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"Questions and Answers from Across the Infertility Patient Spectrum"

By: David B. Smotrich M.D.

On any given day at La Jolla IVF, we will see a myriad of patients. Infertility comes in as many shapes and sizes as humanity. New patients including younger couples, older couples, couples with primary infertility and those with secondary infertility, single males, single females and same sex couples, all cross the threshold of the clinic in search of answers to their perplexing questions regarding their infertility dilemma. Some patients are at the beginning of their fertility journey, others are in the middle of their journey to parenthood and yet others are near the end of the road (La Jolla IVF represents the last stop on their journey to attaining their dream of a family).

The questions and answers are so different for patients in each of these categories that in order to attempt to give some kind of representative sampling for patients across the entire infertility spectrum, one or two questions from each "category" of patients will be explored.

GROUP 1:

These patients have tried to conceive naturally by having unprotected intercourse for one year (if the woman is under 35 years old) or for six months (if the woman is older than 35) and have not been successful in conceiving.

Question 1:

How long will it take to diagnose our problem?

Answer1:

It should not take longer than 6-8 weeks to diagnose the problem and in many cases it can take a much shorter time (more like 4 weeks).

Question 2:

What tests would you recommend we do to help diagnose our fertility problem?

Answer 2:

The first test I always recommend is a semen analysis on the male partner. This is the single most important test for men and is easily performed at La Jolla IVF in about 20-30 minutes. The test can be performed any time but there should be no less than two days of abstinence before producing the semen sample and no more than five days of abstinence. The test detects the number of sperm, the motility (speed and quality of movement) of the sperm and the shape of the sperm (known as morphology). The motility and morphology are more important than count.

For the female I recommend several tests including:

1) Cervical cultures to detect sexually transmitted diseases.

2) Blood tests to determine levels of reproductive hormones. I find the most useful of these is FSH (follicle-stimulating hormone) and E2 (estrogen). These hormone levels give us some indication of the patient's ovarian reserve (how well the ovaries are still doing at producing quality eggs). I also test LH (luteinizing hormone) and P4 (progesterone). All these hormones are necessary for ovulation and implantation of the embryo.

3) Pelvic ultrasound which I use to look more closely at the pelvic anatomy and to examine the ovaries. I use the ultrasound to do an antral follicle count on the ovaries. By doing an ultrasound and performing the antral follicle count (number of undeveloped follicles in the ovary), I can ascertain how many resting follicles there are in the unstimulated ovary and can thereby get an indication (in conjunction with the FSH and E2 levels) of how well the ovary is functioning in terms of the ovarian reserve.

4) I also recommend a hysterosalpingogram which is a pelvic X-ray that can reveal blockage or scarring of the fallopian tubes. Tubal blockage and scarring accounts for approximately 30 percent of female infertility. This test also provides an image of the uterine cavity.

5) For additional information on the uterus, I also recommend an in-office hysteroscopy which is usually performed after a woman has completed her period but before ovulation. The additional information that this simple in-office procedure provides is useful to help detect fibroid tumors, abnormalities of the endometrium and scarring of the uterine cavity.

GROUP 2:

These patients have already had several treatments including medications such as clomid and then moving on to gonadotropins (injectables), inseminations and maybe even their first IVF cycle. At this point all these treatments have failed and they present at La Jolla IVF for an answer as to why they have failed so far. Depending on the woman's age and on what the couple's particular infertility diagnosis is, there may be several treatment paths that the patients may go down.

Question 1:

We have failed one cycle of IVF. What could you do differently that would help us to get pregnant in our second cycle of IVF?

Answer 1:

I will review the records of your IVF cycle and depending on what I find out, here are some potential changes that I could make:

1) The protocol to produce the eggs could be changed to improve the quality and quantity of the eggs that are produced.

2) I would recommend that because the patients have already failed an IVF cycle that the lab should perform ICSI on the eggs to ensure a higher percentage of the eggs are fertilized and there will be more embryos to work with.

3) I would also recommend that the lab grows the embryos to blastocysts (day 5 embryos) as I believe I would want to try and do a blastocyst transfer as opposed to a day 3 embryo transfer. If embryos are able to reach day 5 in the lab, they have crossed a certain threshold and somewhat proven themselves.

4) I would also talk about looking at PGS (Preimplantation Genetic Screening) depending on the age of the woman, so as to try and transfer embryos that have been tested for the common chromosomal anomalies such as Down syndrome.

GROUP 3:

These patients are either women over 45 years old or women who cannot carry a baby for some anatomic or systemic reason or patients who have failed many IVF cycles or who are same sex couples who have to use third party reproduction in order to have a family.

Question 1:

Can you give us some idea of the complexity of using an egg donor and a surrogate in an IVF cycle?

Answer 1:

Certainly egg donor /surrogate cycles are more complex than a conventional IVF cycle. In the case of using an egg donor and a surrogate in a specific instance where the husband is giving the sperm and the wife is older than 45 years and so needs and egg donor and also she has had a hysterectomy and therefore needs a surrogate as well. I always recommend using an agency to find the egg donor and the surrogate unless the couples are able to use family members or friends who are willing to help them out. I do not recommend finding egg donors and surrogates on the internet as this type of reproductive cycle is quite complicated both legally and medically. A good agency is invaluable to steer people through these complicated waters. We at La Jolla IVF want to do the best we can do for patients and what we do best is the medical side of these complicated cycles. Patients do not need to worry about any of the pre-cycle testing or the cycle coordination. Our nurse coordinators will help everyone through the process. I do not recommend using the same person to donate the eggs and carry the baby. I am more favorably disposed to gestational surrogacy as this type of surrogacy gives the intended parents the most protection in legal terms. I would also suggest that intended parents ask the agency and/or lawyer about the states that are most favorable to surrogacy. I recommend using a surrogate who lives in California as this state by far is the most "surrogate friendly".

Question 2:

What is the success rate of a gestational surrogate cycle at La Jolla IVF?

Answer 2:

This depends on the age of the egg giver. In cycles where the eggs come from a female who is under 35 years of age the success rate in 2006 and 2007 has been 80% per embryo transfer cycle. In cases where the egg giver is older than 35 including 22 cases where the egg giver was older than 40 years old the success rate in 2006 and 2007 was approximately 50% per embryo transfer (clinical pregnancy where cardiac activity was verified on ultrasound).

The above questions and answers are simply examples of questions that patients ask. They are by no means exhaustive in their answers and much more detail would actually be given in actual patient consultations. If potential patients would like more information, please call La Jolla IVF at (858) 558-2221 to set up a complimentary consultation by phone. Phone consults are always extended to potential patients at no charge.