Clomid Challenge Test Day 3—FSH and Estradiol Day 10—FSH To evaluate ovarian reserve and chances for pregnancy before assisted reproductive technologies.
Endometrial biopsy One or two days before expected period in order to assure validity To determine if luteal phase is sufficient and uterine lining is suitable for the fertilized egg to implant (but its clinical validity is disputed).
Falloscopy Before ovulation To diagnose any abnormalities within the miniscule tubes.
Fluid Ultrasonography Before ovulation To determine if the uterine cavity is normal.
Hormone blood tests (miscellaneous) Various times throughout cycle (see table) To determine critical factors about your cycle such as whether you produce enough FSH, estrogen, LH, and progesterone, all necessary for successful conception and implantation.
Hysterosalpingogram (HSG) The week after your period ends To determine if the fallopian tubes are clear and the uterine cavity is normal.
Hysteroscopy Usually before ovulation To determine if the uterine cavity is normal (not routinely performed).
Laparoscopy Usually before ovulation To diagnose and treat pelvic disease such as adhesions or endometriosis.
Ovarian Reserve Tests Varies depending on the test See chart.
Postcoital Test (PCT) Close to ovulation (ideally after intercourse during presence of your most fertile cervical fluid) To determine whether the man’s sperm can survive in the woman’s cervical fluid. (This test is rarely performed anymore due to its disputed clinical validity, because the predictive value is poor and the results do not change the recommended therapy)
Ultrasound Several times before ovulation, just before HCG injection and sometimes after To evaluate follicle maturation and size, ovulation, and endometrial thickness and character.
AGING EGGS AND YOUR OVARIAN RESERVE
Inevitably, one of the first questions a fertility doctor asks is your age. This is because it’s still one of the best indicators of your ovarian reserve—the quantity and, to some extent, the viability of your ovaries’ egg supply.
If the quantity is low, it’s usually called a decreased or diminished ovarian reserve (DOR). Ultimately, of course, what you really want to know is the quantity and quality of your eggs, in addition to how well your ovaries will respond if you’re going to use assisted reproductive technologies such as IVF.
In essence then, there are three reasons why a woman would want to test her ovarian reserve. Specifically, to predict:
•approximately how many years of fertility she has left
•her general fertility status for her particular age
•how well her body will respond to drug stimulation preceding IVF
As you know, we are born with all the eggs we will ever have, about 300,000, and after years of menstrual cycles, the supply is depleted, causing fertility to gradually decrease until about age 37. Afterward, it declines more rapidly until menopause, usually by the early 50s. But if age were the only factor determining a woman’s fertility, there would be no need to even test her ovarian reserve.
In reality, even though ovarian reserves diminish over time in all women, the extent to which they do in each individual woman is unique. The one thing researchers now believe is that the steeper decline in fertility to menopause is about 13 years—but the age a woman starts that decline can vary quite a bit. Therefore, two women of the same age may have completely different ovarian reserves.
So, how do you learn about yours? It would be wonderful if there were an easy way to count the eggs in your ovary, in much the same way that you could open a carton of eggs from the refrigerator and count how many good ones remain. Alas, there isn’t, but there are several tests that, along with your age, offer the best tools currently available to estimate your remaining pool of viable eggs.
Unfortunately, none of the tests is ideal, and there is no consensus among physicians as to which are the best. However, there is general agreement that a woman’s increasing age will affect the quality of her eggs, and that she should have at least two or three different tests done to get a better indication of the number of viable eggs remaining. In any case, even if your test results show you have a diminished ovarian reserve, this should not be the sole criterion used to deny you access to IVF or other treatments. If it is, you can probably find another clinic that will work with you.
The list of tests below is in approximate order of most predictive:
Antral Follicle Count
This is one of the few exams in which a radiologist can actually pinpoint how many immature resting (antral) follicles are available to develop in that specific cycle. The higher the number observed in the first few days of a cycle, the better the prospects for IVF (more than 10 is good, while fewer than 5 is problematic). And because that number stays fairly stable month to month, it’s usually considered as accurate as any biochemical test of your ovarian reserve and future fertility.
Antimullerian Hormone (AMH) Test
This blood test analyzes levels of the antimullerian hormone, a substance secreted by the cells of the developing preantral and antral follicles (the immature follicles). It can be performed at any time during the cycle, but, as with the FSH test below, clinics should use age-specific parameters to get an accurate reading.
Follicle Stimulating Hormone (FSH) Levels
This exam, usually done on Day 3 of the cycle, is the most commonly administered test, though its results are somewhat counterintuitive. Obviously, it tests for your FSH levels, but the higher the number, the more problematic it is for a woman desiring pregnancy. This is because a higher level means that her body is working harder and harder, releasing more and more FSH just to get the remaining follicles to mature. However, it’s also worth noting that while a high level of FSH may indicate a poor ovarian reserve, a normal level of FHS still doesn’t tell us anything about the quality of the remaining eggs.
Note: Antral follicle count and the AMH test are considered the most accurate and promising, while FSH testing is still the most prevalent. See the chart, which gives more detailed information on what these tests are, why they are used, and what they reveal.
Clomiphene Citrate (Clomid) Challenge Test
The purpose of a Clomid challenge test is to determine how efficiently the ovaries are working. A healthy ovary requires only a small amount of FSH to stimulate the follicles to mature an egg. Ovaries that are not functioning optimally, on the other hand, require substantially higher levels. Thus, having elevated levels is considered an indicator of poor ovarian function, though having normal levels does not necessarily guarantee normal ovarian function. Alas, such is life.
I include this test because it is still performed in many clinics, but it’s not considered any more predictive than the FSH test alone. Moreover, it’s more invasive, time-consuming, and expensive, and there are often side effects from the drugs.
Estradiol and Inhibin B Test
These two tests are occasionally given, but I won’t cover them here, since all the ones discussed above are considered much more reliable.
Home Ovarian Reserve Tests
As of this writing, these tests are not considered accurate enough for diagnostic use.
Now for Some Good News
An exciting development is the recent discovery that beyond the age of the eggs themselves, the quality of the ovarian environment in which those eggs mature is also of crucial importance. The potential implications of this for older women or those who are going through premature ovarian aging are profound, because it’s now known that physician-prescribed dehydroepian-drosterone (DHEA) is a powerful hormonal supplement that increases androgen levels in women with diminished ovarian reserve.
With an improved androgen-rich ovarian environment, both the number and quality of eggs that such women produce often goes up dramatically. What this means is that as the relevant technologies advance, your ovarian reserve could be approaching depletion, but you might still have a good chance of getting pregnant using DHEA an
d your own eggs, most likely through IVF.*
WAYS OF RESOLVING INFERTILITY
1. Medical Therapy
Whenever any drug is prescribed, you should always verify with your physician precisely what it is for and what the potential side effects are. Basically, there are three different types of fertility drugs: those that stimulate ovulation, those that block production of hormones, and those that facilitate conception and support pregnancy.
a. Drugs to Stimulate Ovulation
The most commonly prescribed drug to induce ovulation is Clomid. It’s considered less invasive than other ovulatory drugs, and in principle, is prescribed when a woman is either not ovulating at all or only sporadically. It’s also used when she has a short luteal phase, with the rationale being that even though a woman is ovulating, a compromised luteal phase is often a reflection of the entire ovulatory sequence. In reality, Clomid is often prescribed as a matter of routine even when the woman’s fertility problem is not known.
Another ovulatory drug is letrozole (Femara). It works differently, clearing from the body more quickly, and doesn’t dry up cervical fluid the way Clomid does. But it hasn’t been studied for as long as Clomid has, so it’s not yet clear if it’s completely safe.*
If neither of those is effective, your doctor may prescribe pituitary hormones (gonadotropins) through daily injections, so you must be carefully monitored with ultrasound and laboratory testing. In addition, there is a significantly increased chance of multiple births, as well as a possibility of developing ovarian hyperstimulation.
b. Drugs to Block Production of Hormones
Occasionally, it’s necessary to suppress ovulation in order to abate conditions such as endometriosis. Women are typically prescribed these drugs for about six months or longer, after which they are then encouraged to try to get pregnant. They are also used in conjunction with high-tech treatments.
Certain drugs are prescribed because some women have an excessively high level of hormones that may disrupt their normal ovulatory cycle. For example, Parlodel is used to reduce prolactin, the hormone that normally circulates in women who are breastfeeding, but it can also suppress ovulation in women who are not.
c. Drugs to Facilitate Conception and Support Pregnancy
Women are often prescribed Clomid to induce ovulation, but as mentioned above, it has the unfortunate side effect of drying up necessary cervical fluid. In these cases, estrogen can be prescribed along with Clomid to counteract its drying effects. But estrogen taken without ovulatory drugs can ironically have an antiestrogenic effect that even further dries cervical fluid.
Progesterone is often given to support a short or insufficient luteal phase. It’s administered by injections, oral tablets, vaginal suppositories, or creams. It acts to prevent a newly pregnant woman from menstruating before the egg has had a chance to implant, thus decreasing the odds of a miscarriage.
2. Artificial Insemination (AI) and Intrauterine Insemination (IUI)
These are the simplest of the assisted reproductive technologies. AI typically involves using a catheter to gently insert sperm just outside or within the cervix, whereas IUI involves placing the sperm through the cervix and directly into the uterus. For both techniques, the sperm may be that of your partner or a donor. Nowadays, IUI is the preferred choice because it more effectively bypasses numerous potential fertility problems, including low sperm count or poor sperm motility, antisperm antibodies, poor-quality cervical fluid, and unexplained infertility
ARTIFICIAL INSEMINATION AT HOME
Artificial insemination is one of the few fertility procedures that you can do in the privacy of your own home. And, though most of you will choose a clinic so that you’re ensured that everything is done correctly, there are times when you may prefer a warmer atmosphere, especially:
•when you want to maintain the intimacy that is lost in a medical office.
•when your fertility is fine, but your partner has ejaculation difficulties that you would prefer to deal with privately.
•when your partner will be gone during your most fertile days.
•when you are single or your partner and coparent is another woman.
Where sperm can be placed
Technically, there are three different types of artificial insemination, depending on where the sperm is inserted inside the woman’s body:
•intravaginal insemination (IVI),
•intracervical insemination (ICI), and
•intrauterine insemination (IUI).
However, IUI should absolutely not be done at home, since it could lead to a serious pelvic infection if performed in a nonsterile environment.
The two choices of sperm
There are two types of sperm that can be used: fresh or frozen. As with everything in life, there are trade-offs for each. The benefits of fresh sperm are that the quantity and quality are better, since there are usually more sperm in a typical ejaculation, and they don’t need to survive the thawing process. In addition, of course, using fresh sperm is less costly because there are no sperm to purchase or storage fees to pay. If you’re with your male partner, fresh is the way to go, and it’s hardly an inconvenience for him!
But if for whatever reason you are using an unknown donor, frozen sperm has many benefits as well, including the fact that there is a reduced risk of passing on a sexually transmitted infection (assuming the sperm bank screens for them). In addition, of course, the donor can be anonymous and doesn’t need to be geographically close to you.
Sperm washing
Frozen sperm can be washed in a clinic with insemination still taking place at home. (The process is described here.) But it’s not necessary to wash fresh sperm if they are only deposited in the vagina or right in the open and fertile cervix. Obviously, in traditional intercourse, sperm are never washed beforehand!*
Using a clinician
You may find that hiring a nurse-midwife or other health practitioner to perform the insemination is the ideal situation, offering both the comfort of your home and the expertise of a qualified practitioner for peace of mind. Of course, you’d want to verify that whomever you hire is experienced in such procedures.
Timing guidelines
When performing artificial insemination at home, use the same guidelines that you would with traditional intercourse: Ideally, your partner or donor should abstain for two days prior to providing the sperm, but not more than four days. If using fresh semen, it’s best to use it as close as possible to accessing it, ideally within a few minutes of ejaculation. If using frozen sperm, the semen-containing vial should be thawed out for about 30 minutes, until it turns liquid. At that point, the vial should be warmed to body temperature in your hands or under your arm for a few additional minutes before inseminating.
You will want to insert the sperm into the vagina on a day when you have the best quality cervical fluid, ideally as close to the Peak Day as possible. And, if you can, do so again each morning, up through the day of the thermal shift, which may just be the next day. You can use either a nonlatex needleless syringe or a nonlatex sperm cup or menstrual cup to insert the sperm.
Resources for performing home inseminations
For more detailed guidance than I can offer here, there are a number of websites you can google that provide very clear instructions on how to do artificial insemination at home.
3. Surgery
These days, surgery means not only traditional cutting with a scalpel but also making tiny incisions using a laser. Surgery may be performed to correct obstructions such as tubal scarring and cervical polyps, as well as to remove adhesions such as those caused by endometriosis and scarring from pelvic inflammatory disease. Finally, it can be used to remove growths such as fibroids in the uterus. While the prospect of undergoing an operation is admittedly not pleasant, advances in technology do mean that many procedures can now be done on an outpatient basis.
4. Assisted Reproductive Technologies (ART)
These procedures usually involv
e removing eggs from a woman’s ovaries, fertilizing them with sperm in the laboratory, and implanting the resulting embryo back in the woman’s body. They used to involve several variations of that basic concept (which is why it was called by the plural “technologies”). But today, in vitro fertilization (IVF) has become the dominant or even exclusive procedure at most fertility clinics. So ART itself has generally come to primarily refer to IVF.*
When it was first developed back in the late 1970s, IVF was a miracle of science and considered revolutionary. Now, decades later, the basic procedure remains the same, though many of its individual steps consist of ever-evolving alternatives. Regardless, IVF is performed for numerous fertility conditions, including ovulatory problems, blocked tubes, advanced maternal age, male-factor issues, and, of course, unexplained infertility.
The Steps for IVF
In considering this technology, you should be aware that it involves a series of procedures that can be both physically and emotionally uncomfortable. The following is how an IVF procedure basically progresses, but keep in mind that there are new options continually emerging for every step:
1. Hormone Suppression
The woman takes drugs over about three weeks in order to suppress her normal ovarian function.
2. Ovarian Stimulation
She is administered a series of injectable hormones such as Pergonal for about 8 to 12 days, to stimulate her ovaries to mature multiple eggs.*
3. Sperm Washing
The man’s sperm are washed to improve their quality. The process basically separates the sperm from the semen and removes chemicals that may be causing adverse reactions in the uterus. The procedure enhances the fertilizing capacity of the sperm.
4. Egg Retrieval
A dozen or so matured eggs are aspirated from the woman’s artificially stimulated ovaries with a vaginal, ultrasound-guided needle.
Taking Charge of Your Fertility Page 24