Infertility is
classically defined as the inability to conceive
and/or carry a child after one year of unprotected
sexual intercourse. While this definition is
generally true, there are exceptions. For example,
many physicians believe that women 35 or older
should consult with a Reproductive Endocrinologist
once they have unsuccessfully attempted conception
for six months.
A fertility
specialist, also known as a Reproductive
Endocrinologist, is a physician who is trained as an
OB/GYN but also has had an additional 3 years of
sub-specialty training in the diagnosis and
treatment of patients with infertility and recurrent
miscarriages. Reproductive Endocrinologists
also receive extensive additional training in
advanced endoscopic surgery related to the uterus,
fallopian tubes, and ovaries. In addition to
being board certified in OB/GYNs, fertility
specialists are also board certified in Reproductive
Endocrinology and Infertility.
Although it is not
required, we cannot order diagnostic testing or
prescribe medications to your partner until we have
performed a medical history on him. Therefore,
his presence at your first visit will avoid a delay
in getting started with treatment.
CD 3 labs measure
the estradiol and FSH (follicle stimulating hormone)
levels in your blood to assess your ovarian reserve.
Although not precise, they provide us with
information regarding the likelihood that you will
respond to treatment with fertility medications,
should that be necessary. We like for the Day
3 FSH level to be less than 15 – preferably less
than 12. Similarly, we prefer for the Day 3
Estradiol level to be less than 65 – preferably less
than 50.
During the HSG, a
catheter will be inserted through your cervix in
order to inject dye into the uterine cavity and the
fallopian tubes. Although an infection
resulting from this procedure is unlikely, we
prescribe antibiotics to you to lessen any risk that
vaginal bacteria could be forced into your uterus
during the insertion of the catheter. At the
same time, we will ask your partner to take
antibiotics in order to eliminate any bacteria that
may be in his genitourinary tract that could be
passed back and forth during intercourse.
A sonogram is
required to make sure that there are no cysts in
your ovaries. If a cyst is found, your stimulation
cycle may be postponed until the cyst resolves, as
the cyst could impair your response, or even grow
during stimulation.
Estrogen levels are used
to help your physician determine your appropriate
daily dosage of FSH medication, as well as to
minimize the risk of potential side effects, such as
ovarian hyperstimulation syndrome.
Texas Fertility and Austin IVF require that all
patients (including partners) who are going through
an IUI or IVF cycle have IDS testing performed.
The test results have to be back from the
laboratory prior to the IUI procedure itself, or
prior to starting stimulation in an IVF cycle.
TFC is open every day of
the year. As our weekend hours may vary, we
update the message on our voice mail system every
Friday, instructing patients when to call in the
event that they need to reach our staff during the
weekend. In general, if you start your flow on
the weekend or on a holiday, you can call the office
between 9-10 am. Please note that we only have
enough staff in the office on weekends and holidays
to allow us to see patients, so if you get our voice
mail system, please leave a message and your call
will be returned before the staff leaves. If
you start your period late in the day, please call
the next morning to let us know that you started
your cycle. At that point, we can schedule you for
a baseline ultrasound examination. If you are
confused about when to call, or if for some reason
your call is not returned promptly, please page the
on call nurse at 235-2385.
Although most ovulation
predictor kits work fine, many of our patients
prefer the Clear Blue Easy Digital Easy Read with
the smiley face indicating a positive surge.
Ovuquick and OvuKit are also effective. It is
typically not necessary to invest in a fertility
monitor.
If you are monitoring a
natural cycle, subtract 17 days from your typical
cycle length and start testing on that day. For
example, if your cycles are usually 28 days, you
would begin testing on cycle day 11. If you
are taking Clomid, please start testing 5 days after
your last Clomid pill.
The LH surge typically
lasts between 30-36 hours. Therefore, testing
at the same time every day prevents you from missing
a surge, and it also keeps you from using your OPK
supplies too quickly.
In order to minimize your
out of pocket expense, you should get your
medication through a pharmacy that is contracted
with your insurance carrier. We are happy to
order it for you, in coordination with our insurance
staff, but it is your responsibility to know where
the prescription should be sent. Once we have
determined where to send your prescriptions, you
will be responsible for monitoring your medication
supply and ordering refills as needed.
Pharmaceutical companies now rarely supply us with
sample or loaner medication, and we are therefore no
longer able to provide you with medication in the
event that you misjudge your supply or fail to order
a refill. Should that occur, the best we can
do is give you a prescription for a small amount of
medication that you can obtain at a local pharmacy
until your mail order refill arrives. Please
note that the local pharmacies charge substantially
more than the mail order pharmacies – especially for
gonadotropins – and they may or may not be willing
to bill your insurance. Therefore, it is very
important to make sure that you have enough
medication at all times – especially going into a
weekend or holiday, as the mail order pharmacies do
not ship overnight on Sundays or on holidays.
We generally prefer that
you take your gonadotropin injections between 6 and
9 pm unless we specifically direct you otherwise.
It is very important that you select a time that you
can keep every day, as medication administration
should not vary by more than 30-60 minutes from your
scheduled time every day.
Although your doctor will
try to order all of the medication that he/she
thinks you will need for your entire cycle in
advance, your response to medication may vary
significantly from cycle to cycle. Therefore, it is
very important that you know how much medication you
have left at all times. Your daily dosage will
be determined by your physician after they review
your ultrasound and estradiol levels.
Your physician and/or
nurse will review this information with you, but we
recommend starting progesterone 4 days after
positive LH surge or 3 days after an IUI.
Those days should be the same, as IUIs are typically
performed the day after an LH surge.
You should expect the
onset of a period between 1-14 days after your last
Provera pill. Please call the office if your
period doesn’t start within 14 days after your last
pill.
Light spotting and/or
cramping frequently occurs during early pregnancy.
Please call your clinical nurse if your bleeding is
as heavy as your normal menstrual flow or if you
have any significant abdominal or pelvic pain.
Depending on the specific
circumstances involved in your case, we will usually
schedule your first pregnancy sonogram to occur
around 6 ½ or 7 weeks of pregnancy, or approximately
3 weeks after the pregnancy test.
Many factors influence hCG
levels – including the number of babies in your
uterus. Although there are many internet posts
correlating hCG levels with the number of babies you
may be carrying, this is frequently not correct.
At TFC, we are all aware of the anxiety that may
accompany high initial hCG levels, but we will not
be able to definitively determine how many babies
your are carrying until your first ultrasound.
Please also keep in mind that over 30% of the time,
the number of babies that you ultimately deliver
will be less than the number of sacs that we see at
your initial sonogram.
Birth Control pills help
to suppress your ovaries and hopefully prevent a
cyst from developing prior to your IVF cycle.
In addition, by suppressing the ovary in the month
before stimulation, more follicles have the
opportunity to develop at the same rate which will
hopefully result in more oocytes being retrieved.
Birth control pills also allow us to appropriately
schedule our patients so we can minimize the
variability in the number of patients going to
retrieval at any one time.
Due to significant normal
variability in semen production, our embryologists
recommend that a semen analysis be performed within
1-2 months of an IVF cycle. For similar
reasons, they insist that a semen analysis must be
performed within one year of the actual IVF
retrieval. This is very important, as
variation in specimens may cause the embryologists
to recommend a different type of sperm preparation
in order to maximize fertilization.
Evaluation of a recent sperm specimen also allows
the embryologist to recommend an optimal abstinence
window so that we can obtain the best possible sperm
specimen on the day of the retrieval.
Antisperm antibodies can prevent sperm from being
able to fertilize an oocyte. Therefore, it is
critically important to diagnose this condition
prior to the retrieval so that a special solution
can be used when the sperm is collected.
Austin IVF is the
only lab in the city that tests onsite for
antibodies. Outside reference labs send
specimens to an out of state lab. In order to
do this, the specimens must be frozen, which can
lead to inaccurate results. The additional
time it takes for the out of state lab to receive
the specimen may also decrease the accuracy of the
test.
Freezing a “back up”
specimen in advance is always an option. This
is strongly recommended if there is any concern
about his not being able to collect a specimen on
the day of the retrieval.
Retrievals and transfers
are performed in an outpatient surgical suite in
building 3 (the building on the north end of the
Northwest Hills Medical Center on Mopac) at the St.
David’s Fertility Surgery Center. TFC is
located in the building on the south end of the same
development.
Based on research
performed by our physicians and embryologists,
Austin IVF performs assisted hatching on all embryos
transferred on day 3. Day 5 embryos (blastocysts)
are not hatched prior to transfer, so if you are
having a blastocyst transfer, you will not need to
take hatching medications. Concerning the
specific medications that we recommend, Doxycycline
is an antibiotic that helps to prevent infection.
Medrol is a low dose steroid that is used to help
prevent your body from rejecting the embryo(s).
Your IVF nurse will give
you a tentative day 3 transfer time on the first or
second day after your retrieval. We do not
look at the embryos on the second day after
retrieval, so we will not be able to make a
definitive determination on whether your transfer
will be on Day 3 or Day 5 until the morning of Day
3. Please call our office if you have not
heard from us by 9 am on Day 3 to confirm whether
you will be having your transfer on day 3 or day 5.
Progesterone is started 2
days after the egg retrieval – regardless of whether
your transfer will be on Day 3 or Day 5. If
you are a donor egg recipient, you will start your
progesterone on the day of the donor’s retrieval.
In a fresh IVF cycle, the
dose of IM progesterone is 25 mg if you are under 40
and 50 mg if you are 40 or over. Similarly,
the dose of Crinone is once daily (in the morning)
if you are under 40 and twice daily if you are 40 or
over.
In a frozen embryo
transfer cycle or if you are a donor egg recipient,
the dose of IM progesterone is 50 mg (1 ml) if you
are under 40 and 100 mg (2 ml) if you are 40 or
over. The dose of Crinone is twice daily
regardless of your age.
A blood pregnancy test is
performed 14 days after the retrieval – regardless
of whether the embryo transfer was performed on Day
3 or Day 5. We strongly suggest that you not
perform your test before day 14, as – if your test
is negative – the result may not be reliable.
Every year we have several patients who call the
office upset about a negative result from a test
performed too early, when in fact, their test when
repeated is actually positive. PLEASE DO
NOT STOP TAKING YOUR PROGESTERONE – EVEN IF YOU ARE
BLEEDING A LOT – UNTIL AFTER YOU HAVE PERFORMED THE
PREGNANCY TEST. Again, every year, we have
several patients who stop their progesterone because
they “just know” that they are not pregnant, only to
have to restart it emergently once their pregnancy
test is positive. Stopping your progesterone
prematurely can cause you to miscarry a normal
pregnancy.
Blood tests are much more
reliable and accurate than urine pregnancy tests.
In addition, a blood test gives us a numeric level
for your hCG hormone that we can monitor and compare
as your pregnancy progresses. If you have very low
levels of the pregnancy hormone, common in an early
pregnancy, a home pregnancy test may not show a
positive result. It is important for the
levels to be monitored to determine if the pregnancy
is progressing normally. If your levels do not
rise appropriately, we may recommend a sonogram in
order to make sure that the pregnancy is in the
uterus and not in the fallopian tube.
Also, by monitoring the blood levels we can adjust
your progesterone dose if necessary. For
instance, if your progesterone level is very high we
will be able to decrease or even discontinue your
progesterone medication. If the level is low,
we may need to increase the amount of medication to
improve the chances for the pregnancy to continue.
