I am going to continue with the response to questions for a bit more. This time I will start with the most recent and work backwards. Here I will address the SCSA question. I will continue to get to the other questions as the blogs roll out.

The SCSA: I do not order this test. Maybe someday I will, but I need more science. When a new test comes out (I know it’s been out for years, but it’s relatively new and not universally performed), there are a few reasons that it becomes popular.

One is that it is a great test and can really distinguish between who is fertile and who is not. Another reason is that some company is making tons of dough and can afford to spend a lot of money convincing your doctor this is a must do test. Another is that some doctors do some quick and dirty research, making a case for the test thus boosting their careers. Another is that some famous doctors are on the boards of these companies, and they use their international reputations to convince other doctors it’s a good test. Another reason is that in order to keep up with the competition, you doctor needs to order the test, even if he does not believe in it, so that you will not leave him and go to the doctor who orders the test. Another reason is that when anything new comes out there is a quick flurry of studies showing its good, but it takes years for studies to come out against. When something is new, a lower quality of research suffices for publication, whereas the standards of publication go up over time. There are probably others.

Now I never said the first reason did not apply to the SCSA, but as you can see other reasons need to at least be considered.

I can say one of the tests sales people came to my office last week and started to tell me about the test. He said the test has clearly been shown to distinguish between the fertile and infertile. I said show me the data and he said it’s not published yet. I thought how strange, you have been selling this test for years, and you are telling me it’s a must do, and yet you can’t show me any data?

I do see that a woman wrote in saying the test helped her. I am very happy about this. The universal question is, if she did not have the test, would her course of therapy have changed?

Why does this matter to me? So what if you get one extra test? Because what if the sperm is actually good, and someone tells you the SCSA says the sperm is bad? What if you don't need IVF, or you don't need ICSI, or you don't need to adopt? That's the issue: giving people erroneous bad news. At NYU, like most good centers, we have been doing just fine without the test. Men with low counts have lower natural pregnancy rates, and may need IVF with ICSI, or even biopsies. But almost every fertility doctor has pregnanies from men with alomst no count, almost no motility and hideous morphology. Can we really tell anyone to give up based on this test, or any test? This test better be perfect, and few things are perfect.

I am going to sign off now. After I get to some more of the questions I will get back to you about this.
I will contact the company again and search the medical data base for some hard published data.

Dr. Licciardi

I am going to continue with the response to questions for a bit more. This time I will start with the most recent and work backwards. Here I will address the SCSA question. I will continue to get to the other questions as the blogs roll out.

The SCSA: I do not order this test. Maybe someday I will, but I need more science. When a new test comes out (I know it’s been out for years, but it’s relatively new and not universally performed), there are a few reasons that it becomes popular.

One is that it is a great test and can really distinguish between who is fertile and who is not. Another reason is that some company is making tons of dough and can afford to spend a lot of money convincing your doctor this is a must do test. Another is that some doctors do some quick and dirty research, making a case for the test thus boosting their careers. Another is that some famous doctors are on the boards of these companies, and they use their international reputations to convince other doctors it’s a good test. Another reason is that in order to keep up with the competition, you doctor needs to order the test, even if he does not believe in it, so that you will not leave him and go to the doctor who orders the test. Another reason is that when anything new comes out there is a quick flurry of studies showing its good, but it takes years for studies to come out against. When something is new, a lower quality of research suffices for publication, whereas the standards of publication go up over time. There are probably others.

Now I never said the first reason did not apply to the SCSA, but as you can see other reasons need to at least be considered.

I can say one of the tests sales people came to my office last week and started to tell me about the test. He said the test has clearly been shown to distinguish between the fertile and infertile. I said show me the data and he said it’s not published yet. I thought how strange, you have been selling this test for years, and you are telling me it’s a must do, and yet you can’t show me any data?

I do see that a woman wrote in saying the test helped her. I am very happy about this. The universal question is, if she did not have the test, would her course of therapy have changed?

Why does this matter to me? So what if you get one extra test? Because what if the sperm is actually good, and someone tells you the SCSA says the sperm is bad? What if you don't need IVF, or you don't need ICSI, or you don't need to adopt? That's the issue: giving people erroneous bad news. At NYU, like most good centers, we have been doing just fine without the test. Men with low counts have lower natural pregnancy rates, and may need IVF with ICSI, or even biopsies. But almost every fertility doctor has pregnanies from men with alomst no count, almost no motility and hideous morphology. Can we really tell anyone to give up based on this test, or any test? This test better be perfect, and few things are perfect.

I am going to sign off now. After I get to some more of the questions I will get back to you about this.
I will contact the company again and search the medical data base for some hard published data.

Dr. Licciardi

I have not answered questions since October, so here we go.

Because it’s been a while, sorry if my answers are a little late for those asking, but I hope other readers will have the same questions and learn from the dialogue.

A woman wrote in frantically about her new experiences using Clomid. In fact she was do distraught, she was really concerned about getting pregnant with her second child even though she was not yet pregnant with her first. Yes Clomid can make you extremely emotional, but no one should really be over the edge. If you feel like this woman, get counseling (which more people really should do) or get off Clomid, or both.

Antral follicle counts are only a guide. If you have a total of 11, you don’t really know how the cycle will work out. 11 is a very adequate number; you will probably have a nice enough response for pregnancy.

Cost efficiency of IUI vs. IVF. If you have PCOS, your injection iui cycles may be more expensive than other women’s cycles because you need to be watched more closely. But, you are more fertile that the average woman. Go over the costs of each with you doctor in the beginning. And of course you need a little luck. If you get pregnant quickly with iui, you look like a genius.

Zero Sperm Morphology. I don’t think sperm morphology is much of an issue unless it’s zero, but usually that translates to a fertilization problem. If miscarriage is the problem we don’t know. The dilemma is no one can tell you will never become pregnant with his sperm.

From to Clomid to IVF with PCOS. Women with PCO can safely be given injectables. The key is starting on a very low dose. It is sometimes a pain because the cycle becomes long, but if you don’t want to go to IVF right away, ask your doctor about a low dose protocol.

MTHFR: I like your doctor’s response. No one has shown that blood thinners are appropriate or even help. Be sure your homocystine levels are normal.

Hypothalamic Amenorrhea. Most women with this do not bleed after Provera or other progesterones, and most do not respond to Clomid. Usually the injections are necessary.

What are normal progesterone levels? We don’t know. All doctors have their own ideas. I don’t think they need to be very high.

BMI cutoffs for IVF. This depends on a few things. Can you be safely administered anesthesia? Are you at risk for having a very complicated pregnancy? Can the doctor find the cervix? Large BMI may have a negative effect on stimulation and pregnancy rates, but not to a great degree.

How many follicles are too many for IUI? IT depends on your age. Once I see more than 5-6 I talk more seriously about the odds of multiples and talk about cancellation. If there are more, I may just cancel the cycle. It’s hard to give you an exact cut-off number; it depends on age and other fertility factors. Making extra eggs is the goal of the injection cycle because extra eggs increase your odds of becoming pregnant.

AMH is a new tool. We have done some research, and are planning more. I’ll write about it in a separate blog.

Poor egg quality. I hate this term because more often than not the doctor throws it out there with little evidence, other than his own frustration. Embryo quality means 2 different things: it’s about how the embryos looks (morphology) and the embryo’s chromosomes (genetics). If you have done IVF, and your embryos barely develop or are very fragmented, you have poor egg quality. This is a morphology issue. If you have done IVF a few times and your embryos look OK, yes you may have poor embryo genetic quality. But it is also possible that you just have not yet become pregnant and your time will come. My problem is with the doctor who tells a 39 year old with 11 eggs and 6 decent looking embryos, 3 to put back, that she did not become pregnant because she had poor embryo quality.

Pumps for Hypothalamic Amenorrhea: Sure. Sounds a bit cumbersome to me, but if you want to give it a go, especially if nothing else is working, go ahead.

More answers next time. Please read disclaimer 5/17/06.

Dr. Licciardi

Does taking a lower dose of fertility drugs improve your chances of becoming pregnant with IVF? I think not, but I can tell you of some exceptions. Mostly I have had some very good experiences with patients confirming that lower is not better.

How do I know?

Well, as it turns out over the past few years I have been seeing more patients from Europe. There are a few things that have contributed to this. One is the blog. It’s been fun getting e-mails and seeing patients from around the world. The second is the exchange rate: for some, New York is now a “reproductive tourism” destination. The third has to do with laws in Italy, Germany and other countries that restrict IVF and donor egg.

Anyway, the European doctors give their patients a much lower dose of drug that we do in the US. Part of this is due to the fact that they may not be allowed to fertilize more than a few eggs, so they don’t bother trying to get more. Another reason may just be due to a general philosophy that less drug is better.

So the typical European woman that sees me has done IVF many times, usually making just a few eggs on a lower dose of drug. Unless she has had a fantastic response, I increase the dose for her IVF cycle with me. In most cases, the egg yield is much higher (still in a safe range) and the pregnancy rate in these women is very high. So the point is that in these women, a higher dose is better because it increases the number of eggs, and therefore there are more embryos available for selection.

Do some women make more eggs with a lower dose? I have seen a few cases of this. This is typically the woman who was given a lower dose for IUI and develops more follicles than she did with her higher dose IVF cycle. Should we go back to the lower dose for the next IVF cycle? It’s a gamble and it takes a little courage. It is really hard emotionally to go into an “experimental” IVF cycle.

Many patients considering this have had many attempts and may not be ready to give up a couple months for a “let’s see” cycle. If you and your doctor can stomach it, you can give it a try. I can tell you I have one woman, who had been through many cycles, who wanted to give it a go, and she did better with less. Was that her month to make more, regardless of drug dose? Who knows, but let’s give her the credit.

But I do think starting on a minimal dose, just because your doctor thinks it’s more homeopathic and will result in better quality embryos, is not correct. To return to our common theme, if one of the self proclaimed experts in minimal stimulation wants to take 100 women and give them minimal stimulation, and take another 100 and give them regular stimulation, and then show us that minimal is better, great. But until this happens we have to say that it’s not better, and may be worse for most people. I know some of you can tell me that you did minimal and got pregnant. I just feel that my experience has shown that overall, regular may be better.

Please read disclaimer 5/17/06, and thanks again, Dr. Licciardi

As I walked from the elevator at my usual 7:00 am, I glanced through the waiting room and something caught my eye: a pregnant woman on the cover of Newsweek captioned by “Fertility and Diet.” “ Oh no,” I said to myself. “Here come about at million questions!” So I figured I would read the article and take the time here to go through some things; beat you to the punch.

According to the article, diet the recommendations are aimed at preventing and reversing “ovulatory infertility.” This goes back to my blogs on PCOS. Therefore if you already ovulate regularly, the diet issue does not apply to you.

It appears that women with better diets had more regular ovulation. Brilliant. Lets start with carbs. The article shows that carbs are fine, but women who ate more “healthy carbs”, such as brown rice, pasta and dark bread, whole grains, beans and vegetables, and whole fruit, ovulated more than those who loaded up on white rice and potatoes. Sounds familiar. For any medical well-being issue, the message is the same.

Trans fats can make you fat. Brilliant. A diet higher in trans fats usually means the diet is lower in the good things mentioned above. This concept can also be applied when examining that plant protein may be better that animal protein.

The milk and cream issue requires a little more analysis. There are 2 types of women who do not ovulate: those that are starving themselves, and those who are eating a bit more that they should. The article does not always make the distinction clear. The point is that if a woman in not eating, milk and ice cream will help her ovulate. Increasing caloric intake, through whatever means necessary, can jump start ovulation. However, if someone is overeating to start with, milk and ice cream may not make a difference, unless she starts to substitute some of the bad food with yogurt and cottage cheese, which will lead to weight loss.

Exercise is good. Brilliant.

To be perfectly clear, I agree with everything they say. Proper diet is a good thing. Potential pitfalls here are that women may feel that by taking an extra hit of salmon per week will feel they can lick their fertility problems, and not get the help they need until they are older. If you are not getting pregnant, eat well and see the fertility doctor. If you are 32, overweight and don’t ovulate much, it’s ok to get on a program, lose weight over 6 months, start to ovulate, and avoid Mr. M.D. If you are 38, ovulate regularly and decide to modify your diet for 6 moths before seeing the doctor, I think you may lose too much valuable time. Do both.

In addition there are reasons for non-ovulation (we call it anovulation) other than those related to weight and diet. Problems with the thyroid, pituitary and adrenal glands can also contribute. Therefore, if you are not ovulating, you are better served by a basic simple workup. If everything is ok, at least you know, and then you can make a decision on how to proceed.

Admittedly, I am jealous that some researchers reported on things we already knew, published a book, and got on the cover of Newsweek. Brilliant! But I am happy that by reinforcing some basic principals people can be healthier, and some more women will get pregnant. We all have experienced that some people process a message better when it comes from the press as opposed to from their doctor, spouse, mother ect.

As usual, see the disclaimer blog.

Thank you,

Dr. Licciardi

A fibroid is an abnormal growth in the uterus. We also call them myomas. I say abnormal because a fibroid shouldn't be there, however so many women have fibroids we consider them common. How common are they? At least 30% of women have fibroids. I have recently heard that some say that up to 60-70% of women have fibroids, although that sounds a little high to me.

How do they get there? We don’t know how they start. We do know that they grow in response to estrogen. They are not seen prior to puberty and get smaller after menopause. It seems that each fibroid starts as one fibroid cell, and this cell keeps dividing resulting in a large fibroid. Even though they come from the cells of the uterus, they do look different than the normal uterine muscle. They are whitter because they have few blood vessels, and they are firmer, about the consistency of a potato. We don’t know why some women have only one; some have 40.

Fibroid size and a word about centimeters. Most medical things are measured in centimeters (cms). One cm equals 2.54 cms. So a 5 cm fibroid is about 2 inches. A tennis ball is about 6.5 cms. How does this compare to the size of the uterus? The uterus, not including the cervix, is about 5 cms tall, 2.5 cms thick and about 5 cms wide. So a 5-6 cm fibroid is about the size of the uterus. A bigger fibroid would be bigger than the uterus. A 10 cm fibroid is a lot bigger. I commonly find fibroids on ultrasound and as I point them out to my patients they say ”wow, that’s big”. But something that looks big on ultrasound may be really a more medium sized and not a problem. Every doctor has a different view on the minimum fibroid size they consider tolerable. It’s usually around 5-6 cms, but it also depends greatly on the location.

Location. It’s either subserosal, intramural or submucus. Patients ask all the time, “is it growing in the wall?” They all are growing in the wall to some degree. The wall means the muscle of the uterus and that’s where fibroids mostly come from. It’s just a matter of how they grow after they start in the wall.

Some are loosely anchored in wall, more towards the outside, but have most of their growth on the outside of the uterus. These are called subserosal (the subserosa is the thin outside layer of the uterus). Some of these become pedunculated, which means they hang like a ball on a short thick string.

Some are mostly intramural, but the wall of the uterus is only about 1 cm thick. So as the fibroid grows bigger than 1 cm, it will bulge either inward or outward (becoming more submucusal or subserosal)

Some grow from the uterine wall but mostly bulge into the inside of the uterine cavity. Now the inside of the uterus is lined with the glandular cells called the endometrium. These are the cells that shed with menstruation. These are the cells that provide a nice place for an embryo to get started. This is the same endometrium that is measured during induction of ovulation and IVF. A fibroid will disrupt the endometrium. It will stretch the lining and cause gaps in the lining, and this leads to abnormal bleeding. More on fibroids to come,

Dr. Licciardi

The questions was: is it necessary to take progesterone if you are doing clomid or FSH injections with iui?   The answer is that you may not need progesterone for these cycles because the ovary can do a great job of producing high levels of progesterone. The corpus luteum is not disturbed by an IVF needle. Also, we usually do not give lupron or antagon or cetritide for an IUI cycle. Personally, I usually do not give progesterone for IUI, but I will in some select cases. Some doctors give progesterone because of the high estrogen levels produced by the fertility drugs. They feel that if the estrogen is high, the progesterone needs to be high too. This is a theoretical concept and has not been shown to be valid for women on fertility drugs. Certainly if the period is coming early after the iui, progesterone should be considered.

 

HA stands for Hypothalamic Amenorrhea, which is when there are no periods due to extreme exercise, stress, etc, despite a good number of resting follicles and a low FSH.  It’s the hypothalamus that sends signals to the pituitary to make FSH and LH. If the hypothalamus doesn’t send the signal (GnRH), the pituitary does not make the FSH and LH. It’s the brain’s way of preventing pregnancy if the body is too stressed. 

 

Moving from Clomid Straight to IVF for PCOS. FSH iui in women with PCO can be done safely, without the production of too many follicles, providing the starting dose of the FSH is low enough.  Even in such cases careful frequent monitoring and occasional cancellation, is necessary. Talk to your doctor about this. Again, the starting dose needs to be very low. In general, 3 cycles of Clomid are attempted before going to the next steps, however there is an exception in women with PCOS. If you are not getting regular cycles off Clomid, and Clomid straightens things out, more attempts, around 6, may be ok. 

 

Abnormal Sperm Morphology Causing Miscarriages: I have not seen this connection, and I have seen tons of men with low morphology. Now maybe you are one of the couples where there is a connection, but you will need to discus this more with your doctor or a second opinion.

 

An 8 mm uterine lining is not thin, it’s fine.

 

An antral follicle count of 11 is fine, you don’t need more. “Normal” FSH can mean many things. In other words there is a big difference between 6.8 and 11.2, and both are in the normal range.   If it’s on the lower end, you will be ok. If you are on the higher end, you may also be ok. You may produce fewer follicles that another woman with more resting follicles, but it sounds like there are enough.

 

Thanks for reading and please see disclaimer 5/17/06. Dr. Licciardi