multiple eggs and the extent of prior testing and treatment. The second factor is that all IVF centers are different. They employ different patient selection criteria, different stimulation protocols and laboratory procedures. These two factors can influence IVF success rates.

There are many ways of reporting IVF success. For instance, utilizing clinical pregnancy rates per transfer or retrieval will cause success rates to look inflated due to miscarriages that can occur after the pregnancy is recognized. The most important means of reporting to consider is the live birth rate per cycle initiated.

Many other factors, including patient selection, cycle cancellation rates, embryo freezing and the number of embryos transferred, can affect success rates. The number of embryos has a vast influence on the pregnancy and multiple gestation rates. If you are concerned about multiple pregnancies, you need to examine the differences between programs.

In summary, you need to look beyond the reported success rates. Your individual prognosis may be better or worse depending on your diagnosis and treatment history. You should ask your physician for an approximate success rate based on all these factors. This can help you make better decisions regarding your family building options.

15. When should I call a reproductive endocrinologist?

Infertility is defined as the inability to conceive after 1 year of unprotected intercourse in women under 35 or after 6 months of trying for women 35 and older.

The basic infertility evaluation can be performed by an ob/gyn. The evaluation may include:

Semen analysis to assess male factor problems with his sperm
Hysterosalpingogram (hsg) x-ray to investigate your uterus and tubes
Ovulation predictor kit and serum progesterone level to assess ovulation
A hormone evaluation (measuring serum estrogen and follicle stimulating hormone (fsh) during days 2-4 of your menstrual cycle) can assess when the 'ovarian reserve' of eggs is diminishing.

In addition, during days 2-4 an ultrasound to evaluate the number of follicles (egg sacs) in each ovary.

Antral follicle count is another useful tool for evaluating 'ovarian reserve'. As women age, they have fewer eggs, poorer egg quality, lower pregnancy rates and increased chances for miscarriages. These important tests can often help you and/or your ob/gyn decide when it may be beneficial to be more aggressive with fertility therapy and seek the expertise of a reproductive endocrinologist.

There are several fertility conditions or circumstances, which may prompt you or your ob/gyn to seek an RE for more advanced fertility therapies:

Age 38 or older, or diminished ëovarian reserveí at any age.Ý The biological clock is ticking loudly, often requiring more aggressive therapies such as fertility medication injections (gonadotropins) with intrauterine inseminations (iui) or in vitro fertilization (ivf).
Documented tubal disease or a history of damage. Previous ectopic tubal pregnancies, pelvic inflammatory disease (pid), or chlamydia infections will often compromise tubal function or patency.
Pelvic disorders causing adhesions (scar tissue), such as endometriosis, or previous abdominal surgeries for conditions such as ruptured appendix or ruptured ovarian cysts.
Significant male factor problems (very low sperm count or motility or abnormal sperm function testing)
Failed clomiphene (clomid; serophene) ovulation induction therapy after 3-4 attempts with ob/gyn. If no success, seek other causes of infertility and a more aggressive approach.
Recurrent pregnancy losses (miscarriages).
Unexplained or idiopathic infertility (no causes identified).
Donor egg, donor sperm or gestational surrogacy

16. How is thyroid disease linked to infertility?

A decreased thyroid function (hypothyroidism) is often under-diagnosed. Hypothyroidism is more common than hyperthyroidism and affects women more than men. Symptoms may include excessive fatigue, cold intolerance, weight gain, dry skin, mental slowing, and constipation. Women may also notice menstrual irregularities, such as menorrhagia (heavy periods) and/or amenorrhea (missed periods), as well as breast discharge (galactorrhea).

Furthermore, lab tests will show increased thyroid stimulating hormone (TSH) and decreased serum levels of thyroid hormone (T4). The increased TSH production by the pituitary adversely affects the pituitaryís production of FSH (follicle-stimulating hormone), which normally regulates ovarian function. This disruption of FSH may interfere with ovulation as well as ovarian hormone production, thus leading to infertility and/or miscarriages.

Hypothyroidism can be easily treated with oral thyroid supplementation such as Synthroid.ÝWomen taking thyroid supplementation when pregnant often need to increase the dose as soon as pregnancy occurs, due to increased metabolic demands of pregnancy.

Unless treated, maternal thyroid disease can be associated with adverse pregnancy outcomes and may also have a negative impact on the childís development.

17. Is vigorous exercise during fertility therapy beneficial or harmful? There seem to be conflicting opinions.

In general, there are considerable benefits to vigorous exercise, which can improve your mental and physical health. However, I advise my fertility patients to decrease vigorous workouts at certain times. There are some studies, which suggest that women exercising vigorously during IFV therapy may have lower pregnancy rates. Therefore, it is logical to decrease the intensity and duration of your workout simply because we do not know for sure if vigorous exercise id OK during fertility therapy. Alice D. Domar, PhD is the director of t he Mind/Body Center for Womenís Health at Boston IVF. In one of her books, she suggests, "mindful walking". Being mindful, means to be in the moment, and to focus on all five of your senses - seeing, hearing, smelling, feeling and tasting. Walking mindfully is exercise and relaxation all in one. Mild exercise will decrease your level of stress and it's highly recommended during fertility therapies.

18. How do clinics define success rates and is this an important factor when selecting a physician and/or practice?

There are many factors when selecting the right physician and practice. IVG success rates are an important factor to consider when making your decision. Although looking at the "stats" is helpful in assessing the general success of a program, it is also critical to look beyond the numbers.

Its helpful to know that IVF success depends on two factors. The first is the coupleís chance of conception. This will be influenced by many factors, including age, diagnosis, years of infertility, ability to produce multiple eggs and the extent of prior testing and treatment.

The second factor is that all IVF centers are different. They employ different patient selection criteria, different stimulation protocols and laboratory procedures. These two factors can influence IVF success rates.

There are many ways of reporting IVF success. For instance, utilizing clinical pregnancy rates per transfer or retrieval will cause success rates to look inflated due to miscarriages that can occur after the pregnancy is recognized. The most important means of reporting to consider is the live birth rate per cycle initiated.

Many other factors, including patient selection, cycle cancellation rates, embryo freezing and the number of embryos transferred, can affect success rates. The number of embryos has a vast influence on the pregnancy and multiple gestation rates. If you are concerned about multiple pregnancies, you need to examine the difference between programs.

In summary, you need to look beyond the reported success rates. Your individual prognosis may be better or worse, depending on your diagnosis and treatment history. You should ask your physician for an approximate success rate based on all of these factors. This can help you make better decisions regarding your family building.

19. How do you determine the need to seek a fertility specialist?

There are certain conditions where conventional wisdom may not apply. Women, age 38 or older should see their doctor even before trying to become pregnant. The biological clock is ticking loudly, and a hormone evaluation (measuring serum estrogen and follicle stimulating hormone during days 2-4 of the menstrual cycle) can assess when the "ovarian reserve" of eggs is diminishing. Older women have fewer eggs and of poorer quality. A basic blood test can then help you and your doctor decide when it may be beneficial to be more aggressive with therapy.

You should also see a physician sooner if you've had pelvic inflammatory disease, previous ectopic pregnancy, or pelvic surgery for ruptured appendix or ovarian cysts, since there may be pelvic adhesions (scar tissue) or damage to your fallopian tubes.

Last, if a woman has very painful or heavy periods, she may have fibroids or endometriosis, and may need treatment in order to get pregnant.

A man should have a semen analysis early if he has a history of conditions such as testicular trauma, mumps or undescended testicles.

20. How successful is a reversal of a tubal ligation?

The success rate for reversal (tubal reanastomosis) depends on your age, your partner, how your tubes were tied and the skill of the reproductive surgeon.

Due to the negative effects of again on egg quality for women 40 or older, In Vitro Fertilization may be a better option. During IVF, the reproductive endocrinologist can stimulate the ovaries, harvest several eggs, fertilize them in the lab, and then select the resulting highest quality embryos to transfer into the uterus.

Similarly, if your partner has sperm problems, IVF is a better option, since sperm can be inserted into the eggs (Intracytoplasmic sperm injection, or ICSI) in order to overcome many make factor infertility problems.

The type of tubal ligation is important. If your tubes were cauterized in several places or large segments were removed the surgery may not be reversible. The reproductive endocrinologist can review the operative report.

During the mid and late 1980's, when I was at the Mayo Clinic, IVG pregnancy rates were lower than todayís success rates. Today, with higher IVG success rates, very few women undergo tubal surgery. There is still a place for tubal surgery in younger women under 35 with other favorable factors.

21. I'm 39 years old and had a tubal ligation four years ago. I've decided to have another baby. Would I be better off having surgery to reverse the tubal ligation, or should I consider IVF?

Before you make your decision, here are some facts you should know:

At age 39 almost 40 to 50 percent of your eggs may be abnormal, therefore increasing your chances of infertility and miscarriage. In-Vitro Fertilization is a better option so that your egg quality can be properly evaluated and healthy embryos can be placed into the uterus.

Tubal Surgery could be performed, but that is not the best option for women who are 38 years of age and older.

22. What is the best way to find out when ovulation occurs?

There are a few ways to find out when ovulation occurs. The simple, inexpensive method includes the use of an Ovulation Predictor kit, which can be purchased over the counter at most pharmacies. This kit will detect a surge of LH hormone in the urine. Ovulation should occur 24-36 hours later. Progesterone levels in the blood rise significantly after ovulation has occurred, and can be measured one week after ovulation with a blood test. Progesterone helps support the uterine lining.

here is also another, more expensive method, which involves using an ultrasound to check the ovaries. However this method is only necessary when timing is critical, as in the case of artificial insemination.

23. Are there any risks associated with PGD (Preimplantation Diagnosis)? Do most patients have this screening done?

For readers not familiar with this technology, PGD is a procedure used to detect genetic or chromosomal abnormalities in embryos created during an IVF cycle by removing and testing a cell from the embryo on day three of development. Two days later, only a few normal embryos are transferred.

In 2002, Fertility Centers of IL (FCI) completed approximately 180 cases of PGD and in 2003 that number rose to over 280 cases. Overall, approximately 10 percent of the patients we see do PGD, but it clearly depends on the age of the woman.

The most common reasons to consider doing PGD is if a woman has a strong history of miscarriages, or if she is over 39 years old. A much larger percentage of women over 40 will do PGD compared to younger women. Aneuploidy (an abnormal number of chromosomes) increases significantly with age, thereby increasing conditions such as Down syndrome and miscarriages.

At FCI, we wait until day three of the embryo's development before doing the biopsy (most day three embryos have five to eight cells, so removing one cell does not hurt the embryo).

n an ideal situation, I would rather have an embryo transfer on day five (blastocyst) with embryos that have been tested genetically, versus doing a day three transfer on untested embryos.

24. If you have blocked fallopian tubes, what are the surgical options and can the damage be reversed? How can you avoid having the tubes removed?

It is very important to determine if your tubes are blocked at the ends away from the uterus (referred to as hydrosalpinx). If a woman has hydrosalpinx in her tubes, the fluid that accumulates can be very detrimental to her chances for success, even with IVF. The tubes can be surgically repaired or tied off to improve pregnancy rates before doing further IVF. You should set up a consultation to discuss this with our doctor, or you can see another reproductive endocrinologist for a second opinion.

25. Does FCI do intrauterine insemination (IUI)? What is the approximate cost and does insurance cover this procedure?

The Fertility Centers of IL does offer IUI for many of our patients when they are using fertility drugs such as Clomid or FSH Hormone injections. We do many husband inseminations for male factor infertility as well as for those who need a sperm donor. The cost for an average IUI procedure is $300, at least 50% of insurance companies cover the cost.

26. Chlamydia is a vaginal infection? How can you find out if it has caused damage that would hurt your chances of getting pregnant?

The condition of your fallopian tubes can be evaluated by doing an ex-ray to make sure they are not blocked or damaged from the eadhesions (scar tissue), secondary to the Chlamydia. If the x-ray (HSG - hysterosalpingogram) is normal, there is no immediate need for laparascopy surgery to further evaluate the fallopian tubes.

27. If you have difficulty getting pregnant, and you have inconsistent menstrual cycles (32 days, 43 days, etc), how can you tell if you are ovulating? Should the partner/spouse have a sperm analysis?

With your cycles every 32 to 43 days or more, you may not be ovulating eggs or you may be ovulating, but not making enough progesterone hormone, (which prepares the uterine lining in order to allow for implantation of an embryo.) This can easily be assessed, by using an ovulation predictor kit and a blood test for progesterone. If your doctor wonít do any testing, I encourage you to set up an appointment with a fertility specialist, who will evaluate you and do a semen analysis on your husband.Depending on your age a blood test can also measure your "ovarian reserve" to see what you have remaining in your ovaries.

28. What is premature ovarian failure (POF)?

Premature Ovarian Failure is a loss of ovarian function in women under 40, when monthly periods stop and estrogen is low, which causes menopausal symptoms. The causes of POF can vary, but may include autoimmune conditions or genetics. When we use the term "POF" the failure can be permanent, temporary or periodic, and there may be residual ovarian function.

Some women with POF may intermittently produce estrogen and even ovulate spontaneously or with the help of potent fertility drugs. The best thing is to discuss various options with your reproductive endocrinologist, including donor egg.

Some of the physical and emotional changes due to low estrogen may include irregular periods or no periods, hot flashes, irritability, sleep disruption, decreased sex drive, depression and drying of the vagina. Due to the lack of estrogen at a relatively early age, women with POF are at increased risk for osteoporosis and heart disease.

There has been recent controversy about the relationship of hormone replacement therapy and heart disease and strokes. Several studies have shown that HRT is normally post- menopausal women (menopause starting at age 50+) maybe increase their risk of heart attacks and strokes. However, data may not apply to younger women with POF. Presently, many reproductive endocrinologists are recommending that young women with POF continue with their HRT. The Premature Ovarian Failure Support Group started in Washington, DC in 1995 and has expanded its source of material and information. I recommend you visit their website at www.pofsupport.org/.

POFSG is a tremendous resource that will give you the knowledge to help you deal with POF and make sound decisions. Patients tell me they have benefited from this dedicated group.

29. What is vitrification (egg freezing)?

Egg Vitrification - or the freezing of unfertilized eggs ñ is one of the newest advances in the field of In-Vitro Fertilization. Through vitrification, a new flash freezing technique, delicate eggs once un-freezable, without damage, can now be preserved for future use. Vitrification may also benefit young women about to undergo radiation treatments or chemotherapy so that their eggs can be preserved for use at a later time.

This new, exciting medical technique can also help single women who want to save their eggs since egg quality deteriorates significantly after age 35. The technique is too new to be able to determine how many years the eggs will remain viable. Fertility Centers of Illinois is one of only a handful of IVF programs, nationwide, that offers this new technology to their patients.

30. Will acupuncture improve fertility?

I have read that acupuncture may improve pregnancy rates with fertility therapy, including in vitro fertilization (IVF). In addition, acupuncture may be useful for stress reduction during fertility treatments. What is your opinion on this?

Traditional Chinese Medicine (TCM), i.e., acupuncture and herbal medicine, when integrated with traditional Western reproductive medicine (fertility medications; inseminations- IUI; in Vitro Fertilization- IVF) may enhance fertility.

Acupuncture involves inserting fine needles into specific 'points' to stimulate invisible lines of energy called Qi (pronounced "chee") running under the surface of the skin. Herbal medicine is often used in conjunction with acupuncture. Traditional Chinese Medicine combines acupuncture with herbs along with other aspects including exercise, proper nutrition and creating a positive mental attitude in order to restore the ying and yang into proper balance and allow the person to achieve a harmonious, balanced state.

When couples are trying to conceive, they are often plagued by significant emotional and financial stress. Acupuncture may help alleviate some of this stress. The treatments help release beta endorphins from the brain which can then induce a calming effect. Many of my patients claim that acupuncture helps them to be more relaxed during fertility therapy. Patients often need to undergo several attempts at IUI and/or IVF in order to get pregnant. Any form of stress reduction (yoga, meditation or acupuncture) can often help the women persist in their fertility treatments, thereby improving their chances for a successful outcome.

In addition, acupuncture may improve blood flow to the pelvic region ... most importantly, blood flow to the ovaries and/or uterus (endometrial lining). Studies in traditional Western peer reviewed medical journals are scarce relating to the benefits of acupuncture. However, one article published in a well-respected infertility journal, Fertility and Sterility in 2002, concluded that acupuncture seems to be a useful adjunct for improving pregnancy rates with IVF. I often recommend acupuncture for many of my patients if the lining of the uterus is poorly responsive to fertility medication stimulation. Many women over age 38 may be 'poor responders,' which means they develop fewer eggs and less Estrogen production in response to the fertility drugs. Some of these 'poor responders' have a better stimulated response after acupuncture treatments.

However, patients need to be aware of potential hazards associated with some herbal supplements which could have harmful effects on reproduction. For this reason I do not recommend using Chinese herbs during active fertility treatments, but only prior to therapy.

Traditional Chinese Medicine integrated with Western Reproductive Medicine may be a good choice for many patients. At Fertility Centers of Illinois (FCI), we have had good success integrating Eastern and Western medicine in order to help alleviate stress and potentially optimize our patient's fertility treatments. For more information, go to our FCI website www.fcionline. We have also had a very positive experience with Pulling Down the Moon, specializing in yoga, acupuncture, and meditation. (www.PullingDowntheMoon.com) Don't just pick any name from a phonebook. You want a well trained acupuncturist, experienced in infertility. For a list of certified licensed acupuncturists experienced in treating infertility, visit www.nccaon.org or call my office 847-215-8899.

I can summarize my opinion about acupuncture as an adjunct to fertility treatments in these simple words: "Acupuncture may help; it can't hurt; you'll feel better."

31. Is natural progesterone safe? ...I am supposed to start using Progesterone in oil injections during my upcoming IVF cycle. I believe this is a 'natural' form of progesterone, but wanted to be sure. I have read that there may be a slight increase in birth defects associated with the ësyntheticí forms of progesterone (Progestins). I became a bit concerned upon reading the insert that accompanied the drug since it warns of potential risks associated with taking progesterone during the first trimester of pregnancy, including birth defects (genital deformities). I am assuming the FDA requires that the warnings be put in regardless of the type of progesterone, natural or synthetic, but would like some reassurance. Can you please help me to understand why we need to continue the use of the progesterone after implantation of a pregnancy? Are there other options such as Crinone (progesterone vaginal gel) which is approved by the FDA for use in assisted reproductive technology.

You do not need to worry about using natural progesterone and here's why. Most IVF programs use Progesterone in oil (intramuscular injection) and some use Crinone or Prochieve (progesterone vaginal gel) and/or Prometrium (oral progesterone). There must be progesterone hormone support given in order to adequately develop and maintain the lining of the uterus (endometrium). After egg retrieval, most women canít make enough progesterone hormone because many of the progesterone producing cells in the ovary are removed when the eggs are retrieved.

Progesterone is a natural hormone produced in women by the ovary after ovulation. Progesterone acts directly on the endometrial lining of the uterus to prepare it for accepting a pregnancy. Progesterone is also made by the placenta during pregnancy.

Although there is still controversy, the synthetic Progestins have been previously blamed for a slightly increased incidence of certain birth defects. More recent studies have indicated that the risk of congenital anomalies in women who inadvertently take synthetic Progestins during pregnancy are either not increased at all or are only slightly worse. Although these studies are reassuring, the FDA does not support the use of synthetic Progestins (Provera, birth control pills) during pregnancy. Most of us who specialize in infertility and hormonal therapy will use only natural progesterone for patients actively trying to conceive. The most commonly used natural progesterone preparations include:

Progesterone in oil (intramuscular injection)
Crinone or Prochieve (vaginal gel)
Prometrium (oral tablet)

Currently, no studies have demonstrated that the use of natural progesterone increases the risks to a baby. The FDA unfortunately lumps all natural progesterone and Progestins (synthetic) together, even though not a single study in over 50 years of use has convincingly demonstrated any problem. At times, natural progesterone has gotten a bad rap by being lumped into the same category as synthetic Progestins.