We cannot really comment on the necessity of the test. But we can say unequivocally: no procedure should hurt. With modern anaesthesia, there really is no excuse for it. For example, in your case, you could ask about misoprostol (to soften the cervix), Ativan (for you), and a local-freezing-spray for your cervix. The procedure itself should never stand in the way of your desire to become pregnant. Hope that helps.

The post What can I do about pain during procedures?  appeared first on Fertility.ca.

AMH is the hormone that is made by the cells surrounding each of your resting eggs. This means that the more eggs that you have, the higher your AMH level will be. The corollary is true too: if your AMH is low, you don’t have a large reserve of eggs.

Your ovarian reserve is not the same thing as your egg quality. However, egg quality is much more difficult to measure. As an inexpensive and simple screening test, your AMH level in combination with your age can be our best single predictor of your fertility success.

AMH can help set your expectations, particularly if you are hoping that a fertility clinic would be able increase your chances for success over trying naturally at home.

Why Is AMH Useful?

AMH is extraordinarily useful for patients who are contemplating fertility treatments, because it predicts how many eggs you may mature in response to fertility medications. The basis of fertility treatments is often the maturation of more than one egg at a time. With more eggs available, we have a greater chance of a higher-quality embryo forming, and therefore a higher chance for pregnancy.

Does AMH Tell Me If I Still Have Good Eggs?

No, AMH does not tell you if you have good-quality eggs. It simply tells you how many eggs you have.
Nonetheless, the number of eggs you have in combination with your age (which itself is actually quite a good predictor of quality), will let you know how successful fertility treatments may be if you are not conceiving on your own.

Does AMH Help Me Decide About My Fertility?

Yes, AMH is helpful in making your fertility choices. This is because fertility clinics rely on a good ovarian reserve. If you have a good ovarian reserve, as defined by a good AMH level, then your success rates will be at the highest level for your age bracket. Unfortunately, the corollary is true, too. If your AMH levels are low, the range of choices and expectations from treatments may be low. AMH may help guide your choices.

My Doctor Gave Me My AMH Number. What Now?

You might want to research your AMH values further. Online, you will quickly discover that AMH might be described in ng/ml, but if you multiply that value by 7.1, you will have your value in pmol/L. This is important if you are comparing your numbers against those of others.

Do you want help deciding if you should do active treatments in a fertility clinic? We use AMH and age as a guide to potential success. View the IVF table according to age and AMH. Bottom line: the higher the AMH the higher your chances for success in any age group.

AMH is not destiny! These odds may not reflect your chances at your clinic. But I think they can be helpful to provide direction.

If you are not sure what to do with your AMH level, get it repeated, get a second opinion if you need to, and speak with a counsellor if you don’t know how to move forwards. AMH doesn’t lead to a single best solution for everyone, but it can provide guidance as you make the decisions that fit with your larger goals for you and your family.

The post How does an AMH test help me? appeared first on Fertility.ca.

You can run a natural start cycle, which simply means that you come in at the beginning of your menstrual cycle, say on day 3, and if there are no cysts, you start taking stimulating medication.

This simple approach is appealing because it is, well, simple.  But there is a catch: it is quite likely that egg growth will be scattered across a variety of maturity levels.  ”Scattered” maturation makes the ideal timing of egg retrieval difficult, and the cycle might suffer as a result.

To keep some eggs from developing too quickly, we like to suppress the ovaries before stimulation. Suppression also makes scheduling treatments easier for our clinic and our patients.  Too many retrievals on the same day would compromise pregnancy rates for everyone.

The longest, deepest suppression is done with the long protocol.  It is, as the name suggests, the longest of the protocols: several weeks on the birth control pill in most cases, overlapping with a GnRH Agonist (Lupron, Suprefact, or Synarel) which is even more suppressive.  By the time you are done with this pre-treatment, your ovaries should be well-and-truly suppressed.

But there is the risk of going too far.  When your ovaries are over-suppressed, the stimulating medications simply will not work.  This means your estrogen starts off low – sometimes less than 50 pmol/l – and never climbs above 200 despite day after day of stimulation.  This happens only about 5% of the time.

So why use the long protocol?  Because when the long protocol works, we get the best pregnancy rates.

The long protocol isn’t the right choice for everyone.

If a woman has a low BMI (less than 21) or other reasons to suspect sensitivity to suppression, we usually opt for an OCP-antagonist protocol.  In this case, we use the birth control pill (aka oral contraceptive pill or OCP) for a bit of suppression, then once the cycle starts, use a GnRH Antagonist (like Orgalutran or Cetrotide) to prevent ovulation.  I like OCP-antagonist cycles, and have had a lot of success with them recently.  It is a more pleasant protocol for patients, with fewer injections and side effects.

The challenge with using a birth control pill, for some women, is that even a low dose pill (Alesse, Yasmin) for a short period (2 weeks) is too suppressive.  Natural start is one solution, but if the woman’s natural estrogen levels are not very high in the luteal phase, her FSH levels will drift up and…the ovaries will start to stimulate too early and egg growth scattering results.  In these select cases, we can use estrogen-priming, in which an estrogen patch (0.1 q2d) or Estrace tablets (8mg daily) are used starting about day 21 in the cycle before stimulation.  Estrogen priming is very successful in bringing down FSH levels, of real benefit to women of borderline ovarian reserve, and we have seen successful stimulations where none were possible before.

The catch (there is always a catch) is that estrogen primed cycles take a long time before we can see if they are going to work…..when we have to cancel them, it is usually quite late into a stimulation.

Estrogen priming is usually matched with an antagonist to prevent ovulation.  But there is one more protocol to consider: a flare cycle.  A flare cycle may involve OCP or estrogen-only pretreatment, but the key is that a GnRH agonist (Lupron, Suprefact, or Synarel) will be started at exactly the same time as the stimulating medication.  The result is invariably rapid egg development.  A flare protocol is the most “raw” of the protocols, sometime yielding difficult-to-interpret results.  But we do use it in select circumstances.

Yes, there can always be hope. But that hope should be balanced with the reality that donor egg cycles will provide much higher success rates, for many clinics in the 50 to 60 percent range, and in some clinics, even higher.

The choice then becomes highly personal for you, as you weigh the relative odds of success against personal desires for a biological child. Your final answer will be highly personal, and I strongly recommend counselling as you consider your options.

The post Is there hope with my own eggs using the estrogen priming protocol or is it truly time to consider donor eggs? appeared first on Fertility.ca.

Of course, we all hope that we won’t have a “journey”. We hope that we’ll achieve pregnancy quickly, on our own, like so many friends and neighbours and co-workers seem to do.

When it isn’t easy – when you find yourself on websites, or at your doctor’s office or a fertility clinic-then you are on a journey.

Many patients arrive at a clinic hoping for a very, very short journey.  Others are willing to let things take a little longer if it means fewer tests or medications.  Sometimes finances must be carefully considered.  A Care Plan will help you and your clinical team resolve these sometimes conflicting goals.

A Care Plan often consists of four parts: Assessment, Planning, Implementation, and Evaluation.  This may be a process that you clearly lay out with your doctor, or it can be something you refer to on your own, to keep yourself on track.

What’s involved in an assessment?

From first contact, the clinical team will assess your situation through medical history, do physical examinations and investigations. It can get quite involved.

How far do you want your assessment to go?

Some patients want just the minimum.  I had a patient who planned to carry the embryos for her best friend.  I can tell you, there are a lot of tests that I can order to “ensure” that she will be safe to become pregnant.  From ECHO cardiograms to 3D sonohysterograms, we can do it all.  She wanted almost none of it.  I insisted on a few things – infectious disease testing and legal counseling – but this patient had identified that she was going to minimize intervention. There are risks that something can go wrong, but she felt it was easier and gentler to do few tests.

Other patients want to rule out everything. For them, the stress of a procedure or investigation is easily balanced by their need for an answer – a need to know that they have explored the outer limits of what science can tell us.

Many patients are less certain of what’s right for them as they begin their journey. This is when it is most important to communicate well your doctor. Making sure that we, your care team, and you, the patient have the same expectations and definition of what is “right” for you can be a challenge sometimes.

When my patients are looking for guidance, I start with the easy tests. Of course, it’s easy for me to say “easy tests” and not everyone will agree with how I might define them. The ideal pace of change is different for every patient. Though if weeks or months are passing, I will suggest more tests and more aggressive therapies.

Once you have identified the tests or treatments that you want to do, you are ready for the plan to get you there.

How do we make a plan?

Planning how to organize your treatments and testing is often done in collaboration with your nurse.

Some patients hope to get their investigations over with and treatments started as fast as possible.

But in practice, as-fast-as-possible can be totally consuming, and perhaps incompatible with other life goals (like keeping your job and your mental health).

A good plan will set expectations that can work for everyone.

Is implementing the hard part?

Implementation, at its best, can be a relatively low-stress experience: you are simply doing what you had set out to do.

Your body may not co-operate with your plans, of course, which is what leads us to the final step…

When do we need to re-evaluate?

At the end of every cycle, you should review your situation. Are you happy with the level of investigations? Of treatments? With the pace and intensity of your care? Is your plan clear? Are treatments being implemented appropriately?

A Care Plan will help ensure that you receive medical care that fits.

I hope this approach helps you.  I have found it a useful framework in my own practice to guide us at every step.

The post My partner and I are just beginning our fertility journey. How do we create the best care plan for us? appeared first on Fertility.ca.

Prolactin is also called luteotropic hormone. If you google this topic, you will find that high PRL is associated with galactorrhea (discharge from the nipples) and vision changes.

But most subfertile women with high PRL won’t have these findings. Some women with high PRL will have irregular cycles, but again, not all.

What causes high PRL levels?

Under normal circumstances, PRL is produced when you are pregnant or breastfeeding. Certain antidepressants can raise your PRL levels, as can stress or exercise.

A high PRL can be associated with an adenoma – a normally non-cancerous tumour in your pituitary gland. An adenoma can overstimulate your brain into producing higher than normal levels of prolactin and can decrease your estrogen levels. Surgery may be an option but most likely medications will return your prolactin level to normal.

When your PRL level is >100 on two occasions, we order an MRI so we can look at your pituitary gland. I have ordered MRIs when PRL levels are <100, but this is on a case-by-case basis. Usually the repeated blood test is all that is necessary.

We need to contemplate treatment when PRL is >20 twice in a row, and other explanations have been ruled out.

What treatments are available?

Elevated PRL may compromise implantation. Subfertility is such a complicated business, we hate to see anything outside of the normal range that could potentially cause a problem. So we tend to treat everybody.

2.5mg/d of bromocryptine is the standard treatment.

Many women experience heartburn, indigestion/dyspepsia, bloating and constipation while taking bromocryptine. If you are experiencing GI distress than does not subside after more than 3 weeks, ask your doctor about taking the medication vaginally instead of orally. You can also ask about cabergoline. It has fewer side effects, but it’s a newer medication and we can’t promise the same safety level.

If there is an adenoma in your brain, and the medications are ineffective or cannot be taken, surgery is an option. But in all likelihood, the medications will be sufficient.

What happens once you are pregnant?

Once pregnant, most –but not all– women are asked to stop their bromocryptine. It can be difficult for clinics to remember who is taking bromo and who isn’t. Once you are pregnant, please remember to ask your doctor to reassess your need for the medication.

The post My tests showed my prolactin levels were over 100 twice now. Why do I need an MRI? appeared first on Fertility.ca.

When you’re lying on your back, your uterus either tilts up towards your belly button (anteverted), or back towards your spine (retroverted). Most women are anteverted.

Between your uterus and your abdomen is the bladder. So, when you have a full bladder, it tends to tilt that upward-tilting uterus back the opposite way, forcing it to temporarily have a nicer, flatter surface. Why is that good? Because during an ultrasound, sound waves have to bounce off your uterus. A “flatter” uterus means a clearer image, so the ultrasonographer can get a much better visualization of your uterus and the lining.

But it also helps for any clinician doing a procedure like endometrial biopsy, or an intrauterine insemination, or an IVF embryo transfer. In these procedures, a rather rigid catheter is being placed into the cervix, and if it can then go in a straight line, it’ll be much more comfortable for you. It’s also easier for the clinician to place the catheter in the exact location needed.

But there’s a fine line between having a full bladder and having an excessively full bladder. The standard advice on how much to drink may not work for you, since everybody is different.

Some women have high urinary frequency; that is, they urinate all the time. They tend to have smaller bladders, which therefore feels “filled up” much faster. Other women are more used to holding their bladder, and they become stretched out, and they can have very large bladders.

So, what do you do if you’re waiting with a too-full bladder? You know it’s too full if you’re pacing and there’s sweat on your brow. You need to let some urine out.

I promise you, it’s not of any value to you or the clinician to have a too-full bladder. The pressure from an ultrasound being placed on your stomach, or a speculum being placed for a procedure, would be uncomfortable or even impossible for you if your bladder is too full.

So go to the bathroom! But don’t completely empty your bladder. Sounds impossible? It isn’t. Take one of the styrofoam cups that many clinics have for drinking water to the bathroom with you, and stop urinating when it’s full. That should be enough to give you relief and keep your bladder full enough for the clinician.

What if you have a retroverted uterus? For these women, a moderately full bladder can help with ultrasound, but not with the procedure itself. If you know you have a retroverted uterus, don’t make yourself miserable trying to have a full bladder. It won’t tilt the uterus or make a difference.

The post I’m supposed to have a full bladder for my ultrasound/procedure. But how full is too full? And what if I’m retroverted? appeared first on Fertility.ca.

In the context of fertility, erectile concerns can often be interpreted as ambivalence about having children. Some men may refuse to have intercourse, or otherwise turn away. They may claim that they no longer want to have children, when really what they are saying is that the situation has created a deep sadness in them.

If your partner might be experiencing male subfertility, talk to him. Validate and listen to your partner’s feelings within the relationship and in the bedroom. I strongly recommend counseling to assist both of you in maintaining healthy communication and a supportive partnership.

The post The emotional side of male subfertility/infertility appeared first on Fertility.ca.

We judge embryo quality in three ways: the number of embryos present, embryo grading, and PGS. In this post, we’ll talk about embryo grading.

Stretched over the first 96 hours of development, we remove embryos from the incubator for about two minutes to look at the embryo and assess its capacity for ongoing development.

Two minutes doesn’t seem like a lot of time, but it’s enough. The gases and temperatures outside of the incubator are inappropriate for embryo development, so limiting their exposure to a non-incubator environment is important. We grow embryos to the blastocyst stage. If the embryo has survived that long, there is a greater likelihood it will continue to develop. This increases your chances for pregnancy.

By day one of development, we should see cells that have two “balls” of DNA collected, from the egg and from the sperm. If there is only one or there are three, or even zero, the embryo is not developing well.

By day three, the embryo should have six, seven, or eight cells.

By day five, the size of the blastocyst is measured instead of the number of cells. A number (usually 1 through 6) represents the size and letters (A through D) make note of the inner cell mass and what will make the placenta (trophectoderm) in the future.

These grading systems are okay, but not ideal. Not all high-quality embryos will implant, and not all low-quality embryos will fail.

To improve our information, there are newer techniques for grading embryos. We now have the ability to watch embryos grow in the incubator for the full 96 hours, their development captured on video throughout. This removes the need to take the embryos out of the incubator, and we collect a lot more data.

The current challenge is to know what exactly to do with that data. Researchers and scientists are working to generate new algorithms to help identify which embryos are most likely to continue to grow. Different companies are working to provide solutions to fertility clinics. The EEVA test, in partnership with Auxogyn/EMD Serono is one example.

Note: Embryos are just one element in implantation. Implantation challenges can be related to embryos, the uterus and overall health. We’ll have another post shortly on how the uterus, its shape and lining, may impact odds for implantation.

The post What are the recent developments in implantation? (Part Two: Embryo grading) appeared first on Fertility.ca.

Embryo grading means we look at embryos under a microscope and estimate whether they have the potential to continue to grow into a healthy, ongoing pregnancy. Grading is done by removing embryos from the incubator for a few seconds (up to a minute) every day, or nearly every day, for the first three to five days prior to embryo transfer. This gives us about two minutes worth of data acquisition over the ninety-six hours it could take to grow an embryo into a blastocyst.

But it’s an inexact science at best. The embryos are only a few days old. There’s a lot of development that happens over nine months.

Recently, we have been using cameras that follow embryo development 24/7. It sounds better, and in some ways it is. It’s an extraordinary amount of information to have. One of the current challenges is what to do with it all.

All kinds of patterns have been observed, but their clinical significance, at this time, remains unclear. If an embryo is not growing as well as expected, does that mean it should never be transferred? Often, we don’t know.

In the months ahead, I’ll be able to share more information with you as we collect more data.

The post What does embryo grading really mean for my chances of having a baby? appeared first on Fertility.ca.

Sometimes, these are valid concerns. But there are things you can do about it.

1. Get a sperm test with DNA fragmentation. Women may not be able to confirm their egg quality until they complete an IVF cycle, but for men it’s much more straightforward.

2. If you have sperm quality worries, it may be appropriate to introduce lifestyle changes and vitamin therapy.

3. Get further testing done. Your testosterone levels can be checked with a simple blood test. Low testosterone levels can often be treated successfully with Clomid or Arimidex. You can also check for varicoceles, dilated veins that heat the testes. They can be found with a physical exam or scrotal ultrasound, and treated through minimally invasive surgery with faster recovery times than in the past.

4. Talk to your doctor to find out if Viagra or Cialis is right for you. You may not need these in other sexual encounters, but procreational intercourse can be quite stressful. If you worry that you can’t have an erection with timed intercourse, it’s okay.

Another option is intrauterine insemination. You might find it easier to just let your sex life be your sex life, and procreation can take the form of providing sperm samples in the morning for the clinic to inseminate later that day. In the event you’re unable to provide a sample one day, frozen sperm is available as a backup. This lessens some of the pressure to have procreational sex.

5. Take your overall health seriously. Some men worry that their ejaculate has less volume than it did when they were younger. In many cases, this can be addressed through better hydration. A volume drop may be related to other health concerns, such as retrograde ejaculation (ejaculate travels backward into the bladder rather than out the tip of the penis). Take care of your overall health by having frank discussions with your doctor.

Now and again, men are concerned they don’t “shoot” as far. Well, it does happen with age. Let me reassure you, there’s absolutely no proof that it makes any difference to anything whatsoever.

I don’t think the distance the ejaculate moves is as important as volume, which is necessary to protect the sperm with seminal fluids while they find their way out of the acidic vagina, into the cervical mucus, and ultimately up into the uterine cavity.

6. Do IVF with ICSI. Intracytoplasmic sperm injection (ICSI) will ensure eggs will be fertilized. Newer techniques in the lab have been shown to be associated with lower DNA fragmentation rates, rather than higher. That’s right! It’s possible the modern techniques are better able to sort out the “best sperm” than nature alone.

The only real problem with IVF is the expense. I don’t mean to minimize it – expense is a very real stress for most couples – but so can be the month-in/month-out lack of success for pregnancy and the strain of a sexual act that can make you feel further away from your partner, rather than bringing you closer.

In our clinic, we strongly recommend that couples consider IVF after all other reasonable options have been exhausted over a five month period. Fertility treatment can take an emotional toll on a couple, and we want to see you move past the hopeful phase and into the pregnant phase as quickly as possible.

The science behind paternal aging and how it may affect the health of children is interesting and changing all the time. (At least, it’s interesting to us.) If you want to know more, please let us know in the comments. I will be very happy to expand this section further.

The post What impact does aging have on male fertility? appeared first on Fertility.ca.