Fertility FILE

Letting Your Fertility Go Up in Smoke

When you spend money to do infertility treatment, you trade your hard-earned resources to get a boost towards getting pregnant sooner. How would you feel about spending money to LOWER your chances? This is exactly what happens when you or your partner smokes.

I usually start off by telling my smoker patients that cigarette smoke, whether actively inhaled or even breathed passively, can harm the ability to conceive. Consider the fact that the tars, ammonia, hydrogen cyanide, fomaldehyde and carbon monoxide found in smoke are toxins that can cause short-term damage to eggs and sperm as well as accelerate the aging process so as to cause long-term damage in females. Toxins are concentrated in the cervical mucus of the female, rendering a hazardous barrier to the sperm as they try and swim past.

Smoking may not just hurt your chance to conceive naturally. It can also lower your odds of success with IUI or IVF, requiring more cycles and more time to achieve the pregnancy you want. Smoking during pregnancy can cause an increase in obstetric complications and even affect the child after birth, including a higher risk of sudden infant death syndrome

BUT, as much as I look negatively on the effects of smoking, I am not in favor of demanding government bans on smoking. I believe in the principle of individual freedom, which includes the rights of smokers to harm their own health as long as the rights of non-smokers are not infringed upon. These include the right not to be exposed to second-hand smoke and the right not to be financially burdened to care for the excess health problems brought on by smoking. In any case, I continue to do my part to offer education to others to help them make their own decisions.

Please remember that the decisions that you make will affect how long it takes before you have a healthy baby.

How Old are my Ovaries?

Diego and Susy Golberg are a couple in Argentina who began a yearly ritual in 1976. Every June 17th, they took portraits of themselves and their eventual family of three sons, producing a vivid photographic reminder of the reality of aging.

Age plays a very important role in reproduction, especially biological age. Chronological age is determined by what it says on your driver's license. Biological age is different, and arguably more significant. Do you know any athletic women in their late-30's who have the "body of a 20-year-old"? Have you ever seen a 35-year-old alcoholic smoker who looks like he's 50? When it comes to a woman's reproductive capability, it's important to consider her ovarian age in addition to just her chronological age.

Near one extreme, you can have a 43-year-old woman with enough quality eggs remaining that she conceives twins on her own. Or you can have a 19-year-old girl who goes into premature menopause. But for most women, their ovarian age stays fairly faithful to their chronological age with a gradual decline in fertility throughout their life until they reach their 30's at which point the decline accelerates. Then by age 40, the decline becomes very sharp.

It's not possible to tell someone's ovarian age with a single test. You can't tell based solely on how healthy and young she looks. There are a variety of clues about a woman's biological age provided by various methods, some of which are more important than others.

CHRONOLOGICAL AGE: Not surprisingly, the biggest predictor of ovarian function is someone's true chronological age. There is no getting around the fact that if you are 46, you still have poor reproductive outlook, even if you are in the biologically youngest 1% of all the 46-year-olds in the world.

FSH LEVELS: There is a blood test that is typically done on day 3 of your cycle. A high FSH (over 10 IU/l) is suggestive of advanced reproductive aging. A value over 15 IU/L is significantly worse. Consistent values over 25 IU/L indicate that you are likely menopausal. A bad test result is bad news. Unfortunately a GOOD FSH result (under ~9 IU/L) is not necessarily good news. If you are 46 and have a FSH of 5 IU/L, that still does not mean you have the fertility of a 26-year-old. Another warning about interpreting FSH levels involves the possibility that FSH results can look much better than they actually are if your estradiol levels are high on the day of the FSH test. This is why reproductive endocrinologists always know to test an estradiol level at the same time as the FSH level. For example, a day 3 FSH level of 6 IU/L with an estradiol of 53 pg/ml is more favorable than a FSH level of 5 IU/L and an estradiol level of 119 pg/ml. The final point to make about FSH levels is that they are a MARKER of ovarian aging and they are not the CAUSE of ovarian aging. Many patients when told they have a high FSH level often ask what they can do to make the FSH level lower. Making it look lower doesn't change the message that the ovaries are old. This is similar to having a red "engine warning" light come on in your car and inquiring what you can do to cut the wire so the light goes out. It still doesn't change the fact that there is a problem with the engine.

OVARIAN VOLUME: In general, younger women have large plump ovaries, because there are more stored eggs left in them. Menopausal women have tiny ovaries that are sometimes so small as to not be visible on ultrasound.

ANTRAL FOLLICLE COUNT: Every cycle, before a woman begins developing her eggs, the number of tiny pre-ovulatory follicles is higher in women with young responsive ovaries as compared to in women with older resistant ovaries.

RESPONSE TO CLOMIPHENE CHALLENGE TESTING: An old way of testing ovarian reserve or ovarian age involves giving Clomid pills and testing FSH levels before and after. Elevated FSH levels pre or post Clomid are signs of ovarian aging.

INHIBIN B: In contrast to FSH testing, higher levels of inhibin B are good and lower levels are bad.

ANTI-MULLERIAN HORMONE: The usage of this hormone to predict ovarian response is a fairly new concept. Again, as with inhibin, higher levels are good. Lower levels are bad.

ACTUAL PERFORMANCE: All of the previous mentioned tests and methods are just predictors of how the ovary MIGHT function. None of them beat actual performance in terms of importance. Even if your age, FSH level and all other testing predict bad news, if you undergo infertility treatment, make a surprisingly large number of good eggs and get pregnant, then you won't really care what the testing predicted. One patient who comes to mind is a woman with small ovaries and a documented day #3 FSH level of 22 IU/L, who came to me for fertility treatment. After I informed her that her chances of success would be low, she polite acknowledged my warnings and then wound up defying the odds, getting pregnant and delivering a perfectly healthy girl at age 41 with her own eggs!

Before asking your doctor to order this whole slew of tests, bear in mind the principle that tests are only of value if they can help us make better decision choices. Knowing that you might have a better or worse outcome may not necessarily change what you decide to do. For example, if you are applying to law school and your LSAT scores tell you that you have a 80% chance of being accepted, but your GPA suggests you have a 55% chance of being accepted, and you are going to go through with the application process anyway despite of which is more accurate, then knowing this additional information doesn't really change your actions. Think about it. I will share more on this very important concept of decision-centered thinking in future posts.

Photos by Bobby Neel Adams.

Q & A : September 27, 2007. A case of PCOS

Dear Dr. Lee,
I was wondering if I could run my situation by u and get some advice or possibilities on what my prob. could be. I have been happily married for over 10 years now. I got preg about 10 years ago when we were first married and miscarried. I have not been preg. since. My periods were always irregular sometimes absent for months sometimes lasting for 3-4 weeks. I had an ultrasound and was diagnosed with PCOS - I have been on metformin for 5 months now and did 2 months of clomid and 3 months of letrozole with nothing. Now I am waiting for my husbands insurance to kick in to have laparoscopic surgery. My husband has been tested and he is fine so the prob lies somewhere within me - what could this be and do u think I could ever even become pregnant. I am 26. Yes, I got married young. I am desperate because my mother and all three of her sisters ended up having to have hysterectomies before they were in their thirties. Any advice would be appreciated. Thankyou.
"B", from Arkansas

Dear "B",
Can you provide some additional information?
Did you grow any follicles on the Clomid or Letrozole?
Did you ever try injectable fertility medications?
What is your approximate height and weight?
Did you have an HSG already to see if your tubes are open?
Dr. Lee

Dear Dr. Lee,
Just within the past two years we have decided to look into this and after a consultation and an ultrasound, I was diagnosed with PCOS. We also had my husband's sperm tested which came back fine. The doctor put on metformin and clomid. I did both for two months with no results. I then continued the metformin and did three months of letrozole. This too ended with no results. We are now at a holding point waiting for my husbands medical insurance to go into affect to take the next step in having laparoscopic surgery to find out more. Being that this was all paid out of pocket and we had no insurance, ( I would imagine this is the reasoning ), I was never told about any follicles growing while on clomid or letrozole. I did recently give a blood test to see if I was even ovulating but have yet to hear the results. I have not tried the injectable fertility treatment because after discussing it with my doctor, decided to start with a less expensive approach again until the insurance takes affect. I am not sure what a HSG is to see if my tubes are open and suppose if I had had one I would know so I guess I have not had that done. My mother and all three of her sisters all had to have hysterectomys in before or in their early thirties so at 26 I am getting more anxious. I am racking my brain trying to figure out what could possibly be keeping me from becoming pregnant especially since I was able to get pregnant 10 years ago.I am 5'4" and weigh 190 although before starting the metformin I weighed 211. As far as symptoms other than infertility, I have literally every symptom of PCOS in addition to migraine headaches, inability to sleep and when I do I have to have atleast 12 hours and even then it is difficult to wake up, and mood swings where I just get so depressed I cry (even tho I am normally a very happy fun person). A cat scan ran during one of my migraine trips to the hospital came back normal. The metformin seems to be working as I have been having normal, regular periods and little pain. Any information on what I need to do and what this could be would be greatly appreciated. Thankyou.

P.S. I have been nausiated and vomiting some the past two days and realized that this occurs without reason maybe twice a month and lasts 3-4 days. I did some more research on the internet and because of the pcos and being insulin resistant, do u think I could be diabetic? I noticed this amongst my "mood swings" and "hunger" and others were symptoms. Sometimes I wake up in the morning and cant make it to the cupboard fast enough for something sweet. Anyway, just a thought - I have been trying to put all this together for years now and I want to thankyou for all your help. I will be watching for your answer. Thankyou again.

Dear "B",
    You have been brave to endure such a long time suffering from PCOS, especially in the context of the frustration of not knowing why you were teased with a brief glimpse of being pregnant way back then. I do congratulate on your having been happily married all this time despite the obvious great stress of infertility. As, always, please accept this feedback in the context of my not knowing more about you and not having the opportunity to examine you. I would suggest you take the following information as potential topics of discussion.
    Many reasons would lead any RE to agree with you having the diagnosis of PCOS (Polycystic Ovarian Syndrome). This is a disease that is not entirely understood, even today. However, we do know that it is somehow related to faulty insulin metabolism. You likely inherited a bad gene that makes your body unable to respond to insulin normally (I wonder if there is diabetes in  your family). Because of this deficiency, you end up having high levels of insulin, which can interfere with egg development. It can also cause a host of other problems, including weight gain, menstrual abnormalities, hairiness, acne and increased miscarriage risk. Your doctor wisely gave you metformin (Glucophage) to address the insulin issue. It is not surprising that you have lost 20+ pounds since starting it. Keep up the good work of taking your metformin, watching your carbohydrate intake and gradually increasing your exercise level.
    I have seen patients start ovulating on their own after losing weight on metformin. I truly hope it happens for you. In the event that you do not ovulate soon, then it's time to consider ovulation medications such as Clomid, Letrozole or best of all, injectable gonadotropins. Unfortunately, when you failed to get pregnant on these medications in the past, we do not know if you grew follicles and ovulated well, but just didn't get pregnant OR if you failed to ovulate even with the medications. If it's the first case, meaning you ovulated consistently and still didn't get pregnant, then I would suggest an evaluation of your tubes. This is best done with a non-surgical x-ray procedure called an HSG. The surgery that your doctor proposes is a reasonable option, but not the best one, in my opinion. Now, if it's the second case, that back when you were on the Clomid and Letrozole, you didn't even ovulate, then the obvious best plan at this point is to work harder at getting you to ovulate.
    So how do we do that? In your situation, it would be reasonable to try injectable gonadotropins with close monitoring to see that you actually are ovulating! If there are no problems with your tubes, you should get pregnant with a high percentage chance once you are ovulating. As for your nausea, obviously you know to do a pregnancy test first. The relationship between diabetes and PCOS goes something like this. A normal person is one whose body uses a little bit of insulin to successfully bring the blood sugar levels down easily. An insulin-resistant PCOS person is one whose body frantically uses a lot of insulin to successfully bring the blood sugar down. A Type II diabetic is someone who despite frantically producing a lot of insulin still can not bring the blood sugar levels down. So while it is possible that you are at risk of becoming diabetic or that you are already diabetic, most likely you are not yet. A combination of diet, exercise and metformin can hopefully delay your development of diabetes until you are 100 years old! Your vivid description of your sugar-craving is classic for PCOS patients. However, you are already on the metformin, so I would have expected improvement in that area. Perhaps a combination of a higher dose (ask your doctor), more will power and REGULAR fun exercise can get those craving under better control so that you can keep losing even more weight.

KEY POINTS TO CONSIDER:
- Ask your doctors if they can focus on helping you ovulate in a proven documented fashion first before resorting to the laparoscopic surgery. If you ovulate, but still don't get pregnant, then go ahead and evaluate your tubes and uterus, either with an HSG (preferred) or with the surgery.
- Continue your great progress regarding weight loss and getting healthier.
- Based on the limited information you have given me, I would be very optimistic about your chances of having a baby within the next few months, provided you make the right decisions regarding treatment.
- Once you get pregnant, keep on the metformin as many believe it can help combat the higher risk of miscarriage that PCOS patients have when they don't take metformin.
GOOD LUCK!

Injecting Fertility Medications

Not all fertility treatment involves injectable medications. However, when it comes time to discuss this topic with the patients who do need to take it, there is a mix of reactions ranging from calm acceptance to sheer panic. Whenever I hear the response that "I don't do well with needles", I'm reminded that I have yet to hear anybody say "Oh, that's wonderful. I do great with needles" It's normal to want to avoid needles and the pain that we associate with it. However, in reality, those nightmares of huge needles are just myths. In reality, I'd say close to 99% of patients who end up taking injectable medications to help in them develop good eggs end up saying it wasn't anywhere nearly as bad as they imagined. The needles are actually short and thin and in many cases come in the form of space-age injection pens. They are NOTHING like the needles in the picture.

Here are links to the instruction videos for the most common brands of ovulation induction medications:

BRAVELLE MENOPUR REPRONEX & NOVAREL INJECTION VIDEOS
GONAL-F INJECTION VIDEO
FOLLISTIM INJECTION VIDEO

Your doctor's staff will show you the technique in person as well, but it's good to watch these for a refresher course in case you forget.

Am I Truly Ovulating?

Linda is a very confident woman in her early 30's who has a very successful career in sales in a science-related field.  She and her husband have been married for six years but didn’t want kids right away. So, she had been diligent about taking birth control pills up until a year ago, when they first made the decision to start trying. She was originally started on the pill back in college to help regulate her erratic cycles. After going off the pill, her period had returned although sometimes coming in 26 days and other times as long as 34 days.

When she first came to see me for consultation, she brought in a stack of color-coded temperature charts that she had created with the help of some ovulation-tracking websites and dropped them on my desk in frustration. She told me her story with sadness. She and her husband had put off having children until now because they both loved their jobs. They also both had a great love of traveling, each year typically going on two major vacations and countless minor ones. They had moved into their dream home two years ago and realized it would be an ideal time to start their family. Everything had been perfect up to that point. Now she is convinced that she waited too long and greatly regretted her decision. I told her that it’s very common to feel this way, but in reality, she most likely had not done anything wrong to permanently harm to her fertility. She continued her story.

When they went off the pill, they were expecting their life of perfection to continue so that they would get pregnant right away. However after eight months of nothing, Linda began being more proactive with diligently charting her cycles. The frustrating part was that some months, the temperature curve looked classic, like in the textbooks, with a clear increase in temperature during the second half of her cycle. However, there were also months in which it looked like a jagged set of random numbers. Her urine ovulation prediction kits had turned clearly positive in some months, with the test line definitely darker than the control line. However, there had also been months where she had a light line that stayed light for 5 days (never darker than the control) and then went negative. And then each month, there was the excruciatingly long wait to see if she was pregnant or not. She said she and her husband wanted to forego all vacations this year and put that money towards doing an IVF cycle to see if they can pregnant instantly.

I reviewed her charts with her and agreed that it was likely that she was ovulating some months and not ovulating on other months. I also confirmed that she had been off the birth control for eight months prior to embarking on the massive charting, and that she had been charting for a year now. Since she was on day 13 of her cycle on the day she first saw me, we had the opportunity to check with ultrasound to see how her follicles here doing. We found that her right ovary had a 14mm follicle. Nothing else was present on either ovary. Her lining was good at 8mm thickness with a triple layer. I explained to her that the follicle would have to grow to at least 17mm or better before it could ovulate. After talking for an hour total about other potential fertility factors, we came up with the plan of following this cycle using ultrasound and seeing how it correlated with her ovulating testing.

Two days later, she called the office excitedly saying she tested positive on her ovulation stick! We brought her in the next day for a repeat ultrasound and saw a single 18mm follicle on the right. So far, so good. She and her husband got busy for the next few nights. She then came back two days later for an ovulation check. To our slight surprise, the follicle was still there and had now grown to 25mm. She also reported vague abdominal pain on that side and even some mild spotting. The follicle had a clear appearance and did not have cloudiness inside as is sometimes seen when a follicle DOES ovulate, but somehow just fills with blood giving rise to what is called a corpus luteum. So even though her ovulation kits detected a surge, she had not physically ruptured the follicle. She had not physically ovulated. After another three days of intercourse, she returned for a final ultrasound. This time, there was a 31mm follicle on the right, still not ovulated. Almost two weeks after the positive surge, her period came.  Optimistically, I advised her to hold off on IVF and start with something much simpler first.

In the next few weeks, we did many things, the most notable being diagnosing her with insulin resistance and starting her on metformin as well as confirming her husband to have a normal semen analysis. She had no apparent risk factors for tubal disease, so we held off on getting an HSG yet. With her next cycle, she was started on clomiphene citrate and monitored using ultrasound. By day #12, she had a lovely follicle on each side, each measuring 16mm. Three days later, her ovulation testing turned positive and she came back for another ultrasound, which showed one follicle to be 22mm and the other to be 20mm. She and her husband got together a lot in the subsequent days. Three days later, she returned. This time, ultrasound confirmed that both follicles were no longer there. They were gone for certain, presumably ovulated! She was scheduled for a blood pregnancy test in two weeks, but she “cheated” two days early and did a urine test, calling us immediately with the good news. She went on to have a healthy baby (just one). She beamed about how she had only spent a few hundred dollars and was thus able to take the money they saved for IVF and take a vacation to Tokyo during her second trimester. =)

KEY POINTS TO CONSIDER:
- An ovulation test does not actually detect ovulation. It detects a hormonal surge that is SUPPOSED to trigger ovulation in the majority of cases. However, it does not guarantee ovulation, as we learned in this specific example. So it’s very much OK to start out doing ovulation tests on your own, especially if it gives you something to do and if it gives you peace of mind that you are having the proper surges. However, if enough time passes and you are still not getting pregnant, then it’s time to take advantage of professional guidance.
- Women don’t ALWAYS ovulate or NEVER ovulate. There are many who will ovulate in some months and not in others.
- Some people may mistakenly equate going to see a reproductive endocrinologist with leaping into IVF or injectable fertility drugs. More often, there are simpler options to start with.
- If a particular strategy has not worked for six months, it's a good idea to consider trying something more effective, even if it's only a little more effective.

Fertility Odds: A Helpful Way of Estimating Your Chances

Just the other day, a young woman stuck up a conversation with me at the dog park while our dogs were playing. When she learned what I did for a living, she excitedly told me "It's great I met you! My husband and I want to start trying for our first baby next year, so I've been meaning to get ready by learning how to take my temperatures. Do you have any suggestions?" As it turned out, she had many girlfriends who were trying to conceive and were always talking about taking their temperatures, charting their cervical mucus , scheduling their times of intercourse and all that. She sounded almost surprised when I shared with her that for most couples, meticulously trying to time their intercourse is a waste of time (with a few exceptions which I'll cover later on in this post).

Let's start with some basic concepts. Every couple has their own magic number that represents their FERTILITY ODDS for that month assuming they have sex every 2-3 days without paying attention to timing. For a couple in their early 20's with excellent sperm and perfectly clean Fallopian tubes and with the wife being an overachiever who ovulated not one, but two eggs that month, their fertility odds (FO) that month might be 50%. (By the way, it's not standard to ovulate two eggs in one month, but there are women out there in which a lot of fraternal twins run in their families. These women could potentially ovulate double from time to time.) While this lucky fertile couple have a really high FO, contrast this to her next-door neighbor, who is 39 years old, overweight, with irregular periods, endometriosis and one blocked tube and a husband who smokes 2 packs a day. Their FO is less than 1%.

In general, the FO in a given month for a couple of average fertility is about 20-25%. But remember the concept of averages. The average American woman is 5'4" tall. However it's not uncommon for women to be significantly shorter or taller than that. Likewise, there are some couples who are super fertile and have higher FO above 30% and others who are subfertile with FO of 5%. In general, couples with high FO's don't obsess about basal body temperature, cervical mucus nor ovulation kits, because they don't have time to do that in between all the babies they have. These are couples for whom pregnancy comes to them right away the moment they get lax about contraception. Couples with average FO's may or may not get to the point where they start stressing about ovulation timing, depending on how lucky they are. For example, compare having a FO of 25% and trying to conceive to playing a simple game with a deck of cards in which the rules are as follows. Every cycle, you shuffle the cards and draw one card at the time of ovulation and hide it in an envelope. You don't get to reveal that card until 14 days later. When you finally do get to see it, if it is a heart, then congratulations! You are now pregnant. If it is not a heart, then your period starts. You place the card back and put the deck away until next month. I'm sure many of you can imagine what it is like to play this game. Now, if you have normal fertility with a normal 25% FO, then you play with a normal deck of cards and it's almost for sure that you will eventually draw a heart, most likely before playing this game for six months. Still, even if you are normal, but just unlucky,  you COULD possibly go on a cold streak and draw 7 or more cards and still never get a heart. However, in time, the odds will even out and you will eventually get your heart.

So what happens if you end up playing this game for three years and still never draw a heart. Obviously, your first suspicion is that you are not playing with a normal deck. Maybe only 2% of the cards are hearts, meaning you'll have to play this for a lot longer before you finally draw a winner. Worse still, maybe there are no hearts in your deck at all, meaning all this time was a waste and the only way you can get pregnant is with medical treatment. Or what about women who don't ovulate. For them, it's like not getting a chance to draw a card at all!

So, after all this background info, I'll now return to the topic of timing intercourse with one's ovulation. OK, stay with me here. As we have just gone over in great detail, every couple has a specific FO each month. The factors that affect your FO include passive factors for which you don't have instant control (age, weight, whether the tubes are blocked, sperm count, overall wellness) and active factors for which you DO have control, primarily when you have sex.

So let's assume that you and your husband  have a 25% FO.

Here are the key points:
1. If you have sex every 2-3 days, your odds of pregnancy that month are 25%.
2. There is a certain day that you are most fertile. If you actually have sex on that day of peak fertility, you might be able to bump your odds up above your regular FO to maybe 30%. You might realize that if you just have sex every 2 days, you'll probably hit that day of peak fertility half the time anyway, without all the bothersome charting.
3. If you DON'T have sex at all in the 4 days leading up to and including your peak day, you drop your FO to 5% that month.
4. If you don't have sex in the 6 days leading up to and including your peak day, you drop your FO below 1%.

So how does meticulous timing affect your chances? It depends on how you do it.

METHOD A: Some couples have sex every 2-3 days anyway, but use ovulation timing to make sure they get together on what they believe to be their one peak day. If they are correct about the peak day (and chances are actually good that they are NOT always accurately predicting the perfect peak day despite all the charting and ovulation predictor kits) then they can boost their chances that month from 25% to 30%. If they guess wrong about the peak day, then they are back to their normal 25%.
B: Other couples deliberately try to abstain until what they think is their peak day. Wives tell their husbands to stay away and save up their sperm until they are given the green light! In this case, if your prediction methods are accurate, then you have a 30% chance that month. If you guess wrong and are early by one day, you have a 25% chance. BUT, if you guess wrong and are late by 1 day, then you have less than a 1% chance!! Why is this? Because if you have sex only AFTER you ovulate, even if the egg is still viable, the cervical mucus undergoes changes to shut out sperm from coming in. After the egg has already released, you can still get pregnant through insemination, thereby using a catheter to bypass the hostile mucus, but studies show it's almost impossible to get pregnant through natural intercourse if it's done only AFTER the egg has released.

So you see, in scenario A, trying to time things might only help a little at best, while most of the time it doesn't change your odds at all. In scenario B, if your timing is accurate, it might help a little or be the same, but if your timing is inaccurate, you have now disastrously LOWERED your chances.

Therefore the best general strategy is to have sex every 2 days, especially in the week leading up to your time of ovulation.

I'll close by fulfilling my earlier promise to list the instances in which monitoring your ovulation is NOT completely worthless.
1. If it relaxes you and lowers your stress to feel like you're doing something. A lot of times, women find great social support from discussing their temperature and charting with other women who are trying to conceive. Anything that lowers stress can contribute to higher FO. It also reassure you about the likelihood that you ARE ovulating. If your monitoring activities clue you in that you're not ovulating, then you will be alerted to seek help before wasting too much time.
2. If you are a couple who have sex only once or twice a month and just cannot for whatever reason make it feasible to have sex every 2-3 days, then it WOULD be useful to employ ovulation monitoring to help you focus on the days that really count.

But remember, if ovulation monitoring CAUSES you more stress or if you do it wrong and it causes you to miss your peak day, then it is clearly harmful to your chances.

The woman at the dog park was herself in a job where she was trained to think analytically and scientifically, so she loved learning this detailed information. She joked about how we humans have evolved into a species for whom normal reproduction requires the act of taking temperatures. By this time, our dogs were exhausted.  She thanked me profusely and asked for my contact information. She also thanked my dogs for enabling our chance meeting.

By the way, here is a video of my dogs, Brandy and Ixie, engaged in friendly combat. =)

Fertility FILE 101: POLYCYSTIC OVARY SYNDROME

Polycystic Ovary Syndrome is a condition that affects close to 10% of the women in the world.

Women who suffer from this condition usually have many of the following findings:
Infertility - PCOS patients are sometimes able to get pregnant naturally, but many of them will have difficulty.
Obesity - PCOS patients generally have greater body mass than women without PCOS. However, it is  not univeral. A few PCOS patients have normal or even extra lean body mass. Another general finding is that PCOS patients tend to gain their excess weight around the midsection (as opposed to the thighs or hips).
Excess Male Hormones - Women have low levels of male hormones, but women with PCOS have higher levels, leading to the possibility of facial hair, chest hair, acne, male-pattern hair thinning, oily skin and bloating.
Irregular or Inconsistent Menses - PCOS patients often do not ovulate every month. Some of them can go a whole year without a single ovulation or period.
High Risk of Cardiovascular Disease - Women with PCOS are generally more prone to high blood pressure, high cholesterol, heart attacks, strokes and diabetes.

While there is no cure for PCOS, there are many available helpful interventions that can address the issues of infertility, irregular menses, obesity, excess male hormones and health risks.

In future posts, we'll look at the specific interventions that can help improve the quality of life for women suffering from PCOS.

Fertility FILE 101: OVULATION

Ovulation is the rupturing of a follicle with subsequent release of an egg.

Women are born with 1-2 million eggs. These lay dormant in the ovaries wrapped in a layer of cells. A FOLLICLE is the name given to an egg surrounded by the layer of cells (known as granulosa cells).

Each month, out of the entire supply of follicles, a small group of them (known as the recruited cohort) begin to grow. Most of the time, under natural conditions, only one of the follicles grows to the mature state. This is called the dominant follicle. The rest of the follicles that month only grow partially and are wasted, lost forever. Under conditions when a woman takes fertility drugs, many more of the original group of follicles can be rescued so that they, too, have a chance to initiate a pregnancy.

From many lectures to my medical students, one analogy that seems to help clarify is to envision the follicle as a slowly-growing "water balloon" which has a tiny grain of sand inside (this sand represents the egg). When the follicle reaches about 18-20mm in diameter and a special hormonal signal, called the LH surge, is sent to it, it will undergo biochemical changes that eventually result in the popping of the follicle and the release of the egg. This special hormonal signal is what those urinary ovulation kits are designed to detect.

Fertility FILE 101: FERTILITY DRUGS

Fertility drugs are given to help women who don't ovulate perfectly on their own. They are also given to women who already ovulate to help them super-ovulate, meaning increase the number of eggs released (better quantity) and to improve the chances that the eggs will successfully become a baby (better quality).

The two main classes of ovulation medications work on the principle of improving FSH activity. FSH (Follicle-Stimulating Hormone) is a natural substance produced in the brain (actually, from the pituitary gland) which communicates with the ovaries to persuade the ovaries to develop and mature an egg or many eggs.

With the goal being to increase the strength of FSH that is talking to the ovaries, there are two ways to do it. We can either help people make more FSH on their own or to actually give them FSH. This is like helping someone who doesn't have enough money by either giving them tips on how to make more money or by just giving them a large amount of money. One way is gentler and easier, the other way is more direct and much more powerful.

CLOMIPHENE CITRATE: Taken by mouth in pill form. This is a gentler medication that can help a woman produce more FSH on her own. Brand names in the US include Clomid and Serophene.

INJECTABLE GONADOTROPINS: These are actual injectable forms of purified FSH. Brand names in the US include Bravelle, Follistim, Gonal-F, Menopur, Pergonal and Repronex.

hCG: hCG comes in an injectable form. While the above two classes of drugs work to help the eggs develop and grow, hCG does something entirely different. It works to trigger the follicles to burst (ovulate) and release their eggs. So the sequence is take clomphene citrate or injectable gonadotropins first. And then when they have done their job, take hCG to finish the ovulation process.

Watch for more detailed information regarding these drugs in future posts.