Frequently Asked Questions

infertility questionsWelcome to the frequently asked question part of our site. Please browse the questions below or search for your specific question before you ask a new one with the form at the bottom of the page.

All the information provided here is for general informational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. We make every effort to provide medically accurate answers, but everyone is different and what is correct for one person may not be correct for you. If you have a serious question about a medical condition of symptom you should seek the advice of your physician or another qualified healthcare provider.

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When to see a fertility Doctor

How long should we try before seeing a Fertility doctor?

You may consult a fertility physician (Reproductive Endocrinologist or REI) any time if you have difficulty conceiving. You can try for up to a year if you are 34 or under, or for up to 6 months if you are 35-39. See a REI right away if you are 40 or over, if you have irregular cycles, if you have had a previous ectopic pregnancy, chlamydia or Pelvic Inflammatory Disease, if you have had endometriosis or ovarian surgery, or if your partner has known sperm issues.

What is the difference between a Fertility specialist and seeing my Ob/Gyn

Reproductive Endocrinology and Infertility or REI MDs are sub-specialists: we train in Obstetrics and Gynecology (OB/Gyn) then do advanced study of male & female hormonal conditions (endocrinology) and infertility testing and treatment including IVF. REI should be board-certified, except for a few older docs. Ob/Gyn MDs offer prenatal care, delivery, gynecologic care & surgery. Fertility specialists can help you get pregnant, including women with recurrent miscarriage, and look after you in early pregnancy, before transferring your care to an Ob/Gyn when you’re ready to graduate from our program!

Do I need a referral from my Ob/gyn or Primary Care MD to see you?

ORH does not require a referral, but your insurance company may require that you have one. Check with your insurance plan if you need a referral or if you have to register with them to get fertility coverage. If you are referred by a physician or other health professional, please let us know. It is helpful to request records of your previous testing and treatment so that we can review them. Many of our patients are referred by friends, coworkers or family members, including former patients of ours who have been successful.

Can I check to see if I am OK to wait a few years before having kids?

If you want to have fertility testing but are not ready to start a family yet then we can help to some degree.  The problem is that the testing of ovarian reserve and other associated factors that we can look at are not a definitive answer.  Things can also change very rapidly with anybody, and so no guarantees can be given.

I had PIH all three times I was pregnant. Would IVF be considered on someone like me despite the risk of PIH etc?

More details: I had 3 pregnancies in the past, and have three children (all c section, the first had a prolapsed cord at 8cm) I had PIH all three times I was pregnant, this was controlled by left side/bedrest etc. After the third I had my tubes burned and tied. I have since divorced and am in a relationship with a wonderful man who doesn't have kids but would like to. Would IVF be considered on someone like me despite the risk of PIH etc?

Well, ultimately the final answer would be dependent upon the specifics of your medical history, a history of pregnancy induced hypertension (PIH) in of itself would certainly not prevent you from consideration for IVF at this clinic. The next step in the process would be to schedule a new patient appointment. We would love to see you.

What happens during my first IVF appointment?

Your doctor will get to know you, review your medical history and your partner's history, and usually do a quick physical exam for you at the first visit. Many fertility doctors don't perform a pelvic examination on the first visit, but some do. We get much more information from a pelvic ultrasound scan. Some clinics do an ultrasound on the first visit, others will bring you in for an ultrasound at a later visit, usually in the first few days of your menstrual cycle.

Typically, your doctor will talk to you about why you may need In Vitro Fertilization (IVF) treatments, and she or he will often need to arrange testing to make sure that you're a good candidate for IVF, even if IVF is the right treatment. If you have had any previous fertility testing or treatments it is very helpful to provide these records before the first visit so that your MD can review them - this may avoid duplicating tests that don't need to be redone. You will usually be offered prenatal testing: checking your blood type, making sure you don't need any vaccines before pregnancy, and offering optional genetic screening tests. Your doctor will explain the IVF process to you, either at the first visit or at your follow-up visits.

This is a general overview, but I hope it helps. Contact your fertility clinic if you have specific questions or concerns, of course.

Can I get pregnant with …

Can I get pregnant with irregular cycles or no periods?

There are ways that we can monitor you to try and determine the reason behind your irregularity and/or lack of menstruation.  There are many ways that we can overcome a lot of issues, but more information from a full work up is needed before we can predict your chances of success.

Can I get pregnant after a tubal ligation (tied tubes)?

After tubal ligation After you have had a tubal ligation it is totally possible to attempt to initiate a pregnancy again. You can undergo a reversal of the tubal ligation in some circumstances depending on how the original surgery was carried out. The other option is to undergo an IVF cycle, which totally bypasses the tubes altogether by taking the eggs from the ovary, making embryos in the laboratory and then transferring them directly into the uterus. A consultation with one of our doctors will allow us to determine the best possible treatment for you and help you on your way.

Can I get pregnant after I have been diagnosed with PCOS

PCOS is a condition that can have serious effects on your ability to achieve a pregnancy, but it is something that can be controlled in a variety of ways.  Once again it is recommended that you have a new patient consultation and a series of investigative testing to determine the best way to proceed with treatment.

Can I get pregnant if I am over 40 years old?

Unfortunately there is a biological clock, and although it starts to tick louder at different times for different people it is very probable that you are going to have some issues over the age of 40. That being said, the only way to find out exactly what your chances of success will be with your own eggs is to have a series of fertility investigations carried out. We will be able to give you a better understanding of your own fertility after that, and then help you decide between the idea of either using your own eggs or those of an egg donor.

Can I get pregnant if I am a single woman?

We do not make any judgments against single women seeking treatment and all infertility investigations are going to be carried out the same as they would be for the female half of a couple. The only difference is that you will need to use sperm from a donor, but there are plenty of donor sperm banks that have a wide range of different donors to choose from. We are able to use sperm from a number of these different banks and we will advice you the best way of proceed with that selection..

Can I get pregnant if I am in a same sex couple?

As far as same sex couples go there are a number of different ways that treatment can be carried out.

When we are talking about treating a female couple then we can either do an intrauterine insemination with donor sperm or we can move to IVF if needed, again with the use of donor sperm.  If the treatment is going to be IVF, then it is possible to use the eggs of one of the couple and then after insemination with donor sperm, the other woman could have the embryos transferred into her uterus.  In this situation it will potentially allow them both to feel more connected to the child.

In the case of a male couple it is going to be a little more complicated as there is going to need to be an egg donor and a surrogate to carry the pregnancy.  This could potentially be in the form of traditional surrogacy when an IUI with the sperm of either of the guys is used, or more commonly when an egg donor undertakes an IVF cycle and the resultant embryos are transferred into a separate surrogate.

In any of the above mentioned situations there will need to be legal documents drawn up and we can point you towards appropriately informed experts.

Can I get pregnant after my partner had a vasectomy?

In the case of a vasectomy, there are a few options open to you in order to try and conceive.  Potentially the simplest treatment is to use donor sperm.  This is not always an option that some couples would like to take, and there are ways to attempt to obtain your partners sperm after the vasectomy.  The first is to actually reverse the vasectomy, a surgical procedure that is carried out by an urologist.  A potential benefit of this is that if the reversal is successful you may not need any more intervention to achieve a pregnancy.  The problem though is that there are often a lot of other issues that come with that surgery that dictates the need for further treatment such as IUI or even IVF anyway.  Another option is to attempt surgical sperm retrieval, again in a urology office.  This will, in most cases, also require the woman to undergo an IVF cycle, but depending on the length of time since the vasectomy was originally carried out it may be more appropriate.

Yet another option would be to have the vasectomy reversed, but at the same time attempt to retrieve sperm at the same time, and freeze that sample if appropriate.  In this situation if the reversal is not successful then there is the back-up of having some frozen sperm without the need for another surgery.

Is it impossible to have a baby once menopause has finished?

Menopause really means that your periods have stopped forever, but in practice we consider it menopause after a year with no periods in women in the typical age range for menopause (average age is 51). There is a very very small chance of releasing an egg and getting pregnant after 'natural' menopause with one year of no periods. This chance is much higher in women who go through 'premature menopause' at a young age, which is more correctly known as Primary Ovarian Insufficiency or POI, and can happen in the 30's or even 20's. Obviously surgical menopause, after both ovaries have been removed, has very little chance of pregnancy at any age, though sometimes part of an ovary is left behind after surgery.

So assuming you are around 50 and have had no periods for a year, the chances are very slim of getting pregnant naturally - close to zero but not impossible. Egg donation is very successful (75% to 80% success rates and higher) for women with POI or menopause of any age who want to get pregnant, but most clinics have a maximum age for treatment. If there is no disease of the uterus success rates are as high as for younger women, but there can be more pregnancy complications and a higher risk of C/section. Some women have medical problems like kidney disease which may make pregnancy inadvisable. Talk to your Ob/Gyn or see a Fertility MD if you do want to have a baby.

What is the best way to see if we can get pregnant?

About 85% of couples get pregnant after a year of trying. It could still happen 'naturally' (at two years it's over 90%) but if you have been trying for more than one year or more (under 35 years of age), 6 months or more (36-40 years of age) or if you are over 40 years of age this is a good time to see a Fertility specialist (Reproductive Endocrinology/Infertility or REI) to find out why your partner is not getting pregnant and to help you to get to that first child.

REI physicians train in Ob/Gyn before specializing in fertility medicine. They can do tests to check the number of eggs left in the female partner's ovaries (ovarian reserve) which can go down as women get older. She should also be checked for hormonal problems which can stop her from getting pregnant including thyroid problems or polycystic ovarian syndrome (PCOS), and the MD will check her uterus for fibroids or polyps and perform a hysterosalpingogram or HSG test to make sure that her fallopian tubes are both open and look normal.

It takes two to get pregnant of course, and the man has a sperm problem in 40-50% of couples trying to conceive, so you will need a semen analysis (sperm test). If there is a sperm issue, it may be the only reason that the female partner is not pregnant yet, or a contributing factor along with problems on the female side. Most REI docs like to see you both partners as a couple, but it is not mandatory that you come to the first visit.

After these tests there are specific treatments for improving fertility depending on the cause(s) we find, such as Clomid can help her ovulate (release an egg) or release more than one egg in a month. Clomid can be combined with Intrauterine Inseminations (IUI) where the sperm is washed and placed inside her uterus. Some couples may need more intensive treatment such as In Vitro Fertilization (IVF).

In short see a specialist for testing and to come up with an individualized treatment plan to help your wife get pregnant. Lifestyle changes may help if needed as well - quit smoking, avoid heavy drinking and drug, and aim for a normal weight applies to both of you.

Can I still conceive after being diagnosed with hydrosalpinx?

Do you have a hydrosalpinx (a tube that is totally blocked at the end farthest away from the uterus) on one side or both sides? If only one side, you can get pregnant from the other tube, but having a hydrosalpinx lowers your chances.

If both sides are blocked you need IVF to conceive, but the chances of success with IVF are higher if you have surgery to disconnect or remove the hydrosalpinges first. For women undergoing IVF, having a hydrosalpinx on both sides reduces the IVF success rate by a third to a half. Fluid inside the blocked tube may be toxic to embryos, so the chances that embryos will implant inside your uterus are reduced - this lowers your success rate with IVF, with other fertility treatment like intrauterine inseminations (IUI), or with 'trying on your own'. One-sided hydrosalpinx may have less effect. Removing the hydrosalpinx or disconnecting it from the uterus improves your fertility. Traditionally this is done with outpatient laparoscopic surgery; we have less-invasive hysteroscopic options as well such as Adiana or Essure to block off the tube where it joins the uterus.

A hydrosalpinx does not stop your ovaries from producing eggs or releasing eggs (though it of course stops the egg and the sperm from getting together inside the blocked tube). Having said that, the disease that blocked your tubes may have damaged your ovaries and caused low egg supply (diminished ovarian reserve). Pelvic infections like chlamydia or Pelvic Inflammatory Disease (PID) are the most common causes of hydrosalpinx, less commonly endometriosis, previous surgery, or ruptured appendix. Low egg supply reduces your chances of conceiving no matter what your age is.

Most women with hydrosalpinx do not need to use a gestational carrier - as long as you're willing to have the hydrosalpinges treated with surgery. Reasons to use a gestational carrier are diseases of the uterus that are not fixable with surgery (like severe scar tissue after fibroid removal), removal of the uterus (hysterectomy), medical conditions making pregnancy unsafe for you, and rarely for repeated implantation failure with IVF embryos.

With a hydrosalpinx I recommend seeing a Fertility specialist MD (Reproductive Endocrinology / Infertility or REI MD), who can do tests including checking you for diminished ovarian reserve, and then come up with an individualized treatment plan to help you get pregnant.

Is IVF the only viable treatment after being diagnosed with a bilateral hydrosalphinx?

Without knowing about your particular case - there are 3 options:

1. Laparoscopy and attempt to re-open one or both tubes, probably with lysis of adhesions - cutting / burning / lasering any scar tissue around the tubes / ovaries

Sometimes a tube can't be re-opened, for example if it is covered in too much scar tissue and stuck to your bowels. Sometimes the tube is stretched out and damaged and may not work well even if the surgery successfully re-opens one or both tubes - this is more likely if the hydrosalpinx is large or has been there for a long time (a chronic hydrosalpinx). If you get pregnant after this type of surgery you have a chance of an ectopic (tubal) pregnancy.

If one or both tubes are not "fixable" they can either be removed at the time of laparoscopy of tied or interrupted close to your uterus so that the hydrosalpinges don't leak fluid into your uterus that lowers your chance of pregnancy with In Vitro.

Pregnancy rates after laparoscopic opening of the tubes (neosalpingostomy) are low - about 20 - 32 % of women get a pregnancy in the uterus, and 5 - 16% get an ectopic (tubal) pregnancy. See the link below. There are few surgeons offering microsurgical tubal surgery at this point.

2. Block your tubes then do In Vitro fertilization (IVF) - this can be done with laparoscopy and tying your tubes or removing the hydrosalpinges. There are two less invasive surgical options where your MD can do a hysteroscopy (done through the uterus with no incisions on your belly) - these are called the Essure or Adiana procedures. These are quicker surgeries with an easier recovery than with laparoscopy, but the Adiana and Essure have a small failure rate.

If both tubes are blocked and you are under 35 with normal ovarian reserve (egg supply) the success rate of IVF can be as high as 60-65% - double to triple that of surgery to open your tubes. If you are a good candidate for IVF this should be your best option for getting pregnant. If you have extra embryos we can freeze them so you may get more than one attempt to get pregnant out of one IVF treatment cycle.

3. Go through IVF without any surgery on your tubes - this can cut the success rate of IVF down by a third to a half, maybe down to the 30-45% range.

Your individual case may be different, and it is worth testing your ovarian reserve (egg supply) and your partner's sperm before making a final decision - if he has a very low sperm count IVF with ICSI (where we inject one sperm into each egg) may be the best option, preferably after blocking the hydrosalpinges.

Hope this helps. I recommend seeing a Reproductive Endocrinology / Infertility specialist (REI) MD for a more detailed discussion of your options.

General Fertility FAQs

When is the best time to use ovulation kit?

The second morning urine is the best time to test - roughly between 10 am and noon. The ovulation predictor test looks for a hormone called LH or luteinizing hormone in your urine. LH hormone surges 24 to 36 hours before you ovulate, but the surge may occur first thing in the morning and it can take 4 hours for the hormone to come out in your urine, so first morning urine is not the best time to test.

If you have 28 day cycles, test between days 10 to 18. If your cycles are longer but regular, like 32 days, start 32 minus 28 or 4 days later - days 14 to 22. Day 1 is the first day of your period. See a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) if you're not pregnant after up to a year of trying and you're 34 years old or under, or not pregnant after six months of trying if you're 35-39. See a REI soon if you have irregular cycles, or you're 40 or older.

Does Acupuncture help with infertility treatments?

Acupuncture may help fertility, but it is not supported by high-quality scientific evidence. One study performed in Seattle had lower pregnancy rates in the acupuncture group doing IVF compared to the no acupuncture group . It’s very hard to conduct properly-controlled trials: for a drug we might compare the pregnancy rate for women taking the drug compared with women taking a sugar pill or placebo, or another drug. For acupuncture it’s hard to define a placebo (fake treatment) group – either putting the needles in the 'wrong places' or using needles that retract - you still get acupressure not acupuncture. We are OK with couples who wish to use acupuncture, but we do not recommend Chinese herbal treatments, as these may have hormonal effects or interact with fertility medications.

Is gamete cryopreservation and fertility treatment for cancer patients covered?

If your insurance doesn't cover it (worth checking) look into Fertile Hope, who offer discounted treatment and/or free medications.

How do you know if you ovulate every month?

Women who don't ovulate don't have regular periods. An Ovulation Predictor Kit is a good way of confirming that you are ovulating – get it from a pharmacy, don't buy a monitor. Start testing every day from Day 10 in your cycle (Day 1 is the first day of your period). Test between 10 am and noon as the first morning urine is not as accurate. We recommend the Ovuquick brand (search online and get the 9-stick pack not the 6-pack). If you test for a couple of months and it's not working see your OB or a see a fertility specialist (Reproductive Endocrinology and Infertility or REI) if you’re trying to conceive.

What is the most effective procedure and medication for couples with unexplained infertility?

After fertility testing, we rarely see 'unexplained infertility'. We used to think 15-20% of infertility was 'unexplained' (with regular cycles, open tubes, and good sperm) - with modern testing it's under 1%. Ovarian reserve testing (ultrasound for ovarian volumes and antral follicle count, Antimullerian Hormone or AMH, and the Clomid Challenge test) 'explains' a lot but there are other possible factors. See a board-certified Reproductive Endocrinology and Infertility or REI specialist for more detailed testing and to give you treatment choices: inseminations (IUI) combined with medications to increase the number of eggs  IVF can be appropriate, depending on your case.

How soon after ovulation can I get a pregnancy test?

A sensitive home pregnancy test should be positive 15 days after ovulation. If the result is unclear get a blood pregnancy test (quantitative beta hCG) through your OB/Gyn. How accurately you determined the day of ovulation may affect the results - ovulation predictor kits are most accurate if you have regular cycles. Basal body temperature (BBT), checking cervical mucus, and tracking symptoms of ovulation are less reliable.

At what age do women stop being able to have children?

On average it's in the 40's, and fertility for most women is very low at 45 and older with their own eggs. There are many individual factors however - we see women in their 20's who can't conceive naturally, and there are healthy pregnancies in 47 year olds, and everything in between. Using egg donation there may be no biological upper limit but risks are higher in the 50's: women 55 and older should not try to conceive.

How long after conception does a person usually find out that they are pregnant?

Roughly two weeks after conception, or about 15 days after a positive ovulation test. If your pregnancy hormone levels are high enough, home pregnancy tests may turn positive a few days before the date of your 'missed period'. Blood pregnancy tests are more sensitive.

What are the first steps in an infertility evaluation?

See a Reproductive Endocrinology and Infertility or REI MD, who will review your medical history and your partner's history, examine you, and recommend appropriate fertility tests for both of you. These may include blood work to check your ovarian reserve (egg numbers and quality) and to check for hormonal problems, an ultrasound scan of your uterus and ovaries, a Hysterosalpingogram (HSG) to check your tubes, and a Semen Analysis for him.

How can I naturally become more fertile?

Lifestyle changes that may help include aiming for a normal weight if you're underweight or overweight, stopping smoking, avoiding heavy alcohol use, and avoiding illegal drugs as well as prescription narcotic pain medications. High caffeine intake may increase the risk of miscarriage, based on a single study - stick to one cup of brewed coffee a day and decaf for the rest (no espresso-based drinks). There are no well-proven herbs or supplements, but Coenzyme Q10 (CoQ10) 500 – 1000 mg a day, may help older women.

If a woman was experiencing infertility, what kind of background events or history is important to know?

Her age is important. Other important factors are her previous pregnancy history, including miscarriages and ectopic pregnancies, and whether or not she has regular periods. We will ask if she has any history of endometriosis, ovarian surgery, Chlamydia or Pelvic Inflammatory Disease (PID) infections, smoking, or cancer therapy (rare). Previous fertility treatment(s) such as Clomid, Inseminations (IUI) or In Vitro Fertilization (IVF) are important to review too, and whether or not these treatments were successful.

What are treatment options for secondary infertility?

First we do tests to find the cause(s) - including diminished ovarian reserve (low egg supply), hormonal issues, blocked tubes, polyps or fibroids inside the uterus, or sperm problems. Treatment depends on the results but may include fertility tablets like Clomid or letrozole with Intrauterine Inseminations (IUI), injectable medicines and IUI, In Vitro Fertilization (IVF), egg donation, or embryo donation.

Is a HSG test effective for infertility treatment?

The Hysterosalpingogram (HSG) test is a diagnostic test, and is the best non-surgical way to check that the Fallopian tubes are open, and that they are normal-appearing. It's also a good screening test that can pick up polyps or fibroids inside the uterus. Sometimes we see evidence of scarring around the tubes. It's an important fertility test to do before treatment. Some women get pregnant after the HSG test, and it’s safe to try to conceive in the month you do the test,  but it’s not really a fertility treatment by itself.

How do you know when you are ovulating? Are there any symptoms?

Regular periods are a sign of ovulating, as is getting pregnant! Some women have mid cycle cramping (mittelschmerz) and may notice more cervical mucus or a change in mucus consistency - 'egg white' like and stretchy. If you have regular cycles, an ovulation predictor kit (OPK) is a better test than checking mucus or basal body temperatures. OPK should go positive between Days 10 to 18 in most women with regular cycles. Start testing every day from Day 10 in your cycle (Day 1 is the first day of your period). Test between 10 am and noon as the first morning urine is not as accurate. We recommend the Ovuquick brand (search online and get the 9-stick pack not the 6-pack). If you test for a couple of months and it's not working see a fertility specialist (Reproductive Endocrinology and Infertility or REI) if you’re trying to conceive.

Does an ovarian cyst cause infertility?

Endometriomas are cysts from stage 3 or 4 endometriosis - most women with these have reduced fertility. If a cyst needs removal, such as a large dermoid cyst, the surgery may reduce ovarian reserve (lower egg numbers and quality). The most common ovarian cysts are follicular or corpus luteum cysts and don't cause infertility, but frequent follicular cysts can be a sign of reduced ovarian reserve.

What are the treatment options for endometriosis?

Options depend on whether or not pelvic pain is an issue, and if you’re trying to conceive now, want kids in the future, or are done with childbearing. Medical treatment options are available -Depo Lupron shots work best, and we can also use letrozole tablets or birth control pills. Surgical options consist of laparoscopy with excision or ablation of the endometriosis, versus definitive surgery for women who have completed their families - removal of both ovaries with or without hysterectomy. Fertility patients may need In Vitro Fertilization after Depo Lupron treatment, or medications and IUI.

What causes infertility in most women?

The most common factor is diminished ovarian reserve (low egg numbers and quality) which is more common as women get older, but infections like Chlamydia or Pelvic Inflammatory Disease (PID), endometriosis, smoking, or ovarian surgery can all cause diminished ovarian reserve in younger women, too. Ovulation problems like PCOS, tubal problems, and fibroids or polyps inside the uterus are common, as are sperm issues for the man. 40-50% of couples with infertility have a sperm issue, which may be the only problem or occur together with issues for the female partner.

How do I use my temperature to know if I’m ovulating?

If you are ovulating regularly you should have regular monthly periods. Basal Body Temperature (BBT) with a special thermometer works, but the temperature only rises after you ovulate. Ovulation Predictor Kits (OPK) are more useful when trying to conceive as they go positive 24 to 36 hours before you ovulate, so you know your most fertile days. Drugstore brands should work; we recommend Ovuquick - search online and get the 9-stick pack not 6. If you have very irregular periods don't do BBT or an OPK, see a Reproductive Endocrinology and Infertility (REI) specialist for testing to find out why you’re irregular.

Is being underweight associated with infertility?

Low body weight may be associated with lower fertility, especially if you also have irregular periods or no cycles (amenorrhea). This means that you're not ovulating (releasing an egg) every month. This can be due to low levels of hormones that control your cycles from the pituitary gland, known as hypogonadotropic hypogonadism, which is more common in women who are significantly underweight, or may be due to stress, eating disorders, or heavy exercise such as long-distance running.

Is having an irregular menstrual cycle dangerous?

If you're young and not trying to conceive it's not dangerous in the short term. Very irregular periods, especially less than four periods a year, over a long period of time (many years) can increase the risk of a type of uterine cancer (endometrial cancer). If you have acne or unwanted hair growth you should get tested for Polycystic Ovarian Syndrome (PCOS) which can cause an increased risk of diabetes. Birth control pills regulate your periods if you’re not trying to conceive, but it’s good to have a diagnosis before going on the pills. Whether or not you’re trying to conceive, you can see a Reproductive Endocrinology and Infertility (REI) MD for testing, and for treatment if needed

What can cause a late period? And how long can a late period be?

There are many possible causes: Pregnancy or not ovulating (releasing an egg) can make your period late by weeks or months. Common causes of not ovulating include polycystic ovarian syndrome (PCOS), underactive thyroid, excess prolactin hormone, aging of the ovary (diminished ovarian reserve), or low hormone levels (hypogonadism) from heavy exercise, eating disorders, or stress. You can see an Ob/Gyn for tests, including a blood pregnancy test; see a Reproductive Endocrinology and Infertility (REI) MD if you’re trying to conceive.

What does 'enlarged ovaries' mean?

Enlarged ovaries (high ovarian volumes) are most commonly caused by ovarian cysts, but if the ovaries are enlarged without large cysts it can be a sign of Polycystic Ovarian Syndrome or PCOS, a hormonal condition that affects about 1 in 10 women. An ultrasound scan of your ovaries will look for ovarian cysts, and is part of the diagnostic tests that we do to look for PCOS, as well as blood testing.

Is infertility just a woman's problem?

No, in couples trying to conceive there is a sperm issue about 40-50% of the time, ranging from mild to severe sperm problems. Semen analysis is an important part of infertility testing. Sometimes the sperm issue is the only problem we find when we test both partners, often there are male and female factors together. Even if the man's sperm is 'normal' it helps a lot if the male partner is supportive!

What things increase risk of infertility?

Women's fertility starts to decrease from the mid 20's, and decreases fastest in he 40's. Smoking, Sexually Transmitted Infections like Chlamydia, endometriosis, ovarian surgery, chemo- or radiotherapy for cancer can all reduce egg numbers and egg quality (ovarian reserve). Chlamydia, Pelvic Inflammatory Disease (PID), endometriosis or surgery can block one or both fallopian tubes. Being overweight or underweight may lower fertility. Infertility in men can be increased by testosterone or anabolic steroid use, being overweight, and heavy use of alcohol, marijuana, or narcotics.

What are the symptoms associated with primary ovarian insufficiency?

Irregular cycles or no periods, especially in a woman who was regular before, is a common sign. However there are many other causes of irregular cycles that we need to exclude, including Polycystic Ovarian Syndrome or PCOS. Hot flashes, vaginal dryness, or mood changes may occur, particularly if the woman's periods are stopped. Some women with primary ovarian insufficiency still have regular periods but see a MD for difficulty getting pregnant.

Can bacterial vaginosis interfere with my ability to have children?

Bacterial vaginosis (BV) is not a sexually transmitted disease and does not affect your fallopian tubes. It is an overgrowth of 'bad' bacteria in the vagina, with less of the 'good' ones.

BV may increase a woman's chance of getting other STDs like chlamydia and gonorrhea. So get treated for BV by your OB/Gyn, but it's not usually a factor in how easy (or not) it is to get pregnant.

If you're under 35 you can try for up to a year before seeing a Fertility specialist (Reproductive Endocrinology / Infertility or REI MD). If 35-39 try for six months, if 40 or over get checked out right away. If you are irregular the next few months see a REI soon too.

What pain relievers are safe while pregnant?

Tylenol (or generic acetaminophen) - regular or extra strength is the safest painkiller in pregnancy. Avoid combinations of tylenol with other painkillers like Excedrin. We avoid NSAIDs like ibuprofen (Motrin, Advil) Aleve and full strength aspirin (325 mg) in pregnancy. Baby aspirin (81 mg) can be given to pregnant women but it's too low a dose for pain.

Local anesthetics (without epinephrine), Tylenol with codeine or vicodin are sometimes used but you should review these medicines with your OB/Gyn before taking them, such as if you are scheduled for dental work.

What is the importance of seeing a fertility specialist when your ovarian reserve is low?

A fertility specialist (Reproductive Endocrinologist) has more training and can better assess your individual situation. It is important to know more details such as: how low is your ovarian reserve (egg supply), what is your age, are there any tube or sperm problems? They can then come up with a treatment plan that's right for you. Some women with low ovarian reserve need tablets or shots to release more eggs, some need In Vitro Fertilization (IVF) with their own eggs, and some need IVF with donor eggs.

Can anyone be tested for infertility?

Yes, most people can be tested for infertility. Limiting factors are age, with a minimum age of 18; many clinics also have a maximum age. We recommend infertility testing after up to a year of trying to conceive in couples where the female partner is under 35, after 6 months if 35-39. In 40 + year olds it makes sense to test right away. Some couples don't get tested if their insurance doesn't cover infertility tests; however, many insurance plans do cover diagnostic testing.

What causes uterine fibroids, and is there a less-invasive treatment then a hysterectomy?

Fibroids are tumors that each grow from a single cell, but are usually non-cancerous. We don't know exactly what causes them but there may be genetic and environmental factors - race and maybe diet play a part. Up to 50% of African-American women have them, up to 25% of other ethnicities. Not all fibroids need treatment - only if they are causing symptoms like heavy or painful periods or pelvic pressure symptoms including pushing on the bladder causing frequent urination, or if they are affecting fertility.

Treatment should be individualized, not 'one-size-fits-all'. Other than hysterectomy these are the options:

1. Myomectomy - surgical removal of fibroids. This can be done through the hysteroscope (a small telescope that goes through the cervix) for fibroids that are totally or partly inside the cavity of the uterus. Open myomectomy goes through a bikini-line or vertical incision in the abdomen and can remove large fibroids or fibroids deep inside the muscle of the uterus. Laparoscopic myomectomy uses a telescope through the belly button, and small incisions, to remove fibroids on the outside of the uterus. These procedures are most appropriate for women who want to have children in the future, but can be done if a woman just wants to keep her uterus. With the open myomectomy, we can do an ultrasound scan during the surgery to find smaller fibroids that could be missed and cause problems in the future. It is safe to get pegnant after a myomectomy but you may need a C/Section for delivery, depending on where the fibroid or fibroids were located.

2. Uterine artery embolization / uterine fibroid embolization (UAE / UFE) - an interventional radiologist can insert material into the blood vessels 'feeding' a fibroid to reduce its blood supply. This can shrink a fibroid but may not make it disappear altogether. This procedure is non-surgical but has complications, including post-procedure pain, infection or blood clots. It is not appropriate for women who want to have kids in the future - it may not be safe to get pregnant, and the procedure can reduce the blood supply to the ovaries, which get part of their blood flow from the uterus, causing diminished ovarian reserve (low egg supply).

3. MRI-guided focused ultrasound (MRgFUS) - this non-surgical procedure uses Magnetic Resonance Imaging (MRI) to direct a powerful ultrasound beam to damage fibroids and cause them to shrink. This can be performed by a specially trained Ob/Gyn or an interventional radiologist. Again, it may shrink a fibroid but may not make it disappear altogether. It is also not an appropriate choice for a woman who wants to have children in the future.

We don't have good medications to shrink fibroids other than Depo-Lupron shots (a monthly or 3-monthly injection given in a Dr's office) which may be used short-term - their best use is to shrink and soften fibroids before hysteroscopic surgery. They are not a long-term treatment for fibroids due to side-effects. This may change in the future as a new class of medicines comes out (oral GnRH antagonists).

If you are interested in future fertility I recommend seeing a Reproductive Endocrinologist, and even if you are not interested in childbearing or done with having kids we can see you as a Gynecology patient for the heavy periods and offer you a more detailed evaluation. There are interventional radiologists who offer the UAE / UFE procedure.There may be one physician offering MRgFUS in the Seattle area in the near future.

What are some natural ways to shrink a subserosal uterine fibroid before pregnancy and during?

Before pregnancy, there are no proven natural ways to shrink a uterine fibroid. Resveratrol, a plant estrogen-like compound found in red wine, can kill fibroid cells in the lab, but there are no clinical studies showing that it works to shrink fibroids in women. It is not advisable to take resveratrol supplements (or red wine) when you're pregnant - studies in rats exposed to resveratrol in their mothers' milk showed long-term effects on the offspring including changes in the brains of male offspring.

During pregnancy, your body is producing large amounts of estrogen hormones, which causes many (but not all) fibroids to grow. Different fibroids can grow at different speeds, and some fibroids don't grow or even shrink during pregnancy. Sometimes a fibroid can outgrow its blood supply which can cause pain. It's rare for a fibroid to get in the way of a normal delivery, unless the fibroid is very large, and is positioned low in the pelvis.

Most subserosal fibroids don't need to be treated with surgery unless they are very large and/or cause symptoms, like an anterior (front side of the uterus) fibroid which pushes on the bladder causing frequent urination.

I want to get pregnant. How often should I be having sex?

At least 2-3 times a week when not on your period. If you have regular cycles days 10 - 18 are the most fertile time and you can have sex every other night. You can also use an ovulation predictor test and have sex for the three days starting with a positive test.

Don't douche after intercourse. Nearly all lubricants like KY jelly are harmful to sperm but are not a major factor for most couples, but if you usually use lubricant switch to pre-seed (see link below). I have no commercial interest in pre-seed.

If you have regular periods, you can try for up to a year if you are under 35, six months if 35 or over, before seeing a Fertility specialist (Reproductive Endocrinologist). If you are irregular, or if you are 40 or over, see a Reproductive Endocrinologist soon.

What are the best ways to get pregnant

It could take up to 6 months to a year to conceive even for couples under 35 with no 'fertility issues'.

Have intercourse at least 2-3 times a week when not on your period. If you have regular cycles days 10 - 18 are the most fertile time and you can have sex every other night. If you are regular, you can also use an ovulation predictor test and have sex for the three days starting with a positive test. If you have irregular cycles using the ovulation predictor kit is not a good idea, it is better to find out why you are irregular and fix any treatable cause. We recommend the OvuQuick brand (search online for 'OvuQuick kit' and be aware that it comes in 6-day and 9-day kit sizes) but most drugstore-brand tests are OK. Test between 10 am and noon as the hormone that the kit detects may peak at 3 or 4 am so when you first get up it may be too early in the day to test.

Don't douche after intercourse. Nearly all lubricants like KY jelly are harmful to sperm but are not a major factor for most couples, but if you usually use lubricant switch to pre-seed. We am not affiliated with the makers of OvuQuick or pre-seed.

If you have regular periods, you can try for up to a year if you are under 35, six months if 35 or over, before seeing a Fertility specialist (Reproductive Endocrinologist). If you are irregular, or if you are 40 or over, see a Reproductive Endocrinologist soon.

What can I do if I want to have twins

Be careful what you wish for ... twins are more high risk than a single baby, although most twins do fine with good OB and neonatal care, some twins have long-term problems, some are premature and some don't even make it to viability and are born before 24 weeks. The risk of cerebral palsy, a serious birth defect, is 4 - 5 times higher in twins compared to a single baby. You have a higher chance of pregnancy complications including serous ones like preeclampsia or placental abruption, a higher risk of C/Section, and even a very slight increase in divorce rate.

I know the media and Anne Geddes and other baby photographers all love to show pictures of cute twins all dressed up ... the kids with cerebral palsy are generally not shown on the front cover of a magazine.

Couples who need treatment for infertility, from simple treatments like Clomid to advanced treatments such as In Vitro Fertilization (IVF), often have an increased risk of twins if more than one egg is released with fertility medications, or if more than one embryo is replaced into a woman's uterus after IVF.

If we're treating couples for infertility who can't get pregnant on their own twins may be an acceptable risk of the treatment. Many couples tell me they want twins - they have been trying for a baby for one or many years, and many couples want two babies total and would love to have twins and 'be done'. We do our best to avoid triplets or more, though. In this case the risk of twins is justified by the benefit of treatment of their infertility.

If you don't have any problems getting pregnant your natural chance of twins is about 1%. I don't recommend going to an Ob/Gyn or Fertility MD just because you want twins (wanting twins for "social reasons") - if you end up with complications to you or the babies, would it be worthwhile compared with just having two more kids separately? I would not recommend "getting fixed" in your early 20's until you are 100% sure that you're done either, we have great birth control options like the Mirena IUD which is about as effective as having your tubes tied but reversible if you have one more child and then want another one later.

I want to have another child, but my first child passed away due to tay-sachs. Will my second child have tay-sachs?

I'm really sorry to hear of your loss. The form of Tay-Sachs that kids get is a terrible thing for parents and kids to have to go through.

Tay-Sachs is a single-gene disorder where both you and your partner have an abnormal gene for the disease and one normal gene. A child that gets one abnormal gene from each parent gets Tay-Sachs disease, a kid with one abnormal gene from one parent and a normal gene from the other is a Tay-Sachs carrier and will be normal, like you and your partner.

Unless anyone else in your family or your partner's family had a kid with Tay-Sachs before (very rare) there is no way that most people would know this before you got pregnant with your first child. So it's not your 'fault' that you had an affected child, but there are ways to do things differently in the next pregnancy.

Getting pregnant 'the normal way' there is a one out of four (25%) chance that your next child will also have Tay-Sachs. There are two choices - one is to go through In Vitro Fertilization with Preimplantation Genetic Diagnosis (IVF with PGD) where take eggs from your body after 8-10 days of fertility shots, fertilize them with your partner's sperm, and test the embryos before putting embryos back inside your uterus - we want to pick embryos that are normal or Tay-Sachs carriers but NOT the ones with the disease.

The alternative is to get early testing when you are pregnant to see if the fetus has the disease - this is mostly for couples who would terminate the pregnancy if another child has the disease.

I recommend that you see both a genetic counselor, if you haven't already, and a Fertility Specialist (Reproductive Endocrinologist / Infertility or REI MD) to talk about PGD, and not trying until you have seen both. A maternal-fetal medicine (MFM) MD can offer testing of the baby when you're pregnant.

Rarely, some couples' insurance will cover PGD testing if you have had a child with a genetic disorder and can get pregnant normally (so don't have infertility) but want to avoid another affected child. Sometimes your MD needs to write a letter for you, and getting coverage can be a slow process.

If you go the PGD route, REI MD's can work with different labs that do the actual genetic testing of embryos. I recommend a practice that works with Genesis Genetics, who are the most experienced lab in the USA for single-gene disorders. See the link below. I have no business interest in Genesis, but I know that you're in good hands with Dr. Mark Hughes.

What kind of tests are done to diagnose endometriosis?

The diagnosis and treatment of endometriosis depends very much on whether or not you are trying to conceive as well. Some women with early-stage endometriosis have little or zero pelvic pain or fertility issues. We used to diagnose these women when they had a laparoscopy to tie their tubes (there are now less invasive ways to block the tubes in women who are done with childbearing).

The 'gold standard' for diagnosis is still to perform a diagnostic/operative laparoscopy, an outpatient surgery performed under anesthesia where a small incision below your belly button allows us to pass a surgical telescope into your abdomen and pelvis and look for endometriosis and often destroy or cut out endometriosis if we find it. More advanced endometriosis may show up on pelvic ultrasound (a sonogram which is best perfomed with a transvaginal probe), bur early-stage endometriosis will not show up on ultrasound. If you are trying to conceive, a hysterosalpingogram (HSG) does not 'see' endometriosis but looks for blocked tubes or scar tissue around the tubes, which can occur in women who have endometriosis, as well as for other reasons like past infections.

If you're not trying to conceive and your main problem is pelvic pain, while it's more satisfying to have a 'proven' diagnosis, it is acceptable to treat the pain with medications (Depo-Lupron shots) without performing a laparoscopy first.

If you are trying to conceive, having endometriosis may change the course of your treatment in subtle or obvious ways. Having endometriosis (and surgical endometriosis treatment) may cause diminished ovarian reserve (low egg supply), scarring around the tubes or pelvic adhesions (scar tissue), or both. Some women with endometriosis need in vitro fertilization (IVF) to deal with these issues, and Depo-Lupron shots before IVF may improve success rates.

Are there any healthy home remedies for bacterial vaginosis?

Bacterial vaginosis (BV) is not a sexually transmitted disease and does not affect your fallopian tubes or cause infertility. There are no proven home remedies to treat BV once you have it. One very small study suggested that eating 150 ml of live yogurt containing Lactobacillus acidophilus every day helped a small number of women to get less BV infections compared with eating pasteurized yogurt, but this is prevention not treatment.

BV may increase a woman's chance of getting other STDs like chlamydia and gonorrhea. So get treated for BV by your OB/Gyn, but it's not usually a factor in how easy (or not) it is to get pregnant.

Are there any foods that can cause infertility?

There is little evidence that specific foods cause infertility. There was one study (link below) published in the journal Human Reproduction that looked at diet and fertility in 18,000 women without a history of infertility who were trying to conceive or got pregnant in an 8 year period. Women with a high intake of low-fat dairy foods (skim or low-fat milk, yogurt, cottage cheese) were more likely to have infertility associated with problems with ovulation (egg release) than women who ate full-fat dairy. Women who don't ovulate don't have regular periods, so this finding may not apply to women with regular cycles. The lowest risk of infertility due to anovulation was in women with at least one serving a day of high-fat dairy - defined as whole milk, cream, ice cream, cream cheese or other non-cottage cheese. Yes, ice cream - this should be the most popular fertility study in years. Of all the high fat dairy choices, whole milk appeared to have the strongest effect in this study.

One study doesn't 'prove' that there is a link or even tell us that low fat dairy is 'bad for fertility' - there could be some other thing that is really 'good for fertility' that the high-fat dairy eaters did or ate more compared with the low-fat dairy eaters (or something bad that the low-fat dairy eaters did or ate more). Having said that you're welcome to run with it and try one serving a day of full-fat dairy, preferably whole milk, just pay attention to serving size and don't increase your total calories by a large amount.

Extremes of body weight are associated with reduced fertility. Body Mass Index (BMI) is not a perfect measure of being overweight or not (it doesn't work for someone who is 'all muscle') but a healthy range for fertility is about 18.5 to 25. The ability to get pregnant may fall more at a BMI of 35 and above, although many women can conceive even in this range. See the link below for a BMI calculator.

If you have regular periods, you can try to conceive for up to a year if you are under 35, or six months if 35 or over, before seeing a Fertility specialist (Reproductive Endocrinology and Infertility or REI). If you are irregular, or if you are 40 or over, see a REI physician soon.

Is there anything that can be done to prevent infertility if I don’t want kinds now?

Don't smoke, or quit now if you do. Aim for a normal weight if you're overweight through diet and exercising regularly (Body Mass Index or BMI 18.5 to 25). Use condoms to avoid STDs if you’re not in a stable relationship, and get tested if you are at risk.

Don't wait too many years to start trying, and if you're over 35 when you start trying see a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) if you're not pregnant after 6 months of unprotected intercourse. See an REI when you're ready to start if you don't have a regular period every month, if you have had endometriosis or Pelvic Inflammatory Disease (PID), a previous ectopic pregnancy, or any surgery on your ovaries.

At what age should I begin to be concerned about infertility if I don’t want a baby yet?

If you're asking you're already beginning to be concerned. In general, peak fertility for women is in the 18-30 age range, and fertility decreases in your 30's and 40's. All women are different - there is no age where everyone can get pregnant or no-one can get pregnant; having said that pregnancy is much less common at 45 years and older. On average, your fertility goes down every year from age 40 to 45.

I would start to be more seriously concerned as you get closer to the 38-40 age range, but if you have a fertility issue at 38 it would be better to find out sooner rather than later. There is a lot of individual variation in ovarian reserve or egg supply (the number and quality of eggs that a woman has left) at any age, so there are 35 year olds with good egg supply and 35 year olds with diminished ovarian reserve.

If you're aware of your fertility but don't want a baby yet it wouldn't be unreasonable to do some basic tests to get an idea of how healthy your ovaries look at 35. These would be an ultrasound scan of your ovaries, looking at the size of each ovary and the number of egg-containing follicles on each side or Antral Follicle Count, and blood tests on Day 2 or 3 of your cycle for estradiol, Follicle Stimulating Hormone or FSH, and Antimullerian Hormone or AMH. Day 1 is the first day of your period. If you're on hormonal birth control such as pills, NuvaRing, Mirena or Implanon we would skip the estradiol and FSH tests. A fertility clinic (Reproductive Endocrinology and Infertility or REI practice) can perform these tests and interpret the results.

If the results look good you can relax and wait a couple of years longer before trying. If there's a problem with low ovarian reserve, options include freezing your eggs if you're single or not in a long-term relationship, or freezing embryos for later use if you have a partner or wish to use donor sperm but aren't ready to get pregnant now. You could also decide to pursue fertility treatment sooner based on the results.

Do I need surgery to treat endometriosis?

In general, you only need endometriosis surgery if you - 1. Want to have kids and have a large endometrioma (endometriosis cyst within the ovary) or 2. Are completely done with wanting kids and wish to have definitive surgery - removal of both ovaries (with or without hysterectomy).

Surgery rarely 'cures' endometriosis unless the surgery is removal of both ovaries (with or without hysterectomy). Removing both ovaries takes away most of a woman's production of estrogen hormone which stimulates endometriosis tissue and may cause it to grow.

Any other surgery (laparoscopy with laser treatment or cautery or excision of endometriosis, and/or removal of endometriosis cysts) may not remove all the endometriosis in your pelvis - even if your surgeon destroys or excises all visible spots of endometriosis on the surface of the uterus or behind the uterus, on or in the ovaries or on the pelvic side wall, there may be deeper areas of endometriosis not visible on laparoscopy which are missed. Endometriosis may also be hidden underneath areas of scarring.

Because of the above, some women get good pain relief after surgery to treat endometriosis, and some women don't get good pain relief after surgery. Women with significant endometriosis (more than just a few spots on the surface of the uterus or ovaries) often do better with surgery to confirm the diagnosis and to treat visible disease, followed by Depo-Lupron injections to suppress any endometriosis that's left behind, than with surgery alone. Surgery alone may provide short term relief of endometriosis pain (a few months up to a few years) before the disease and pain symptoms recur. Women who undergo multiple laparoscopies may get diminishing returns, with less and less pain relief with each successive laparoscopy.

Depo-Lupron can be used on its own without laparoscopy too - it also (but reversibly) takes away most of a woman's production of estrogen hormone which stimulates endometriosis tissue. If you have pelvic pain symptoms suggesting endometriosis and your pain goes away with Depo-Lupron you are at least 80% likely to have endometriosis.

If you want to try to conceive and you have only small endometriomas, or early stage endometriosis without any endometriosis cysts visible on ultrasound, the surgery may do more harm than good by damaging some normal ovary tissue, which can reduce your ovarian reserve (the number of eggs left in your ovaries).

So the answer is complex but in summary - not everyone with endometriosis needs surgery - it is only definitely needed for big endometriosis cysts or women who are done childbearing. Unless you have both ovaries removed cure is unlikely, but you may get benefit in terms of reducing your pain for a period of time. Medical treatment with Depo-Lupron after surgery often gives better pain control than just surgery. Depo-Lupron can be used on its own without surgery, too.

Does Chlamydia lead to infertility?

Chlamydia infections may reduce your chances of having children, but they don't always cause fertility problems. Chlamydia can lead to pelvic inflammatory disease which can cause damage to the fallopian tubes and even damage to the ovaries as well. This can increase the chances of difficulty getting pregnant, tubal pregnancy (ectopic pregnancy) or low egg supply (diminished ovarian reserve).

Get treated ASAP if you have Chlamydia at the moment, and see a Fertility MD (Reproductive Endocrinologist) if you are trying to conceive now or in the future.

Polycystic Ovarian Syndrome (PCOS) FAQs

What causes polycystic ovarian disease and what can be done to treat the cause?

PCOS has a genetic component; we don't know all the genes yet - and is influenced by environmental factors and lifestyle including obesity and activity levels. Insulin resistance / 'pre-diabetes' may be the first thing that 'goes wrong' in PCOS. The closest we have to treating the cause is losing weight, with a moderately low-carbohydrate diet (Weight Watchers and South Beach are good) plus regular exercise (cardio and weights) and using insulin-sensitizing drugs like metformin. Surgery is no longer a recommended option.

What are the symptoms of PCOS?

Most women with PCOS have one or more of: irregular periods or no cycles, acne, oily skin, unwanted hair growth especially on the face or lower stomach, infertility or subfertility (difficulty getting pregnant). Some women with PCOS have little or no symptoms - we look at symptoms, blood tests and an ultrasound of the ovaries to make the diagnosis. Not all women with PCOS have fertility issues.

How do docs treat PCOS?

It depends on if you’re trying to conceive or not? If not trying to conceive birth control pills are often used, sometimes with anti-androgens like spironolactone as well to decrease acne/hair growth more than birth control pills alone. If trying to conceive we use insulin sensitizers like metformin, plus ovulation-inducing tablets - most commonly Clomid or letrozole. Sometimes low-dose shots or IVF (In Vitro Fertilization) is needed. Surgery for PCOS is no longer a good option.

If was diagnosed with PCOS, polycystic ovarian syndrome, why would I start to develop unwanted facial hair and loss of scalp hair?

With PCOS the ovaries produce excess male-type hormones (androgens) like testosterone, which cause unwanted hair growth (especially in the midline of the body like the face or lower stomach) and sometimes male-pattern hair loss. If not trying to conceive birth control pills are often used to lower androgens, sometimes with anti-androgens like spironolactone as well to decrease hair growth more than birth control pills alone. Vaniqa cream may help for excess hair growth on the face only.

Polycystic ovarian disease treatment if TTC?

A Reproductive Endocrinology and Infertility (REI) specialist confirms the diagnosis of PCOS and checks for hormone problems or low egg supply. Semen analysis and a Hysterosalpingogram (HSG) to check for blocked tubes are good tests to do as well. Treatment may start with metformin (insulin sensitizers) with or without ovulation inducing tablets like Clomid or letrozole. Some women need IVF (In Vitro Fertilization) if simpler treatments aren't working, or rarely low-dose shots to induce ovulation.

Can you still get pregnant with polycystic ovary disease?

Yes, some women with Polycystic Ovarian Syndrome (PCOS) get pregnant easily without any help, some need only insulin-sensitizing medications like metformin. Others need tablets like Clomid or letrozole to induce ovulation, rarely fertility shots or IVF (In Vitro Fertilization). About 8-10% of women have PCOS. Your age also affects your chances. See a Reproductive Endocrinology and Infertility (REI) specialist if trying to conceive for an individualized treatment plan

What is meant by polycystic ovaries?

Polycystic ovaries (PCO) refers to one or both ovaries being bigger than normal and/or having a high number of small egg-containing 'antral follicles’. This is determined with an ultrasound scan of the ovaries. PCOS or Polycystic Ovarian Syndrome needs 2 out of 3 of: 1. Irregular cycles 2. Clinical or blood test signs of too much male hormones - acne, unwanted hair growth or oily skin and 3. PCO. Up to 20% of women have PCO, about 8-10% have PCOS.

I have recently been diagnosed with PCOS however instead of having infrequent periods I am menstruating constantly, could it still be PCOS?

Most women with PCOS don't ovulate (release an egg) regularly, with infrequent periods like cycles over 35-40 days or skipping whole months, or even no periods at all. Not ovulating can also cause frequent irregular bleeding as the lining of the uterus can become thick and bleed unpredictably. You should be checked for thick lining, fibroids or polyps inside your uterus; very thick lining needs an endometrial biopsy test to rule out precancerous changes.

What are some strategies for managing weight when diagnosed with Polycystic ovary syndrome POCS?

Many women with PCOS gain weight or find it hard to lose. Moderately low carb diets (South Beach or Weight Watchers), and complex carbs instead of simple cards are good: brown rice, whole wheat bread/pasta, less sugars, and more protein. Portion control is also important, paying attention to serving sizes. Exercise is recommended: do weights and cardio at least three times a week: weights increase muscle mass, which burns more calories. Some women lose weight on metformin treatment, too.

How can I get tested for polycystic ovary syndrome? Should I go to my normal gyno or reproductive endocrinologist?

If you’re trying to conceive see a Reproductive Endocrinology and Infertility (REI) specialist for testing, and treatment options. We can also see women with PCOS issues who are not trying to conceive. PCOS is diagnosed with 2 out of 3 of: 1. Irregular periods 2. Clinical signs like acne, unwanted hair growth and/or blood tests showing too much male-type hormones (androgens) 3. Ultrasound appearance of polycystic ovaries: high ovarian volumes or antral follicle counts. We also "rule out" other causes of PCOS-like symptoms, such as thyroid, prolactin, or adrenal gland issues. Treatment is different depending on whether or not you’re trying to conceive.

What causes excessive hair growth on a woman's stomach after having a baby?

There are a few conditions that can cause unwanted hair growth in women (hirsuitism). Polycystic Ovarian Syndrome (PCOS) is the most common, affecting 8-10% of women. Hair growth in the midline of the body (such as the upper lip, chin, lower stomach, or your back) can be due to PCOS. Weight gain can make PCOS symptoms worse. We diagnose PCOS with blood tests and a sonogram, and treatments can reduce the hair growth. Other conditions that can cause unwanted hair growth include adrenal gland disorders.

Male Fertility FAQs

How can I tell if I have a low sperm count?

Get a Semen Analysis at a fertility clinic or a urology office rather than a general medical testing lab. Home sperm tests are not very useful, and you can't tell by looking at your semen. If you're not trying to conceive assume you're fertile; if you and your partner are trying to conceive without success you should both see a fertility specialist (Reproductive Endocrinology and Infertility or REI) for testing and individualized treatment.

Do steroid injections or NSAIDS affect sperm count?

They should have no major effects on sperm count. I’m assuming you're talking about 'regular' prescription corticosteroids like triamcinolone (Kenalog) - these have little to no effect on sperm, unlike anabolic steroids like testosterone or Dianabol, which can cause major reductions in sperm count. Some studies indicate that heavy use of Non-Steroidal Anti-Inflammatory Drugs or NSAIDs, including aspirin, may affect sperm motility and sperm morphology (the % of normal-shaped sperm) as well.

Is there a natural way to increase sperm count?

Men who are overweight may get better sperm numbers and quality by losing weight, and men should cut down heavy alcohol use and quit using tobacco, avoid illegal drugs and anabolic steroids, and review any prescription drugs with their MD. An abnormal semen analysis, such as a low sperm count, always needs a second test 1-2 months later for confirmation.

How to increase sperm count?

An abnormal semen analysis, such as a low sperm count, always needs a second test 1-2 months later for confirmation. Based on how low the count is, and/or sperm quality tests like motility and morphology (the % of normal-shaped sperm) are, we may do hormonal or genetic blood work. In some guys taking tablets or rarely shots can increase count. Men who are overweight may get better sperm numbers and quality by losing weight, and men should cut down heavy alcohol use and quit using tobacco, avoid illegal drugs and anabolic steroids, and review any prescription drugs with their MD.

How do you treat oligozoospermia?

Oligozoospermia means a low sperm count. Any abnormal Semen Analysis needs a second test 1-2 months later for confirmation, ideally through a fertility clinic. Hormonal testing may identify treatable problems, and tablets may improve sperm; hormone shots are needed very rarely. Mild to medium low sperm count is often treated with Intrauterine Inseminations (IUI), where washed sperm is placed inside the woman’s uterus. Severe sperm problems need IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection) or the use of donor sperm.

What is the criterion for oligozoospermia?

The World Health Organization defines oligozoospermia as less than 20 million sperm per ml (milliliter). More recent studies show that in men with proven fertility, the lower limit of normal is around 15 million sperm per ml. Semen Analysis should be done through a Fertility clinic or a Urology lab not a general medical testing lab, and an abnormal result needs a second test 1-2 months later for confirmation.

What should my husband do if we are TTC (trying to conceive)?

A Semen Analysis through a fertility clinic is a good place to start for him. In couples who aren't getting pregnant after trying for a year or longer, almost half the time there is a sperm issue (40-50% of couples). It could be the only problem or occur along with problems on your side. He should also quit tobacco use, cut down alcohol if he has moderate to heavy drinking habits, avoid using drugs, and aim for a normal weight.

How to check whether you have azoospermia at home?

Azoospermia should be diagnosed by an Andrology lab at a Fertility clinic or a Urology clinic. More than one semen analysis is needed to confirm the diagnosis. If we see a semen sample with no sperm we use a centrifuge to 'spin down' the specimen so that we can find very low numbers of sperm. See a Fertility MD (Reproductive Endocrinology and Infertility or REI) for a complete Semen Analysis test. Even if you have a microscope at home I don't recommend home testing for this condition.

What causes azoospermia?

Azoospermia (no sperm or no living sperm) could be due to obstruction (blockage) or a sperm production issue. It should be confirmed by more than one semen analysis: a fertility clinic will 'spin down' a sample with no sperm so that we can find very low numbers of sperm. Many men still have some sperm production, so sperm can be surgically retrieved for IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection), or donor sperm can be used for fertility treatment such as Intrauterine Inseminations (IUI) . See a Fertility MD (Reproductive Endocrinology and Infertility or REI) for help.

I want to know whether there is any guaranteed treatment for azoospermia?

Unfortunately, there is no treatment for severe male infertility that is 100% guaranteed to work using your own sperm. Donor sperm is the closest thing for couples where the male partner has azoospermia as it's sperm from healthy men without known fertility issues. Having said that, many men with azoospermia can have children using their own surgically-retrieved epididymal or testicular sperm, combined with IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection). A genetic test identifies some men ahead of time who won't get sperm at retrieval. Having Donor sperm as a backup is a good idea.

How do doctors treat infertility in men?

We may do hormonal tests, looking for low testosterone, high estrogen, thyroid or prolactin issues or abnormal LH or FSH hormone levels. Some men get better sperm with treatment of hormone problems. Some men need genetic tests, and/or a consultation with an Urologist. Mostly we treat mild to medium sperm problems with Intrauterine Inseminations (IUI) where washed sperm is placed inside the woman’s uterus; severe sperm problems need IVF with ICSI (In Vitro Fertilization with Intracytoplasmic Sperm Injection) or use of donor sperm. No sperm (azoospermia) or very severe sperm problems may need a surgical sperm retrieval procedure.

Is male infertility a common problem?

Yes, it is very common. In couples trying to conceive without success we find a sperm issue about 40-50% of the time, ranging from mild to severe sperm problems. Semen analysis is an important part of infertility testing. Sometimes the sperm issue is the only problem we find when we test both partners, but often there are male and female factors together. Even if the man's sperm is 'normal' it helps a lot if the male partner is supportive.

Does the male partner need to take a sperm count test (for wife's infertility)?

Absolutely. In all couples not getting pregnant after a year or more trying, the male partner should get a Semen Analysis; 40-50% of these men have a sperm issue, ranging from mild to severe sperm problems. About half the time the sperm issue is the only problem, and the other half have male and female factors together, like blocked tubes or low egg supply. If your sperm test is normal you don't need much else  in the way of testing. Men with abnormal sperm counts may need hormonal or genetic blood work.

 

My husband had done a sperm count and it was zero, does he need a testicular biopsy?

Not right away. If only one sperm count was zero (azoospermia), he should repeat the test 1-2 months later - make sure it's at a fertility clinic where if there are 'no sperm' they can centrifuge or ‘spin down’ the semen so that even a few sperm will be seen. If no sperm are seen again he will need hormonal testing, and genetic tests - karyotype and Y chromosome microdeletions (YCMD), and we will refer him to a Urologist for a physical examination. Most men have sperm that can be surgically retrieved, but certain YCMD mean that a testicular biopsy should not be done.

What should my husband expect during his first infertility visit?

We review his medical and lifestyle history, including alcohol, tobacco and prescription medication use, and recommend a Semen Analysis for fertility testing. When both partners attend fertility visits (preferred but not mandatory), the man may look bored, or nervous, or rarely embarrassed by the whole fertility thing. Some can find the humor in the situation which helps. Men with significant sperm issues benefit from a scheduling a physical exam with a Urologist at a later date; men with normal or near-normal sperm tests don't need to get a physical exam, so the embarrassment factor should be fairly low. A Semen Analysis can be collected at home if you live less than an hour away.

How would you know if you have a high enough sperm to have a baby?

I recommend getting a Semen Analysis 'done right' at a Reproductive Endocrinology and Infertility clinic rather than at a hospital or a general medical testing lab such as Labcorp or Quest.  We have trained Andrologists, using the correct equipment and microscopes, and quality control standards to give you the most accurate results. A complete Semen Analysis looks at Sperm Count (the concentration of sperm per milliliter of semen), Motility (the percentage of moving sperm), Morphology (the % of normal-shaped sperm), and a screening test for Sperm Antibodies. Morphology has two different standards - the 'strict' or Kruger morphology standard, where 15% is a perfect score and < 5% is very low, is a more useful test than the older World Health Organization or WHO standard, where 30% is a perfect score, for men trying have a child.

Does having deformed sperm on a guy's semen analysis increase the chances of a deformity in his future baby?

Men with low morphology (% of normal-shaped sperm) may have more genetically abnormal sperm. Morphology testing is far from a perfect test but may mean that you need more workup or can change fertility treatment recommendations. More genetically abnormal sperm increases the chance of miscarriage or chromosomally abnormal pregnancy, but does not cause common birth defects. Morphology has two different standards - the 'strict' or Kruger morphology standard, where 15% is a perfect score and < 5% is very low, is a more useful test than the older World Health Organization or WHO standard, where 30% is a perfect score, for men trying have a child – this test should be done at a Fertility clinic.

Can we skip male infertility tests if my husband objects?

We can't make your husband do a test he doesn't want to but it's a bad idea to 'skip' testing for him. In couples who aren't getting pregnant after trying for a year or longer, almost half the time there is a sperm issue (40-50% of couples). It could be the only problem or occur along with problems on the woman's side. A Semen Analysis is a good test to do early on. A Semen Analysis can be collected at home if you live less than an hour away. It is possible to start with your tests and do the Semen Analysis later if your husband is unwilling to be tested early on – we can discuss the test with your husband at the first visit or at the second meeting, when we go through fertility testing results and make a treatment plan.

Is male infertility less common than female infertility?

Infertility is slightly more common in women. About 40-50% of couples with difficulty conceiving will have some sperm issues, ranging from mild to severe problems. Sometimes this is the only reason for a couple's infertility, and sometimes male infertility problems and female infertility issues occur together in both partners.

Part of the reason that women have more infertility issues is that getting older often has more effect on female fertility than on male fertility, as a woman makes few, if any, new eggs in her lifetime, with a peak number of eggs at birth. The number and quality of eggs left (ovarian reserve or egg supply) declines in women in their 30's and 40's, and rarely in their 20's. Men have less consistent effects of aging, as they make new sperm all the time, so some men in their 50's or 60's may have little or no sperm problems.

How important is the sperms morphology when trying to conceive?

There are several different standards for morphology reporting. There is an older standard called WHO morphology, where 30% normal forms is a 'perfect score'. The most common method of reporting nowadays is called Kruger or 'strict', where the ideal range is 15% or greater normal morphology.

To answer your original question: yes, low morphology means your husband may be 'subfertile' and it may be harder to conceive naturally. Dr Kruger's group compared morphology with other numbers like count and motility, and all were helpful at identifying men with subfertility, with a value of under 5% for strict morphology being the suggested cutoff. More abnormal shaped sperm means he may have more sperm with genetic abnormalities.

Even if the abnormal morphology test was done at a fertility clinic using the Kruger or strict morphology, one repeat semen analysis 1-2 months after the first is still a good idea.

None of the sperm tests are 100% predictive, though - you may still get pregnant 'easily' as it only takes one good sperm to fertilize an egg.

I recommend seeing a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) for further testing and advice, if you aren't already seeing one.

Egg Donor FAQs

What are the requirements of becoming an egg donor and how do I apply?

The basic requirements of all our egg donors are:

  • Age between 18-30 years old
  • non-smoker
  • in good health (no mental/physical health issues)
  • have regular periods
  • live within commuting distance to our clinic in Bellevue
  • Body mass index of under 30
  • US Citizen

If you meet all these requirements and are interested in applying to our program please fill out our egg donor application.

For more information on our egg donor program.

Will becoming an egg donor affect my chances of having a child of my own in the future?

As far as we know being an egg donor does not affect your future fertility potential. But 'just to be safe' as well as to reduce the chances of kids from the same donor having kids together without knowing it, we limit each donor to no more than six egg donation cycles in her lifetime, across the US. As part of becoming a donor you will be tested to make sure you have normal or above-average egg supply (ovarian reserve), which is part of checking your fertility potential.

What are the risk factors for egg donors who want to have children of their own in the future?

As far as we know being an egg donor does not affect your future fertility potential. There is no evidence that the medications used for egg donation increase cancer risks or other health problems for donors, either. But 'just to be safe' as well as to reduce the chances of kids from the same donor having kids together without knowing it, we limit each donor to no more than six egg donation cycles in her lifetime, across the US. As part of becoming a donor you will be tested to make sure you have normal or above-average egg supply (ovarian reserve), which is part of checking your fertility potential.

Do you have an online egg donor database?

Yes, we have an online egg donor database that potential patients can view. It contains basic information on our egg donors. More detailed information on a specific donors can be obtained by asking us via the contact form. We provide the password protected information to any of our current patients. While we endeavor to keep the list 100% current, there might be new donor that have not made it onto the database yet. If you are not seeing a donor that meets your requirements we encourage you to ask us if we have any new donors that might be suitable.

Fertility Medication FAQs

Can taking prescription birth control too long cause infertility?

Birth control pills or the Nuva Ring have return to fertility within weeks of stopping them. Many women start birth control pills as teenagers, and stop them in their late-30's when ready to conceive - fertility is the same as for non-Pill users, their age when starting trying to conceive may be a factor rather than the length of time on the pill. Depo-Provera shots can stop periods for 6-18 months after stopping - during this time fertility is low but there are no long-term bad effects.

Can I give myself intramuscular injections for my fertility medications?

It's easy to give subcutaneous injections (under the skin on your belly) yourself. Intramuscular (IM) shots are harder to give yourself, especially progesterone in oil. Most IM shots are less painful given into the gluteus muscle in the upper outer part of either butt cheek, which is hard to do yourself. Some women do the shots themselves, looking in a mirror. Ask a Nurse or Medical Assistant to 'mark the spot' for you.

Can Depo-Provera cause infertility?

Depo-Provera only reduces your fertility if your periods don't come back for a while after stopping it. It sounds like your periods started back right away, so your fertility should be back to normal. Most couples get pregnant in the first year of trying (about 85%) and it can still happen naturally in the second year, but this is a good time to see a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) to help you to get pregnant.

How long it takes depends on many factors, including your age. We can check for hormonal problems, low egg supply (diminished ovarian reserve), blocked tubes, problems inside the uterus like polyps or fibroids, or sperm problems. 40-50% of couples who aren't getting pregnant easily have a sperm problem - this can be the only issue, or occur along with other problems on your side. After testing for fertility issues, your doctor can come up with individualized treatment options to help you get pregnant.

Does taking the birth control pill affect you tolerance for alcohol?

Current research (in contrast to some older studies) suggests that birth control pills and even changes in natural hormones over the menstrual cycle have very little to no effect on alcohol metabolism.

Different people having different responses to drinking alcohol can be due genetic variations in two enzymes, alcohol dehydrogenase (ADH) and aldehyde dehydrogenase (ALDH). A fast ADH enzyme or a slow ALDH enzyme can cause toxic acetaldehyde to build up in the body, creating dangerous and unpleasant effects. These variations may affect a person's risk for alcoholism, though there are many other factors.

You probably have enzyme variants that give you more unpleasant effects than 'average'. You don't need to get your liver enzymes tested unless you drink heavily.

Stay on the birth control pills and stay safe. A lot of the harmful effects of alcohol are not diseases like liver cirrhosis or pancreatitis but social - the man who drinks and perpetrates domestic violence, the person who should have taken a cab but thought they were OK to drive. There is no shame in being a light drinker, but if you're with friends who aren't please look out for them.

Can certain drugs or medications cause infertility?

It's possible. For men testosterone treatment, anabolic steroids, narcotic painkillers, SSRI antidepressants like sertraline or venlafaxine, sulfasalazine, smoking, heavy alcohol, and marijuana can all affect fertility. Sperm numbers and quality are relatively easy to measure compared to female fertility.

In women we know less about the long-term effects of medicines on fertility or ovarian reserve (egg supply). Medications that raise prolactin hormone levels can affect ovulation and reduce fertility - chlorpromazine, prochlorperazine, haloperidol, risperidone, metoclopramide, methyldopa, cimetidine, some older antidepressants like amitriptyline, SSRI antidepressants like sertraline or fluoxetine, and many others. Immunosuppressants such as cyclophosphamide can cause reduced ovarian reserve. Drugs that may affect the ovaries but have not been well studied long-term include newer immunosuppressants like tacrolimus and sirolimus, and antirheumatic drugs like hydroxychloroquine or methotrexate.

Recurrent Loss and Miscarriage FAQs

Is a full term baby still possible after 2 abortions and 2 miscarriages?

You may still have a healthy baby: you've been pregnant 4 times already. Abortions rarely cause problems, but any surgical procedures (D&C) may cause scar tissue inside the uterus. After 2 miscarriages you should see a Fertility MD (Reproductive Endocrinology and Infertility or REI) to look for causes of recurrent miscarriage, including problems inside your uterus like polyps or fibroids or an abnormally shaped uterus, blood clotting disorders, immune system problems, or low egg supply (diminished ovarian reserve). Rarely, infections may increase the risk of another miscarriage.

What are some ways to prevent a miscarriage in women? No sex?

Sex when pregnant doesn't increase the risk of miscarriage, but we usually advise women who are bleeding in the early part of pregnancy (a 'threatened miscarriage') not to have sex until the bleeding has stopped; if more bleeding follows after sex it just adds to the anxiety of the situation. A woman who's had two or more miscarriages needs testing to look for a cause, by a Reproductive Endocrinology and Infertility or REI specialist if you’re trying again, or an OB doctor if you’re already pregnant.

Is there something that could cause multiple miscarriages after already having one child?

Many possible causes of miscarriage exist. You have more chance of another success than multiple miscarriages with no child. With 2 or more miscarriages we look for low egg supply (diminished ovarian reserve), uterine problems like polyps or fibroids or an abnormally shaped uterus, abnormal antibodies in your blood and other immune system problems, blood clotting disorders, or hormonal problems. Rarely, infections may increase the risk of another miscarriage. Genetic tests can be performed on both partners if needed. See a Reproductive Endocrinology and Infertility (REI) specialist for testing and treatment to reduce the chances of another miscarriage.

What are the risk factors for miscarriage?

There are many possible 'risk factors' for miscarriage but some women have no risk factors that can be identified ahead of time. Prior miscarriage(s), extremes of female age - early teens or 35 or over, smoking, uncontrolled diabetes or thyroid disease, a personal or family history of blood clots, or autoimmune diseases like lupus may all increase the risk of miscarriage. At least one previous child decreases the risk.

What is the treatment for recurrent pregnancy loss?

Recurrent pregnancy loss is defined as two or more miscarriages. Low dose ‘baby’ aspirin - 81mg a day, plus heparin or enoxaparin shots, may be needed for antiphospholipid antibodies or blood clotting disorders. Surgery is indicated for a uterine septum (a dividing wall inside the uterus) or for polyps or fibroids affecting the cavity of the uterus. We treat any thyroid or prolactin hormone issues. IVF may be needed for women with significantly diminished ovarian reserve. PGD (preimplantation genetic diagnosis) may be offered, and is a good idea if either partner carries a chromosome translocation, where part of a person’s DNA is switched between two chromosomes. See a Reproductive Endocrinology and Infertility (REI) specialist.

How soon are you allowed to try again after pregnancy loss?

After one miscarriage, it's best to wait a month; there is some evidence of a higher chance of another loss in the first month. After two or more miscarriages (recurrent pregnancy loss) you should see a Reproductive Endocrinology and Infertility (REI) specialist to look for causes of recurrent miscarriage, before you get pregnant again. After one loss you should see an REI if it took a year or more to conceive.

Can anyone recommend any treatment for coping after pregnancy loss?

Psychological support from friends and family is important. Counselors are available: Your OB or fertility clinic can give recommendations. Support is available from others with experience of infertility or pregnancy loss in online communities. Medically, see a Fertility specialist (Reproductive Endocrinology and Infertility or REI MD) to look for possible causes of miscarriage. Two losses is considered recurrent miscarriage, not three losses. Many causes of miscarriage can be treated to reduce the chances of another pregnancy loss in your next pregnancy.

Intrauterine Insemination (IUI) FAQs

Can you get infections through artificial insemination?

It’s rare but possible. If there are signs of a male bacterial infection, with infection-fighting white blood cells in the sperm (pyospermia) we would not use that specimen for an Intrauterine Insemination or IUI as we might spread infection to the uterus or tubes. Viral infections like Hepatitis B, Hepatitis C, and HIV can be transmitted by sperm, so sperm donors are tested for infectious diseases. Washing the sperm for IUI doesn't completely remove all of a viral infection from the sample.

Is it ok to get an IUI during ovulation?

Yes, it's still OK. There is a window where the egg could be fertilized, from around 3-5 days before ovulation until the day of ovulation (and maybe one day after ovulation). The day of ovulation might be the best day to do an Intrauterine Insemination (IUI) - if you choose one IUI per month we time it for the day of expected ovulation, for two IUIs a month we choose the day before ovulation and the day of ovulation. If we are monitoring a treatment cycle with ultrasound, and you have a decent-sized follicle and then get a positive LH surge I would do an IUI on the day of your surge. The egg has up to 24 hours after ovulation when fertilization could occur.

In Vitro Fertilization FAQs

When doing IVF is it possible to get pregnant naturally?

It's unlikely but possible for an egg to fertilize naturally during an IVF cycle - we removing most of the eggs from the follicles in your ovaries at the time of egg retrieval, but a small number of eggs could remain in or around the ovaries. For this reason, egg donors need to abstain from intercourse during their treatment until advised that it’s safe to resume.

Is IVF ever done without fertility drugs?

Yes, but natural cycle IVF (no fertility drugs) where only one egg is typically obtained, or 'minimal stimulation IVF' with Clomid or low-dose fertility shots has much lower chances of success compared with 'conventional IVF' with higher doses of injectable medications, when we are aiming to obtain multiple eggs. Costs are lower, and the risk of multiple pregnancies is lower, but the results are worse. More eggs give us a higher chance of having high-quality embryos from which to choose the best ones to transfer back into you.

If you conceive a child via IVF, what traits can you currently select for?

IVF can be combined with Preimplantation Genetic Diagnosis (PGD) where we test one or more cells from each developing embryo. PGD can be used for most single gene disorders (diseases caused by one gene) such as cystic fibrosis, Huntington's, Polycystic Kidney Disease, etc. We can also test for chromosome rearrangements like translocations, or testing embryos for genetic 'normality' (sometimes called Comprehensive Chromosome Screening or CCS). PGD can be performed for family balancing for couples who have at least one child, and desire a child of the opposite gender. PGD cannot be used to select height or any other physical characteristic, or intelligence, and should not be used to select eye color or other appearance traits.

If you get your tubes tied, could you still have a baby with help from IVF?

Absolutely, having blocked tubes is the reason IVF was invented. IVF is often a better approach than a surgical tubal ligation reversal. See a specialist (Reproductive Endocrinology and Infertility or REI MD) who offers both options to assess your individual situation. A basic workup includes checking your partner's sperm (Semen Analysis) even if he's the father of your kids, and checking your egg supply or ovarian reserve.

Is IVF the only option for couples who cannot conceive on their own?

Most couples who are trying to conceive without success don't need In Vitro Fertilization (IVF) or ICSI (Intracytoplasmic Sperm Injection) - if cheaper and easier treatment is appropriate we try other things first. Sometimes IVF is the right answer: if inseminations aren't working, for severe disease of the fallopian tubes or diminished ovarian reserve (low egg supply), or for severe sperm problems needing ICSI. See a Reproductive Endocrinology and Infertility (REI) specialist for testing and for treatment options.

How many IVF treatments does it take to become pregnant?

Typically one to three fresh IVF cycles, but your age and ovarian reserve (egg supply) are obviously major factors. In general, the best results with IVF are up to age 40. Success rates drop each year after 40 and are very low by age 45, using your own eggs. If you have embryos to freeze with a fresh IVF cycle, it can increase your chances of success and lower the number of fresh cycles that you need. Egg donation has high success rates at any age.

Will preparing for an IVF cycle be painful?

In Vitro Fertilization or IVF involves around 8-12 days of fertility injections. Typically there is some discomfort from the shots, which usually go in under the skin in your stomach area, similar to diabetics taking insulin shots. During this time your ovaries get bigger and you may feel bloated or uncomfortable - most women don't feel like jogging or heavy exercise at this time. You should be asleep, or very deeply sedated, during the egg retrieval procedure itself, where eggs are removed from your ovaries under ultrasound guidance by placing a needle through the vaginal wall. After this procedure your ovaries may be sore for a day or two and you may take some pain tablets like vicodin.

Before embryos are put back into your uterus, usually 3 to 5 days after the egg retrieval, some clinics put you in intramuscular progesterone shots, which are shots that go in your buttocks - most women have their husband or partner give these shots, which can be mildly painful. Other clinics use vaginal progesterone instead which is a more comfortable option. Putting embryos back inside your uterus, or embryo transfer, is painless but you have a medium full bladder, and many clinics give you valium to help you relax for this procedure.

So, not very painful but some discomfort and mild pain is possible. Talk to your fertility clinic about your concerns, too.

Can someone over the age of 45 undergo IVF?

Yes, it's possible, but the chances of success are low if we use the woman's own eggs. At age 45 the pregnancy rate with IVF treatment is around 1 in 100 or 1%, and miscarriages are more common in this age group, so the live birth rate is less than 1%.

A woman over 45 is much better off with IVF using an egg donor. Pregnancy and live birth rates vary from clinic to clinic, and with using fresh donor eggs or frozen donor eggs. In our practice we aim for at least a 75% success rate with fresh donor eggs, and we have been into the 80's success rate for the last three years.

You should also check with your own clinic, as some have age cutoffs for IVF with your own eggs, such as not allowing IVF with your own eggs over age 43, or over age 45.

Am I at risk of getting pregnant with twins if I go through IVF?

There is always a chance of twins with IVF, but most IVF pregnancies are a single baby. The risk of twins is affected by how many embryos are transferred into your uterus, your age, the stage of the embryos (day 5 or 6 blastocyst-stage embryos are more likely to implant than day 2 or 3 cleavage-stage embryos), and the quality of the embryos. If you are under 35 with high quality embryos, there is about a 40% chance of twins if two embryos are transferred, and less than a 5% chance of twins with one embryo transferred - a single embryo can split into identical twins. Blastocysts are more likely to split.

Identical twins from IVF is a rare event. Most twins from IVF are non-identical, from two different embryos. Not all pregnancies that start as twins end as twins - some twin pregnancies result in miscarriage of one twin and survival of the other one so that you end up with a single baby.

The pregnancy rate with IVF may be up to 10-20% higher with two or more embryos transferred compared to a single embryo. The ideal candidate for a single embryo transfer is a woman under 35 using her own eggs (or any age using an egg donor under 35) with good quality embryos, and preferably with extra embryos available to freeze. It's also preferable if it's your first IVF cycle, or you've been successful with IVF before.

Talk to your MD about your concerns regarding twins and together you can decide the right number of embryos to transfer. They can give you specific guidance as they know your individual situation.

Tubal Ligation FAQs

What are my options if I had a tubal ligation in the past and I want to get pregnant?

Your choices are a surgical tubal reversal or In Vitro Fertilization (IVF). Surgery may have high tubal patency rates (at least one tube stays open 70% of the time) but has a higher chance of ectopic (tubal) pregnancy. IVF may get you pregnant faster. The decision is affected by your age, and your partner's sperm count and quality – we recommend getting a semen analysis for him, whether he’s a new partner or you have children together. See a specialist (Reproductive Endocrinology and Infertility or REI MD) who offers both options to assess your individual situation.

If my tubes are tied, what are my chances of getting pregnant naturally?

Your chance of getting pregnant is about 2% over the first 10 years after your tubes are tied. Some methods of tying your tubes, like putting clips on the tubes, have a chance of getting pregnant of about 4% over 10 years. If you are trying to conceive again see a Fertility specialist (Reproductive Endocrinology and Infertility MD) to discuss surgical tubal reversal or In Vitro Fertilization (IVF).

How much does it cost to have your tubes untied?

Insurance plans generally don't cover reversal of a tubal ligation. Costs vary from state to state and between Fertility centers as well. When comparing different clinics, look at the total cost including facility fees if the surgery is done at a hospital or surgical center. Some couples have insurance coverage for In Vitro Fertilization (IVF).

Is it normal to miss your menstrual cycle after you have your tubes tied?

Having your tubes tied does not affect your periods.

There is a small chance of getting pregnant after a tubal ligation (about 7 women out of 1000 who have their tubes tied will get pregnant in the first 10 years after surgery). So you need to see your Ob/Gyn for a blood pregnancy test to be 100% sure - if you are pregnant, it might be a tubal (ectopic) pregnancy which can be dangerous.

If you're not pregnant your OB can find out why you are not regular, such as a hormone-producing ovarian cyst. If you continue to be irregular you will need more testing to find out why, but not if it's a "one-off" episode and you go back to being regular every month.

Is a tubal reversal an option if my tubes were clipped, tied, and burned?

The choices are In Vitro Fertilization (IVF) or surgical tubal reversal.

IVF involves taking fertility shots for about 8-10 days to make multiple eggs, doing a short ultrasound-guided in office procedure to remove around 10-15 eggs from your ovaries (an egg retrieval). The eggs can then be fertilized by your partner's sperm, either by mixing the eggs and sperm and letting them fertilize 'naturally' in the lab (conventional IVF) or injecting each egg with a single sperm, a procedure called ICSI. The fertilized eggs grow into embryos, and we can put the best 1-3 embryos back inside your uterus (embryo transfer, a simple in-office procedure) and freeze any extra embryos. Success rates can be as high as 60% if you are 35 with good egg supply (ovarian reserve). The frozen embryos can be used to have another child, or if you don't get pregnant the first time, or if you have a miscarriage. Not everyone has extra embryos to freeze.

Surgical tubal reversal is an outpatient surgery, done either through a surgical telescope (laparoscopy) with small incisions on your lower abdomen, or through a small bikini-line incision (mini-laparotomy). Success rates vary and depend on how much tube was destroyed, with up to 70% of women having at least one open tube after reversal with good surgical technique. There are two ways to burn the tube (unipolar and bipolar electricity) with unipolar cautery doing more damage. Tubal reversal surgery is less successful if the tubes were burned either way. There is a higher chance of tubal pregnancy than with IVF, and this is a much more delicate surgery than tying the tubes in the first place. It needs to be done by a Reproductive Endocrinology specialist, ideally using microsurgery or robotic surgery. If the surgery is successful you will need birth control again.

It is hard to say what's the best option without knowing more about you - it can be helpful to get the operation report and pathology report from your sterilization to see how much tube was removed and what exactly was done. If the far ends of the tubes were removed (fimbriectomy) IVF is the best choice.

It is worth doing a sperm count for your partner upfront, as if he has low sperm numbers or quality then IVF with ICSI is the best choice. It is also worth testing your fertility including your ovarian reserve (egg supply) - even with 3 kids and six pregnancies, this could be low at age 35.

Hope this helps. I recommend seeing a Reproductive Endocrinologist who does both tubal reversals and IVF, who can look at your individual case.

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