Archive for the ‘Questions to Ask’ Category

What is assisted hatching?

Saturday, May 1st, 2010

Assisted hatching is an optional extra procedure used in IVF where a small hole is made in the shell (or ‘zona’) of a Day 3 embryo. This is supposed to help (in some cases) the embryo ‘hatch’ out of its shell and transform itself into a blastocyst (usually on Day 5).

Probably the best site to get a clear understanding of assisted hatching is the one from the Advanced Fertility Center of Chicago, which shows in great detail how the hatching process works, including a pic of an embryo actually in the process of hatching to become a fully hatched blastocyst. Cool!

In New Zealand assisted hatching is not part of the default IVF protocol, so you would need to ask your specialist about it.

My understanding is that public funding won’t cover assisted hatching (I could be wrong about this – please chime in if you know of criteria for eligibility). But, if you were doing a publicly funded cycle and your specialist agreed it might be a good idea, you could presumably pay for it out of pocket (it’s a few hundred dollars).

If you are a self-pay patient, obviously the choice is with you and your specialist, so ask. However (and someone please update me if this is no longer the case), if you have the OK to transfer more than 2 embies, apparently the clinics are not allowed to do AH on more than two. I can’t fathom the reasoning on that (especially for women over 42), but there you go … Minor trivia, but worth knowing in advance (if you’re like me, you hate surprises cropping up during the cycle).

Just to give a broader perspective, in the States, where patients are either paid for by insurance or out of pocket, assisted hatching (AH) seems to be used more widely. The Advanced Fertility Center of Chicago says they do it on all embryos, but they also offer the following useful list of criteria:

Who should be treated with assisted hatching?

The most commonly used indications for assisted hatching with an in vitro fertilization case are:

  • Age factor – Couples having IVF with the female partner’s age over 37
  • Egg quantity and quality factor – Couples in which the female’s day 3 follicle stimulating hormone (FSH) level is elevated
  • Embryo quality factor – Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division)
  • Zona factor – Couples having IVF with embryos that have a thick outer shell (zona pellucida)
  • Previous failures – Couples having IVF that have had one or more previous IVF cycles that failed

In our IVF clinic, we use assisted hatching on just about all cases – because we think it increases the pregnancy and delivery rates.

For the original page, see http://www.advancedfertility.com/hatching.htm

I’m pretty sure that assisted hatching can be used whether you are doing a 3-day or a 5-day transfer, but generally not for 2-day transfers (the embryologists say the embryo is usually too small then and there’s a risk it could break up if the zona is punctured). With a 3-day transfer, they will do this immediately before they put your embies back. With  a blast (5-day) transfer they would presumably do the AH on day 3 before putting the embryos back for their last two days of development. Anyway, these are just a few things to discuss with your specialist.

As for risks, my understanding there is a very very small increased likelihood of conjoined twins if assisted hatching is used. My own specialist told me that, although this was statistically true, the reality was that the increased chances are so miniscule that they don’t really have practical significance.

Who should be treated with assisted hatching?

The most commonly used indications for assisted hatching with an in vitro fertilization case are:

  • Age factor – Couples having IVF with the female partner’s age over 37
  • Egg quantity and quality factor – Couples in which the female’s day 3 follicle stimulating hormone (FSH) level is elevated
  • Embryo quality factor – Couples having IVF with poor quality embryos (excessive fragmentation or slow rates of cell division)
  • Zona factor – Couples having IVF with embryos that have a thick outer shell (zona pellucida)
  • Previous failures – Couples having IVF that have had one or more previous IVF cycles that failed

In our IVF clinic, we use assisted hatching on just about all cases – because we think it increases the pregnancy and delivery rates.

Conflicting expert opinions – how do I know who’s right?

Saturday, April 10th, 2010

So, you finally plucked up the courage to go for a second opinion (see also When and how should I seek a second opinion?) and guess what – now you have two or more well-qualified and plausible experts with compelling arguments telling you to do the exact opposite. Maybe one cites empirical research and another doesn’t; maybe they all cite different research. Maybe one sides with the ‘mainstream’ while the others are mavericks – who’s more credible? Who should you trust?

Here’s a classic example encountered by women in their late 30s and 40s with elevated FSH or low AMH (which means they have diminished ovarian reserve – very few eggs left, on the fast track to early menopause). [This example may not relate to your case specifically, but the reflections about how to deal with it are definitely generalisable.]

Specialist A: Once your Day 2/3 FSH is over [insert cut-off; some say 10, some say 12, some say 15, some say 20] the odds of pregnancy through IVF are so incredibly low that IVF is a waste of time altogether, so we would actually not treat you unless you plan to use donor eggs. Just move on already!

Specialist B: Your FSH is elevated, which means you will be a poor responder to stims (Gonal F, etc) and your odds will be lower than other patients your age. It’s like your ovaries are old and going deaf, so we have to give you a very high dose of stims (i.e. ‘shout’ at your ovaries) to get them to wake up and produce any eggs at all. So, I would recommend we put you on maximum dose stims and see what happens. If that doesn’t work we will try mega mega doses.

Specialist C: Your FSH is elevated, you will be a poor responder, but actually, large doses of stims for women like you will often cause your ovaries to shut down and not respond at all. If they do respond, the dose is so high that you will end up with fried eggs that are unlikely to result in a live birth anyway. No, your ovaries are like an old squeaky violin that has to be coaxed gently into life so that it sings the sweetest tune  it possibly can. I recommend a very low-stim IVF, IUI or TI (timed intercourse) cycle with either very low stims right from the start, or just starting with no stims and letting your own [already elevated] FSH drive follicle growth before adding a ‘tiny boost’ to help things on their way.

Yes, intelligent people do hold different views. The field is still growing and not everything is cut-and-dried (and  actually, never will be). They all have theory and evidence to back their explanations …

Specialist A will cite a ton of empirical research showing the inverse correlation between FSH levels and IVF response (number of eggs produced) and success rates. No argument with that.

Specialist B will cite studies showing that the higher the dose, the more eggs patients produce, and the more eggs you retrieve the higher the success rates. It’s a numbers game.

Specialist C will say ah yes, but what those studies don’t show (but mine do) is that, although you get more eggs from higher stims, in older women and those with high FSH, those eggs are of lower quality, less likely to fertilise, and most importantly, less likely to result in live births.

They are all speaking the truth based on what they have seen and read; they all have evidence and experience to back their claims. So, how do we weigh up conflicting arguments and figure out what makes the most sense for us?

First, let’s talk about the big studies (either randomised experimental trials or retrospective studies) showing that Protocol X works (or, helps) better than protocol Y. These are very important to understand, but what YOU need to consider is not “does it help” on AVERAGE across a large study of all sorts of different women; the real question to have in mind when you read (or, discuss with your dr) such research is WHOM does it help (what age, dx, individual characteristics), and under what conditions? And, will it help ME with my unique constellation of age, treatment history, diagnosis and other characteristics?

There are some aspects of fertility treatment that are so nuanced, unpredictable and idiosyncratic that the reality is NO-ONE is ever going to get “the” answer through large study research. Once you’re past the relatively well-established big picture stuff and trying to individualise protocols based on what you see and what you’ve seen in the past, it’s less about big picture science and hypothesis testing and more about human judgement and pattern recognition.

When we’re in this territory, fertility treatment is less a “science” and more of an “art” or a “craft”. You’re having to trust pattern recognition, judgement, intuition and instincts because the research just isn’t there to the level of detail you’d need to be able to make a call. Also, many of the cutting-edge treatments have no more than a plausible theory and a few success cases; the research needed to fully test them is still in progress or may be years away or may never be done because they help such a small segment of the ttc population – but they may still help (see also New and “untested” treatments). Just about all of my ttc journey was in that murky domain -  I was too specific a mix of age, diagnosis and treatment history for enough large studies to have been conducted to clearly indicate what would work in my case. There were no easy answers – there wasn’t a clear right or wrong because the research out there could only predict what would happen across a large group (that included many women NOT like me), not what would happen in MY case (or cases very similar to mine).

When you’re in instinct and judgement and pattern-recognition territory, the only things you can do are arm yourself with as much knowledge as you can muster, listen to the instincts and judgement of the people who have had more experience with cases specifically like your own, and listen to your own instincts and debate these back and forth with your specialist(s). It’s a crap-shoot, but some people have a knack for this stuff …

Or, the simple version for the example above (please just insert your own dilemma and the answer is likely the same): high stims work for some people; low stims work better for others. Which are you? Well, you won’t know until you try because the studies have been done on a huge range of women, only a fraction of whom are like you in various ways – and none of them are exactly like you. So, research like crazy to try and figure out what seems promising for women and couples most like you, and when it’s still not clear how to choose among various plausible options on your shortlist, go with your gut.

See also: New and “untested” treatments for some thoughts about which new-fangled ideas to consider seriously.

We did IVF but had heaps of empty follicles – help!

Monday, April 5th, 2010

Some of us do IVF, go for those scans and see hardly any follicles after all those injections. Others are relieved to see a healthy crop developing as they go through their cycles. Unfortunately, the number of follicles (or “follies”) doesn’t necessarily equate to the number of eggs collected. And for some women, a huge proportion of the follies are ’empty’. This is sooo frustrating after seeing all those follies on the screen and usually having a fantastic E2 (estrogen level) to match.

There is such a thing as “empty follicle syndrome”, but unfortunately it’s still not all that well understood, and there are various theories …

  1. The most common explanation given by the specialists is that egg maturity and quality are related to how easy they are to get out. Those that are flushed out are lower quality than those that came out easily. ‘Empty’ follicles may not actually be empty; they may just contain very poor quality eggs. OK, there’s obviously a heavy element of truth to this (i.e. it’s a known fact about eggs in general), but the big question, of course, is whether (and how much) it applies in YOUR case. It probably does, to some extent, in just about all cases of empty follicle syndrome. But that’s actually a “There’s nothing we can do about it” diagnosis, and not much use unless you are looking for  a reason to switch to donor eggs or give up altogether. So, the following are some other plausible theories that may or may not apply, but many of which CAN be addressed.
  2. One theory is that you got a dud trigger shot. It’s rare, but it can happen. And it’s unlikely to happen again. But if you want to be absolutely sure, some women use a double trigger shot the next time. This is when you inject not one but TWO vials of Ovidrel (the usual trigger used in NZ), one after the other. Very important: The vials should come from two different batches (check the batch numbers on the packet before signing them out and taking them home – you can’t return injectable drugs for exchange or refund). I’ve not seen any mention that this could have any adverse effect on the egg quality – it’ll cost you some $$ for one more vial of trigger (but this is cheaper than one more IVF cycle and a lot cheaper than the baby once he/she arrives!), but apart from that, it’s a “won’t hurt, might help” measure as far as I can tell. But ask your dr.
  3. Another theory floated a lot is that you may have ovulated just before retrieval, but not so long before that they would have seen collapsed follies. The remedy for this, if true (and it’s very hard to tell) is to schedule your egg collection just a bit earlier – say, 34 to 35 hours after trigger, instead of the usual 36. Reasons to hesitate about doing this might be if several of the eggs that were retrieved were immature – collecting early could exacerbate this problem.
  4. A rather delicate theory to probably NOT raise with your specialist is that the person doing the retrieval wasn’t very skilled. Yes, well, obviously a possibility, but hard to tell as a patient, and there’s no way you’ll get an admission about this one!! If you’ve had several cycles with ’empty’ follies, was it the same person doing the procedure each time?
  5. OK, time to start thinking outside the very simple boxes outlined above. One possibility is that the protocol disagrees with you – gets you follies but most of them are ‘decoys’. Now, you won’t get far on this one if you are under one of NZ’s one-size-fits-all specialists. Obviously, there are some cases where a change in protocol might be risky (e.g. greater risk of overstimulation, OHSS), but personally, I couldn’t bear to go into a new cycle on the exact same protocol as a failed one, so ask lots of questions about alternatives – and see also the post: What are the main IVF protocols used in NZ? The other protocol-related thing to ask about is what stims are being used. In NZ, just about everyone gets put on straight FSH (Gonal F or Puregon), but some specialists will add some LH (e.g. Luveris) into the mix. This seems to help some women with egg quantity or quality or both; others seem to do better on straight FSH.
  6. Some fertility specialists say that if your eggs are overcooked, i.e. if you stim too long before triggering and the egg over-ripens, then the resulting egg will stick to the follicle lining and not come out easily. The same is said about eggs that are ‘undercooked’ (i.e. if you triggered too early and the egg is not yet mature). Although there is some empirical research on the best time to trigger based on follicle size, it’s become quite clear to me (after listening to others’ experiences) that one size does not fit all, and some women need to trigger earlier than the norm, some a bit later.
  7. The other possibility is that maybe your ovaries are of the “less is more” variety, so that if you halve your dose you may get fewer follies but the eggs in them are likely to be (a) really there and (b) better quality. I haven’t seen a lot of research on the latter, but I have talked to a low-stim specialist about this in some depth, and also to several women who swear they get far fewer empty follies when they are on a much lower dose. [And, I suppose my experience was similar numbers but better embryo quality, so I’m a fan of the low-dose option in general.] Internationally there is a fast-growing interest in the reproductive endocrinology (fertility specialists) community about low-stim and natural approaches to IVF.One of the more interesting recent innovations in IVF is in vitro maturation (IVM), where the eggs are removed from the follicles while immature and then matured in the lab. This is nil to near-nil stims technology. Last I heard – in a Nov 2007 National Radio interview with Dr. Simon Kelly (Fertility Associates Auckland) it hadn’t been approved by the ethics people, but it may be by now, or that  may be coming soon. If it sounds interesting, get yourself a consultation with Simon – he did a post-doc fellowship at McGill in Montreal, where IVM was pioneered.

OK, there’s a big laundry list of possibilities here. My own experience grappling with infertility has taught me to push back quite hard if only the “we can’t do anything about it – you just have bad eggs” explanation is being offered. OK, the bad eggs thing may be true (and in my case it certainly was, since I was IVFing over 40 and with high FSH!), but that doesn’t mean there aren’t some other treatable explanations that are also in play. There are quite a few non-drastic options here to tinker with the protocol, and IMHO they are well worth discussing seriously with your dr. If he or she is reluctant, make sure you ask whether your specialist thinks this is likely to be risky or harmful in some way, or whether they think it’s relatively harmless but just unlikely to be effective. If it’s the latter, and if your instincts are telling you it makes sense, then ask to try it.

Can I get travel insurance with an IVF pregnancy?

Wednesday, February 10th, 2010

So you’ve been through (or, are about to go through) the white knuckle ride of IVF cycles and all you desperately need at this point (apart from a 40-week pregnancy) is a nice, relaxing break overseas on some tropical island. But you have a cycle coming up and there’s a slight chance that this one could actually work. Will this cause a problem with travel insurance?

For most “normal” people – you know, the ones who just have sex with their spouses and get pregnant (I know, that’s just sooo last millennium!) – getting pregnant before you leave isn’t a problem and isn’t considered a “pre-existing condition” or anything you could be excluded for. Well, guess what, if you’re unlucky enough to need IVF to conceive, do some very serious shopping around before you buy travel insurance. Here’s why …

Here’s a quick summary of what I’ve been able to find out. Some of it is second hand info though, so check directly with providers before buying. The main purpose here is to alert you to the wide variation in policies so you can ask good questions and choose wisely.

Southern Cross:

  • Pre-pregnancy undergoing IVF or egg donation no cover
  • Once pregnant – no longer considered “treatment for infertility” so they are covered without implications up to 28 weeks.
  • Cover is for unexpected medical complications only. Common symptoms such as breast tenderness, constipation, fatigue, frequent urination, heartburn and nausea (morning sickness) are not covered.

Downunder:

  • Single uncomplicated pregnancy arising from assisted program cover available up to 26 weeks – additional premium required.
  • Multiple pregnancy no cover.

Travel Insurance Direct:

  • up to 26 weeks no complications single pregnancy but only if not result of assisted reproductive programs.

Flight Centre’s ‘Travel Sure’ Policy (via Vero):

  • Brochure says: “We will not under any section pay for…
    13. claims directly or indirectly arising from:
    a) pregnancy… if you are AWARE of the pregnancy prior to the Relevant Time (which means when the policy is issued), AND..
    i) where complications of this pregnancy or any previous pregnancy have occurred prior to this time, OR
    ii) where the conception was medically assisted.
    This exclusion will be waived from the time the appropriate additional amount payable has been received by us IF the cover is separately applied for AND accepted by us in respect of your pregnancy only”.
    The usual clause that travel must be completed by 26 weeks applies.
  • One IVF patient reported, “Flight Centre … rang me back this morning and said that even though fertility treatment is not noted in their wording they would decline any claims on the basis of: at the time you take out the policy “you are not aware of any circumstance which is likely to give rise to a claim”. He said that doing fertility treatment which may result in a pregnancy would be considered a ‘circumstance’. I was so outraged I burst into tears and hung up on them. … He said if I wanted to take out insurance we could always take them to the disputes tribunal in the event of a claim being declined. Charming.”

ASB (via Tower):

  • One IVFer reported that they cover pregnancy as a special benefit (without needing to declare it as a preexisting medical condition), but only up to 20 weeks. However: You are not covered for.. “pregnancy known to exist at the date of inception of this policy AND for which you have been receiving medical treatment or medication…”.

Westpac gold card travel insurance:

  • ‘Pregnancy is considered a pre existing condition. There is no cover for any expenses as a result of your pregnancy except for an unexpected/unforeseen medical complication or emergency that occurs during the period of insurance and when you are no more than 26 weeks pregnant at the time of the unexpected/unforeseen medical complication or emergency occurs.’
  • When asked about whether they would cover a pregnancy that had resulted from fertility treatment, one IVFer said the customer service agent “didn’t exactly say either way, just that they would look at it on a case by case basis.”

Here’s what another IVF patient found out when she did some further digging:

I rang Mondial yesterday (who do the insurance for House of Travel) and spoke to their assessor in the ‘pre-existing medical conditions’ section who said they assess for multiple companies (she didn’t name them) and she said all the companies she was aware of had similar exclusions.

According to their policy, if you are ‘not yet pregnant’ (at the time of taking out your insurance) but are undergoing any fertility treatment now or before your travel, you are not covered for any medical costs or cancellation related to pregnancy.

However, if you are already pregnant at the time of booking your insurance, whether naturally or from fertility treatment (including but not limited to IVF) then they will cover you until 26 weeks with a singleton pregnancy, or 19 weeks with a naturally occurring multiple, but not with multiples arising from fertility treatment.

Her suggestion was to take out normal insurance when you book (making sure it covers you from the date of taking it out rather than the date of travel), and if you get pregnant, then you could cancel that cover and take out a new policy (with a different company probably!)

I have contacted Consumer NZ on this one and they plan to look specifically at this issue the next time they review travel insurance (later in 2010). Stay tuned!

When and how should I seek a second opinion?

Thursday, October 15th, 2009

Suppose you had a friend who was grappling with a cancer diagnosis and kept wondering whether his/her specialist had really considered all the possible treatment angles that might work. Suppose he or she had been receiving some treatment but there hadn’t really been any sign of progress. What would you advise? Probably a second opinion, right?

For some unknown reason, fertility patients seem to struggle with this notion that it’s somehow disloyal to seek a second opinion. Yes, it is awkward. But actually, it’s just good common sense if there’s any little voice inside your head saying “maybe there’s a better way …”  I know several women/couples who have switched specialist within the same clinic and have really agonised over how they are going to “break up with” their initial specialist. But the reality is this happens all the time, and people need to find the fit that’s right for them. My local clinic (FAA) actually makes that transition incredibly smooth and most of the drs are perfectly happy when it happens. [Actually, some may be relieved about getting rid of a “difficult” patient! ;)]

Even if you’re not actually switching specialists, it’s perfectly reasonable to seek out a second opinion if you want to. If you’re publicly funded you may have to pay for the second opinion consult, but that’s money well spent if it’ll give you peace of mind and/or some good ideas that can get you closer to building the family you want.

Remember, just as in any other profession, each individual specialist has certain diagnoses and treatments that they have a particular interest in and more experience in treating. Some gravitate toward the more straightforward cases (early 30s, no tubes, standard protocol, easy success); some specialise in particular issues (endometriosis, PCOS, thyroid problems); some are really passionate about taking on the really challenging cases (women over 40, poor responders, egg quality problems). It’s a good idea to ask around about who’s had success with cases like yours. And that’s a good place to start for a second opinion. Just think, women/couples in the States fly 5 hours from coast to coast seeking a second opinion; we are incredibly lucky that even the other end of the country isn’t that far away! And if travel is really a problem, you can often book a phone consult.

Over the years, one thing I’ve noticed is that the truly professional specialists I’ve spoken to have NO problem at all with my seeking a second opinion. They support my being proactive and are very happy to listen to any ideas I glean from those other consultations. They don’t let egos get in the way of my treatment. While working with my own specialist, I got a copy of all my notes and did a phone consult with a specialist in the States who’s considered the #1 go to guy for women with my particular diagnosis. My specialist in NZ was like nooooo problem – and was very open to the ideas I came back with. We did, of course, have a healthy debate about which of the ideas seemed to make the most sense in my case, but the main thing was that we had that discussion and we made some good decisions together about what to try next.

How do you know you should seek a second opinion?

Well, everyone’s different. For some people, it’s when they’ve just had a failed cycle, they can’t afford to do more than about one more, but the specialist is suggesting just going with the same again. For others, they’ve tried discussing other ideas with their specialist but feel like these aren’t being taken seriously or at least the reasons for not trying these things aren’t being adequately explained. For me, it was feeling like we’d already discussed and tried all the ideas we could think of together, so I needed a fresh perspective, a new source of ideas. Whatever the situation, if there’s a little voice in your head wondering whether you and your specialist have adequately explored all the possibilities, that’s a sign you might want a second opinion. It could just end up confirming what your current specialist is telling you, in which case that’s also useful because it eliminates doubts that you’re doing the right things.

If you think you might want to get a second opinion on your case, here’s what to do:

  1. Get a copy of your notes from the clinic so you know exactly what protocols you have tried already, any testing that’s been done, how you responded to treatment (including E2 levels, follicle sizes, the embryologist’s ratings of embryo quality, etc).
  2. If you can, make a 1-2-page bullet point summary of your history and any testing. This makes it a LOT easier for the new dr to get up to speed quickly on where you are at.
  3. Ask around (e.g. on the Everybody BB’s Infertility forum) to find out which drs at which clinics have had success with your particular diagnosis and history.
  4. Call that dr’s clinic and speak with his/her receptionist; ask for an in-person or phone appointment; ask where and how to send your summary/notes/file.
  5. You don’t have to formally tell your current specialist that you’re seeking a second opinion, but you’ll probably end up informing his/her nurse or receptionist when you request a copy of your file/notes. It’s a courtesy to mention it, but if it’s causing you anxiety then don’t force yourself to. The specialist will understand.
  6. If you are doing a consultation with someone who works at another clinic from your ‘home’ clinic and if you like what they are suggesting as a new plan, discuss with them whether it would be feasible/advisable to (a) ask your current specialist to follow a new protocol; (b) cycle at your local clinic but with the new specialist either calling the shots or providing advice to your own specialist; (c) travelling and doing the whole cycle at the new clinic; or (d) doing egg collection and transfer at the new clinic, but monitoring (ultrasound and bloodwork) locally. All of these options have been done around the country at one time or another.
  7. Don’t worry too much about having to persuade your current specialist to try something new – quite often the specialists will just get in touch with each other and work out how best to work together. Ask your ‘second opinion’ specialist what he/she thinks is the best way to handle this. The politics and the details of this shouldn’t be your problem – you are going through enough stress already!
  8. Don’t worry too much about the ‘disloyalty’ issue either. You have the right to expect specialists (and any healthcare provider, for that matter) to be professional about second opinions and NOT to make you feel guilty about seeking one out. If you find someone is not being particularly professional about it, that tells you more about them than it does about how you handled it. Your priority is to get a baby/family out of this, and their priority should be to help you achieve that dream. The specialists won’t be a part of your life forever, but your babies will!

We’ve had multiple losses – what should we be asking about?

Wednesday, October 14th, 2009

“We seem to have no trouble getting pregnant, but we’ve had several first trimester losses.” Or, “We put back good-looking embryos every time, but they just don’t stick.” If this sounds like you, here are a few ideas you might want to discuss with your doctor.

Miscarriages can be caused by any one or more of the following factors:

  • structural
  • hormonal
  • immunological/autoimmune
  • environmental
  • genetic

Let’s start (as the drs often do) with the fairly basic hormonal tests. One of the first that’s included in a fertility workup is testing progesterone in the luteal phase. Most drs order this for CD21 (Day 21 of your cycle), but actually you should really have it done at 7dpo (7 days past ovulation). Of course, 7dpo=CD21 if you ovulate on Day 14 of your cycle, but if you usually ovulate late or early, or if it’s unpredictable, you might want to track your ovulation using BBTs (basal body temperatures) and go at 7dpo. If your progesterone (P4) levels aren’t high enough, you may need progesterone supplements (like utrogestan pessaries) after ovulation (O). Some specialists believe this is a VERY common problem with older women and that if you’re over 40 and ttc naturally you should take P4 after O every cycle.

Another important one to test early, especially if you have any family history or tend to feel tired a lot, is thyroid conditions. Hypothyroid (underactive thyroid) does pop up reasonably often as a cause for conception and sometimes miscarriage problems and is easy to test for. You can ask your GP for this if you’re not seeing a specialist.

If you’re ttc naturally you should also check whether you have a luteal phase defect, i.e. once you ovulate it takes fewer than 12 days for AF (your period) to arrive. You can usually figure this out by charting your basal body temperatures (BBTs) – and a really good site for learning how is Fertility Friend. Again, if your LP is too short, this can be easily fixed with progesterone support after O.

There’s a panel of blood tests you can ask for that are used to diagnose some of the possible causes of “recurrent pregnancy loss” (RPL) or “recurrent implantation failure” (when those embies just don’t stick). Broadly speaking, they cover three categories of issues – autoimmune issues (your body may be rejecting embryos as foreign bodies), clotting issues (not sure the exact mechanism for this, but if your blood clots too much, this makes pregnancy loss more likely – some clotting issues are caused by autoimmune problems) and some genetic issues. Here’s the list that we were sent for, and I think it’s a pretty typical list for New Zealand (some countries like the States seem to test for half a dozen kitchen sinks, several of which aren’t available in NZ):

  • Coagulation screen
  • Thrombophilia screen
  • Autoantibody screen incl.
  • antithyroid antibodies,
  • anti-gliaden antibodies
  • Factor V Leiden
  • Karotype
  • MTHFR mutation
  • Anticardiolipin antibodies
  • Lupus anticoagulant
  • … and a karotype for DH (who gets off easy, as usual).

Probably the next logical step is to get either a saline sono (ultrasound during which they squirt saline solution into your uterus to help them see better) or an HSG (similar, but it’s an X-ray procedure where they shoot iodine dye into your uterus and can also check whether you have blocked tubes). Either of these should tell you whether you have any structural issues in the uterus that might be preventing you from achieving or holding onto a pregnancy. Examples include uterine polyps, fibroids, scar tissue, and an unusual shaped uterus. The most likely issues can often be treated with some fairly minor surgery.

The main environmental causes of miscarriages are not usually tested for, but things you should look around you to check your exposure. Some to keep an eye out for include lead, mercury, organic solvents and ionising radiation. Other more common culprits like cigarettes, alcohol, coffee and other drugs should be cut right out (or, down as much as possible) while ttc. Some naturopaths will do things like send a sample of your hair for analysis for heavy metals, which can highlight things you are exposing yourself to without knowing it. They also advise avoiding those forms of radiation and related exposure that we are not often aware of. These include long-haul flights (which expose the body to as much radiation as a full-body X-ray, or so they say) and keeping a cell phone in your pocket right next to your ovaries – think about it!! Well, who knows which of these various things are real causes, but if you want to make sure you try everything you can to prevent another loss, you’ll probably do what I did and take the ideas pretty seriously.

But what if my specialist won’t run all these tests?

This is quite a common comment from a lot of women/couples dealing with RPL (recurrent pregnancy loss). It may be frustrating, but there is another way to look at this. OK, you may not be able to test for the entire kitchen sink, but maybe you can ask your specialist to consider treating you as if you did have several of these issues going on but they just may well be undiagnosed. That may sound nuts, but there are actually quite a few low-tech options you can ask about that many doctors will agree fall into the “won’t hurt, might help” category. These include:

  • low-dose aspirin (usually 100mg/day) – addresses clotting issues
  • high-dose folic acid (4-5mg/day) – helps prevent neural tube defects
  • progesterone support (usually Utrogestan pessaries) after O on every cycle you are ttc
  • low-dose estrogen support after O too (2mg estradiol valerate, for example)

If you’re doing IVF, each cycle is a bit more high stakes, so you may be able to push for a bit more of a kitchen sink approach. Some other things that people are often allowed to try even if there hasn’t been a definitive diagnosis of a particular cause for repeated losses/failures include:

  • progesterone shots instead of (or as well as) the pessaries – for after egg collection
  • a low-dose steroid such as Dexamethasone – to address any undiagnosed immune issues
  • Heparin shots – Heparin is a blood thinner, so this also addresses clotting factors

Finally, don’t forget that there’s good evidence that acupuncture improves pregnancy and live birth rates for patients undergoing IVF – and good reason to believe this is also true for couples trying to conceive naturally or with IUI. Click on the category Acupuncture and Chinese Medicine in the left-hand column to see more posts on this topic.

Choosing a good acupuncturist

Monday, October 12th, 2009

When I started ttc over the age of 40 and was gearing up for IVF, I decided I should start acupuncture to help maximise my chances. Boy, have I learned a few things since then!

How to tell if your acupuncturist is NOT a good choice:

I initially chose an acupuncturist who was quite close by, whom I eventually decided wasn’t a good choice. To help others choose a good one, maybe it would help to describe what made me think so …

  1. Didn’t ask me what day of my cycle I was on when I went, and didn’t alter acupuncture points according to where I was in my cycle.
  2. Did not have a clear understanding of IUI/IVF, i.e. what happens at different parts of the cycle.
  3. Didn’t seem to have a clear understanding of what happens in a natural cycle, e.g. when implantation occurs (7-10dpo).
  4. Wasn’t able to explain clearly what my Chinese medicine diagnosis was, or the rationale behind the treatment plan. [This wasn’t an ESL issue – the person was a born and bred kiwi.]
  5. In hindsight, seemed to be trying to treat so many things in one acu session (loads of needles; I was a total pincushion) that I started wondering if some of the points used were actually cancelling out the effect of others.
  6. Wasn’t actually formally trained in acupuncture. [I know, I know, what was I thinking?!]

When I switched to another [competent] acu, the difference was just night and day on ALL the above points.

Acupuncture Qualifications and Credentials

The New Zealand Register of Acupuncture has a list of those acupuncturists who are members of the NZRA. If someone is NOT a member of NZRA or another relevant professional association, you should certainly raise an eyebrow. However, the fact that someone is a member of one of these NZ ‘registers’ is NO guarantee of quality. The acupuncturist I mentioned above, who had NO formal qualifications in acupuncture, was (and is) a long-time member of NZRA. Current requirements to join NZRA include a “qualification that meets the NZRA’s criteria” and some form of clinical assessment, but it would appear that several acupuncturists with no formal qualifications appear to have been “grandfathered” into the association early on and not subject to these requirements.

So, who IS a good acupuncturist?

For those of you looking for an acupuncturist, here’s a list of people who come highly recommended by fertility patients around the country (note that I can’t vouch that they really ARE brilliant since I’m not a Chinese medicine dr myself, but am just sharing what others have said). The following interpretation guide should help:

**Absolutely raved about ALL the time by patients (including those who’ve had success!) AND I’ve also heard endorsements from at least one credible expert source
*
At least one or two patients have spoken positively about them AND I’ve also heard endorsements from at least one credible expert source
[no asterisk]
Have been recommended by patients, but I haven’t also heard any expert endorsement about their competence, nor any concerns

Auckland

  • Dr. Vitalis, Mairangi, North Shore, 09 486 5111 **
  • Laura Bradburn, Acudoc, Auckland Central, 09 626 7120 (but she’s apparently on maternity leave in late 2009)
  • Lisa Houghton, Acudoc (above) and the Motherwell Clinic, Mt Eden, 09-630-0067
  • Bessie Lu, Village Acupuncture, Mt Eden, 09 630 3168

Hamilton

Napier

Wellington

Nelson

  • John Black, Nelson Chinese Medical Clinic, 22 Nile Street, Nelson 03 546 8733 *
  • Paddy McBride, Acupuncture Richmond, 40 Oxford Street, Richmond, Nelson 03 544 0411 *

Christchurch

  • Dr. Tracey Bourner (Ph.D. in research), Riverside Acupunture and Chinese herbs, Opawa, 03 981 1683 *
  • Georgia Bryant, Acupuncture for Health, South Brighton, 03 388 7346 *
  • Eleanor Marks in St Albans 03 960 9702
  • Suzy Tapper, Ferrymead Acupuncture, 03 384 8589

What should I ask a prospective acupuncturist before agreeing to work with them?

Whether or not a prospective acupuncturist is on the above list, it’s always a good idea to ask them a few questions before you agree to work with them. Here’s a list of questions to help get you started:

Where did you train? What acupuncture or Chinese Medicine qualifications do you have? Have you done any advanced training or courses since then? Are you a member of the New Zealand Register of Acupuncturists or some other professional association? [The ‘gold standard’ would be a bachelor’s degree in acupuncture from a reputable school in China or elsewhere PLUS some advanced training (master’s degree or other), preferably specifically in acupuncture and Chinese medicine for fertility PLUS some sort of certification that actually evaluates competence. Note that being “registered in New Zealand” simply means being a paid member of a professional association and is no guarantee of competence.]
[Assuming this is at a first/introductory appointment:] What is my Chinese Medicine diagnosis? Please explain (in lay terms) what it means and what your treatment approach would be. [Just my view, but if someone can’t explain what they are doing in understandable terms, that’s a good indicator they don’t REALLY have a good understanding of it themselves.]
How would my treatment differ before vs. after ovulation in my cycle? [Wrong answer: It wouldn’t. A good answer might include explanations like: The follicular (pre-O) phase usually emphasises kidney yin treatment, whereas in the luteal (post-O) phase we typically treat kidney yang. Also, points used after O should be those that would support a pregnancy; some of the ones used before O are good for that phase of the cycle but not safe if you might be pregnant.]
How would my treatment differ during an IVF/IUI cycle vs. during a natural cycle? [Wrong answer: It wouldn’t. A good answer would show some thoughtful logic such as: You’d generally tend to use less aggressive acupuncture treatment while someone’s on stims – you don’t want to make their ovaries blow a gasket!]
What successes have you had with women/couples of a similar age and with a similar Western diagnosis to mine/ours? Please describe one or two recent success cases. [Obviously, more success cases similar to yours are better. But keep your ears tuned too for evidence of the kind of systematic detective work a good practitioner would use to ‘listen’ to how the body responds and tweak the treatment. A fertility-challenged body is like a squeaky old violin that needs to be worked with carefully to make it sing the sweetest tune it possibly can.]
What professional associations are you a member of? Which Chinese Medicine-related conferences and seminars do you regularly attend? How else do you keep up with new developments? [You want to make sure you are working with someone who understands Chinese Medicine as not just an ancient tradition that you get trained for once and that’s it, but as a growing discipline that creates new knowledge all the time. If your acupuncturist isn’t making an effort to keep up with the field, that’s not a good sign.]
What would you say are the two or three most important advances in Chinese Medicine for the treatment of infertility in the past few years. Do you have a copy of a good recent article I could look at? [If your prospective acupuncturist can’t rattle off a few really interesting recent developments that are relevant to your case, that’s a sure sign he/she isn’t keeping up with the play. And beware of someone who doesn’t want to give you an article “because you probably won’t understand it” – first, they may not actually have any relevant articles because they don’t keep up with the field, and second, that’s a hint that they don’t see you as an intelligent and active partner in your own treatment.]

If the choice is not clear cut after asking the above questions, I’d suggest doing a session or two with each possibility and seeing which one seems like a better fit for you. Even the raved about acupuncturists on the list above have some patients who just don’t ‘click’ with their style. So, make sure the person you choose feels right for you.

· Where did you train? What acupuncture or Chinese Medicine qualifications do you have? Have you done any advanced training or courses since then? Are you a New Zealand registered acupuncturist?

[see Qualifications and Credentials, above for how to evaluate answers.]

· [Assuming this is at a first/introductory appointment:] What is my Chinese Medicine diagnosis? Please explain (in lay terms) what it means and what your treatment approach would be.

[Just my view, but if someone can’t explain what they are doing in understandable terms, that’s a good indicator they don’t REALLY have a good understanding of it themselves.]

· How would my treatment differ before vs. after ovulation in my cycle?

[Wrong answer: It wouldn’t. Correct answers would include: The follicular (pre-O) phase usually emphasises kidney yin treatment, whereas in the luteal (post-O) phase we typically treat kidney yang. Also, points used after O should be those that would support a pregnancy; some of the ones used before O are good for that phase of the cycle but not safe if you might be pregnant.]

· How would my treatment differ during an IVF/IUI cycle vs. during a natural cycle?

[Wrong answer: It wouldn’t. Correct answer: You’d generally tend to use less aggressive acupuncture treatment while someone’s on stims – you don’t want to make your ovaries blow a gasket!]

· What successes have you had with women/couples of a similar age and with a similar Western diagnosis to mine/ours? Please describe one or two recent success cases.

[Obviously, more success cases similar to yours are better. But keep your ears tuned too for evidence of the kind of systematic detective work a good practitioner would use to ‘listen’ to how the body responds and tweak the treatment. A fertility-challenged body is like a squeaky old violin that needs to be worked with carefully to make it sing the sweetest tune it possibly can.]

· What professional associations are you a member of? Which Chinese Medicine-related conferences and seminars do you regularly attend? How else do you keep up with new developments?

[You want to make sure you are working with someone who understands Chinese Medicine as not just an ancient tradition that you get trained for once and that’s it, but as a growing discipline that creates new knowledge all the time. If your acupuncturist isn’t making an effort to keep up with the field, that’s not a good sign.]

· What would you say are the two or three most important advances in Chinese Medicine for the treatment of infertility in the past few years. Do you have a copy of a good recent article I could look at?

[If your prospective acupuncturist can’t rattle off a few really interesting recent developments, that’s a sure sign he/she isn’t keeping up with the play. And beware of someone who doesn’t want to give you an article “because you probably won’t understand it” – first, they may not actually have any relevant articles because they don’t keep up with the field, and second, that’s a hint that they don’t see you as an intelligent and active partner in your own treatment.]

2-day, 3-day or blast transfer?

Friday, September 25th, 2009

When you do IVF, it is possible to transfer your embryos

  • on Day 2 after egg collection (usually 4-cell embryos),
  • on Day 3 after egg collection (usually 8-cell embryos) or
  • on Day 5 (after the embryos have reached blastocyst stage).

If you have only a small number of embryos and plan to transfer them all, the usual procedure is to put them all back on Day 2 because the uterus is the best possible place for them. However, if you’re doing assisted hatching, you usually need to keep them out for one more day and transfer on Day 3.

If you have a large number of embryos, and particularly if several of them are high grade, you will usually be encouraged to take them all to blast because that turns your ‘longlist’ dilemma (which to choose, which to choose …) into a ‘shortlist’ of embryos that are more likely to be viable.

As any specialist will tell you, odds of a pregnancy with a blastocyst transfer are higher than the odds with a Day 2 or Day 3 embryo transfer. This is an undisputed fact.

Some specialists will also tell you the extreme version of this (which is not actually proven, and is IMHO quite questionable), i.e. that if your embryo doesn’t make it to blast it wouldn’t have been a viable pregnancy anyway.

At virtually all NZ clinics (from what I have heard), the default is to make any leftover embryos go to blastocyst stage before they are frozen. The kicker is that many (and sometimes all) embryos don’t make it as far as blastocyst, i.e. they die in the petrie dish some time between Day 3 and Day 5.

Why does my clinic want us to take our embryos (or leftovers) to blastocyst stage?

The main reasons for these policies (as I understand it) are:

1. For women and couples with a large number of embryos, it is often difficult to tell which are the ‘winners’ that should be put back to give the best odds. By taking them all to blast, only some will make it, and in the ones that do, quality differences will hopefully be more obvious, thereby making the choice easier.

2. There are loads and loads of frozen embies that will never be used and no-one knows what to do with them. Ethical dilemma, and a logistical storage dilemma. Getting people to take their fresh embies to blast, and/or making any leftovers go to blast, cuts those numbers down.

3. More frozen embies means more TERs, which means greater expense for the govt (if you are publicly funded) or greater expense for couples (if you go private) – and more stressful 2wws with lower chances of a BFP each time (compared to a blast transfer). If those embies aren’t going to make it, they think you are better off finding out during the 2ww of your fresh cycle than prolonging the agony and expense. [Personally, I think this is a trade-off each couple needs to consider for themselves; having all frosties tank while you’re in the 2ww makes a VERY stressful time even worse.]

4. They don’t want to give people the “false hope” of thinking that their spares in the freezer are potential children because most of them are not. Quite apart from the points made in #3, above, if you’re an older mum, the months you spend doing TERs that end in BFN are months you are getting older before trying another fresh cycle. [I know some women overseas who cycle and freeze several times before transferring ANY for this reason; if they do get pg on the fresh cycle they will be too old and very low odds by the time they try for a sibling, so they bank several embies up front in the hopes that they might get 2-3 kids out of the lot. I have a friend who banked about a dozen embies at age 43-44, got pg on her last fresh cycle at 44, now is 46 and looking to do TERs, thankfully using embies made at age 43-44, not the near-zero-odds ones she’d produce now (if any).]

5. If you’re transferring blasts it’s easier to talk couples into transferring just one (because of the higher odds) and this reduces the number of twin births, which reduces the burden on the taxpayer, health system, the pregnant mum (twin pgs are sooooo not fun, trust me!), and the parents (possibility of losing one or both is higher, health problems are higher in twins than singletons, the first few months in particular are really really gruelling).

So, what are the main arguments against making your fresh embryos or leftovers going to blast?

The big issue here is, of course, could a potentially viable embryo die in the lab when it would have lived in utero? It’s unlikely but possible, in my view. Here’s why:

1. The number of embies that don’t make it to blast seems to me to be far higher than you’d expect for the age of the woman. Just an observation. This not only raises suspicions for me that viable embies are being lost this way, but in all those cases where there are none left to freeze (so many recently, it’s heartbreaking), it also massively increases the stress when you are in the 2ww and find out that EVERYTHING now hinges on your fresh cycle. Even if the day 3ers aren’t viable, some couples would rather have the psychological comfort of knowing there was another non-zero chance if they get a BFN.

2. There are some absolutely clear cases where people have had babies from embies that any self-respecting embryologist would stake their career on their not making it to blast. Case in point a board buddy of mine who put back four including two 5-cells that were so fragmented they looked like dollops of oatmeal, in her words. The embryologists gave them NO hope of surviving, so she just thought what the heck, put them all back. She’d had 5 failed IVF cycles already and was 35. She got pg with quads including one set of identical twins, so one of those oatmeal dollops turned into a baby (or two!). They are now 6yo, BTW.

3. The research apparently shows that blast pregnancies are more often boys, yet this is not the case with IVF pgs from 3-day transfers. This strikes me as extremely compelling evidence that SOME genetically normal girl embryos for some reason don’t make it in the lab but DO make it in utero.

It’s not an exact science of certainties; it’s a mix of probabilities and possibilities. Each couple is going to weigh these considerations quite differently. A lot depends on the woman’s age, how many cycles and TERs you can do without going broke or insane, how many kids you want eventually (and how you feel about ‘surplus’ embryos once you’ve achieved your quota), how stressful the various scenarios are to YOU, how many eggs you get each time, etc etc. Also, the aforementioned downtime (with the woman getting older) while you try multiple low-odds TERs instead of moving onto another fresh cycle.

The major issue I have with this is that IMHO (and based on reports from women all over the country I have spoken to) clinics in New Zealand consistently fail to consult adequately with patients, particularly on whether leftover embryos are taken to blast. The vast majority of patients are left with the impression that they had no choice in the matter. Frequently, ALL leftover embryos die before making it to blast, and patients are upset and dismayed to find out that they COULD have asked for their leftover embryos to be frozen on Day 3 instead. Here’s a typical comment from an IVF patient:

I had no idea we had the opportunity to freeze embies at day 3. This has NEVER been offered to us. From what we understand they are to be frozen day 5. We unfortunately have never had any to freeze as we’ve waited to day 5 for them to get to blast. I didn’t even know it was possible? I wonder why [my clinic] have never mentioned this?

This situation is especially upsetting if you are on your last IVF cycle and can’t ttc any other way (e.g. because of no tubes or MFI/sperm issues). When you’re standing in those shoes, it can just feel like the clinic has done everything it can to get you off their books (or onto another fresh cycle and more $$ in their coffers). I’m not saying that’s the motivation behind what clinics do; I’m just saying that can be what it feels like for patients who haven’t been offered the opportunity to give genuine informed consent on an important aspect of their treatment.

So, how should we tackle this and make sure we get what we want?

  • Think through these issues ahead of time and discuss them as a couple – there are trade-offs for either choice and there’s no single right answer
  • It may also be useful to ask the clinic lab/embryologists for some concrete data on what % of embryos make it to blast for women your age
  • Discuss the issue with your doctor and state clearly what you want
  • Write on your IVF consent form exactly what you want – make sure the nurse is clear on this too
  • Confirm this with the embryologist when you meet with them (e.g. at egg collection)
  • Confirm this AGAIN with your embryologist when you go in for embryo transfer
  • If you get any resistance from the embryologist, call in your doctor and refer them both to your consent form – INSIST on what you want. It’s your right!

Our IVF/IUI/TI cycle just failed … What should we be asking at the review?

Thursday, September 24th, 2009

After all the waiting to GET on the waiting list and then all the waiting ON the waiting list, finally you got to try the “big guns.” You’ve somehow overcome your fear of needles, vaginal scans and then (for IVF) the dreaded egg collection procedure; you’ve survived the harrowing 2ww … and it’s a BFN. Or a chemical pregnancy. Or a pregnancy and then a miscarriage.

After all that anxiety, fear, hope and expectation, a failed cycle is just devastating. You’re booked for a review appointment with your specialist – but what should you be asking about now?

The most important question, of course, is WHY your cycle failed. There could be many possible explanations, some of which are just guesses and some of which are backed by concrete evidence or could be investigated further.

You don’t want to go through the expense and stress of another IVF cycle and only afterwards find out there was something else you should have addressed first. Here’s a quick list of other things you should be sure to have checked out if you haven’t already:

  • Male Factors. A full semen analysis is necessary – not just counts/motility/morphology but also tests for antisperm antibodies and SCSA (tests for DNA fragmentation).
  • Polyps and Fibroids. Uterine polyps and fibroids, even if they’re small, can influence the menstrual cycle and can interfere with implantation. They can typically be seen via ultrasound and can be removed through a relatively simple surgical procedure.
  • Thyroid Issues. Thyroid issues can impact fertility and need to be ruled out as a contributing factor. A thorough thyroid test needs to include TSH, free T3/T4 and anti-thyroid antibodies.
  • Ureaplasma. Ureaplasma is an infection for which you should be tested. “Ureaplasma may cause the formation of sperm antibodies and an inflammation of the uterine lining, either of which may interfere with implantation of the embryo” (Source)
  • Factor V Leiden. Testing for Factor V Leiden is also important. “Factor V Leiden is a relatively common hereditary blood coagualtion disorder and can lead to stillbirth or unexplained recurrent miscarriage” (Source)
  • Hysterosalpingogram (HSG). An HSG is a test to determine whether the fallopian tubes are open. Even if you’re doing IVF this is important because you could have a hydrosalpinx, which is a blocked tube that leaks toxic fluid into the uterus and can affect implantation. (More info)
  • Recurrent miscarriage/recurrent implantation failure testing panel. In New Zealand, the usual procedure is to run a set of blood tests (on the female partner) such as:
    • Coagulation screen
    • Thrombophilia screen
    • Autoantibody screen incl.
    • antithyroid antibodies,
    • anti-gliaden antibodies
    • Factor V Leiden
    • Karotype
    • MTHFR mutation
    • Anticardiolipin antibodies
    • Lupus anticoagulant
    • … and a karotype for the man

Follow this link for a very comprehensive list of possible causes of recurrent miscarriage that can be investigated systematically if you need to do some more serious digging.

  • Endometriosis. If you have period pain that requires more than a couple of Panadol (or any other of the possible symptoms of endometriosis), ask for a laparoscopy to investigate. Endometriosis is quite common and often missed or misdiagnosed, e.g. because women think their period pain is normal. For more information, check out Endometriosis New Zealand’s excellent website.

OK, nice laundry list, but what should I be asking my doctor?

Before your review appointment, if you did IVF, call the embryologist who worked with you during your cycle and ask him or her what they thought about the quality and maturity of your eggs, the fertilisation rates and the quality and development of your embryos. If you can, it’s best to do this soon after (or, the day you go in for) embryo transfer so that it’s fresh in the embryologist’s mind. Pump them for any information you can get.

When you see your doctor, start with an open-ended question about what he or she thought went well in your cycle and what didn’t. Summarise what the embryologist told you as well and ask the doctor to comment.

Your next question should be around the various other possible causes of cycle failure listed in the bullet points above. How many of these have we eliminated as a possible cause, how did we do so, and which of them should we investigate before leaping into another cycle? Make sure you study these beforehand and think whether you recognise any relevant symptoms.

You may find yourself in a situation where the doctor pronounces you have an egg quality problem. Now, this is a difficult one because, from a Western medicine perspective it’s seen as untreatable and just the hand you’ve been dealt. Further, this is really little more than an “eyeball” assessment, assuming you haven’t done a PGD (preimplantation genetic diagnosis) IVF cycle where the embryos are actually tested for chromosome abnormalities. Visual egg and embryo quality is correlated with chromosomal normality/abnormality and pregnancy rates, but it isn’t a direct assessment of these things. You can definitely have great looking eggs/embryos that are abnormal. And there are a few instances where very scrappy, sad-looking eggs and embryos turn into perfectly normal babies, but unfortunately not very often.

If you do get the “bad eggs” speech, there are a couple of questions you should raise. One is whether you can try a different protocol that might be better suited to your delicate eggs. For example, some specialists argue (and have evidence) that higher doses of stims can “fry” some women’s eggs, so that a lower dose may be more gentle and damage them less. [I personally had a dramatic improvement in embryo quality when I dropped my dose from 450IU to 150IU, and I know others who have experienced the same.]

The other thing to insist is that “bad eggs” isn’t just assumed to be the ONLY cause of your failure. Even if it’s true and you are looking at moving forward with donor eggs, you need to be sure you don’t have uterine or autoimmune issues or endometriosis (etc) that could jeopardise the success of that cycle.

Most fertility specialists in New Zealand don’t really buy into the idea of alternative medicines, but if you’ve been given the “bad eggs” or “old eggs” speech, I’d strongly recommend reading the following piece by Dr. Randine Lewis about the Chinese medicine perspectives on “poor egg quality” and whether there’s anything you can do to address it.

This website/blog also has several posts on acupuncture and Chinese medicine – see the menu at left to find items on that topic.

New and “untested” treatments

Wednesday, September 23rd, 2009

Here’s a topic that comes up for discussion quite a lot.

“My dr won’t let me try X – why not?”

“My doctor talked about the ethics of infertility treatment and how some clinics will try (and charge for) all sorts of unproven treatment where often there was no medical reason for a particular patient to require that unproven treatment.”

The unproven treatment issue is a really interesting one because most medical professionals consider “proven” to mean something supported by multiple randomised controlled trials. The problem is that cutting-edge ideas are new and haven’t had the chance to be sufficiently trialled (or, in some cases, don’t lend themselves to such randomised designs for ethical and/or practical reasons).

So, should all the new ideas be ignored until they are considered “proven”?

Well, here’s how I tackled this dilemma with our doctor. If I’d already tried the standard options and if there was another idea that (a) wasn’t too off the wall, (b) had at least a plausible basis in theory, (c) had some small-scale evidence that it might help and (d) there was no logical reason to think it would hurt, then we’d discuss it and he’d often agree to let us give it a shot.

Of course, there were quite a few things I argued pretty hard on and he just wouldn’t do it because he didn’t think there was sound enough reason. He always explained why and didn’t treat me like an idiot – very important; I think every patient has the right to expect this.

Moral of the story:

  • Do educate yourself about the various options and ideas that might help someone like you
  • Do ask your doctor about them – and take copies of any research papers you can find
  • Do insist your dr explains their rationale for not trying them – or for tweaking them before trying them
  • If, after you listen to the rationale, it still seems to you that your doctor is being overly conservative in not trying something that seems to make sense to you, do seek out a second opinion

When you’ve only got a few shots at something so life-changingly important as conceiving a child, you owe it to yourself to make sure you don’t get to the end of the struggle with regrets and what-ifs. Leave no stone unturned!

See also: