But that doesn’t mean sexuality doesn’t matter.

Sexuality and fertility and, yes, love, are all mixed together for all of us.

If fertility is difficult, if your sex life is feeling stressful or unfulfilling, it can hurt your emotional well-being. It can hurt your relationship. It can hurt you.

For some couples, integrating your sexuality (your desires, preferences, and physical pleasure) into the process of trying to achieve pregnancy can make a big difference in the journey. Here are a few suggestions:

• Find a fertility counsellor. These counsellors specialize in fertility issues and are familiar with the stresses involved, including on your sex life. Here’s a list of Toronto-based ones.
• For women and their sexual partners — check out OMGYES. Based on a large-scale study of women (cisgendered), this modern website features thoughtful, graphic videos of sexual techniques that can elicit more pleasure, and assist you in reaching orgasm. It’ not a free service, but you can start with a free sample video to try it out.
• For men — it can be touch to talk about, but sometimes the pressures of “making a baby” can overwhelm sexual desire. If you have concerns, consider starting here and reach out to us if you are interested in referrals. Many men will temporarily use Viagra, for example, to assist in the fertility setting. And don’t hesitate to seek therapeutic support: for many, the quantification of sperm at a fertility clinic (the detailed discussion of how many, or how few, sperm are present) can take a toll on sexual self-esteem. Of course, logically we know that sexuality and sperm counts are different things. But for many men, the two feel like one and the same. An experienced therapist can help you, and your partner, regain confidence.
• Nowadays, many modern, independent sex shops offer educational courses and workshops led by professionals on sexual topics, including improving your sex life. While these events may not be geared specifically toward those trying to conceive, they can help you learn new techniques and approaches. These events also tend to be more LGBTQ-friendly.

Do you have other tips or resources? Feel free to share them in the comments.

The post My fertility struggle is taking the pleasure out of my sex life. What can I do? appeared first on Fertility.ca.

Some common values such as AMH, estrogen and progesterone can be measured and reported in completely different units. The units used can depend on the study you’re reading, or whether an American or Canadian institution processed your test.

So make sure to inspect the unit that comes after the number (for example: pg/ML? ng/ML? pmol/L?), and convert numbers into the same unit system when you’re trying to draw comparisons. We find that EndMemo provides a very clean interface for your medical needs.

The post I’m researching test results & hormone levels, but some sources use different measurement units. How do I convert them? appeared first on Fertility.ca.

My suspicion is that this comes down to two reasons. Financial, yes, but importantly, emotional: For all of us, the plan was to achieve pregnancy naturally. It is a difficult step to move the act of fertilization into the laboratory.

But, if it has been more than six months of trying naturally together, there are three situations in which IVF may make the most sense:

1. Sperm

Whenever male factor is present, couples may choose to try to maximize sperm quality. This could be done through lifestyle management, through vitamins to maximize sperm quality, through medication such as Clomid to maximize the stimulation of the testes, and through intrauterine insemination to deliver more sperm to the ends of the fallopian tubes.

But none of the above is as effective as doing IVF. This is because with IVF, we can bypass all concerns associated with count, motility, morphology, or obstructions related to previous vasectomy or a congenital absence of the vas. All are treated with a single procedure, by doing intracytoplasmic sperm injection, or ICSI. ICSI places the sperm into the eggs.

It is an extraordinarily effective treatment, as long as the sperm’s DNA can support a healthy embryo.

And so before doing IVF, you might consider getting a karyotype done to confirm normal genetics, and a DNA fragmentation assay of the sperm, if available, to ensure that the DNA being delivered is well packaged and likely to be easily handled by the eggs.

For these reasons, male factor subfertility may often be a serious frustration, but if sperm’s DNA quality can be confirmed, then your expectations for successful IVF can be very high.

2. Tubes

It’s rare that compromised fallopian tubes will be able to be reopened through a cannulation procedure, very rare. The reality is that IVF is a far more successful approach, because it simply bypasses the fallopian tubes. Pregnancy rates can often be superb for a couple facing a situation where eggs and sperm are of good quality, the uterine structure is healthy, and the maternal health is excellent. If it is just a mechanical issue – sperm could not reach the eggs – IVF is a bypass.

As noted, we can try cannulation, or sometimes, if tubes are only partially compromised, we will look to inseminations.

“Partial compromise” can be very difficult to diagnose. Imaging, such as sonohystogram and HSG (hysterosalpingogram) will routinely miss compromised tubes, and the gold standard of investigation – laparoscopy – is highly interventional and invasive. For that reason, we miss fallopian tube compromise with great frequency, and arguably the number one cause for unexplained infertility will prove to be tubal dysfunction. It is for that reason that unexplained infertility is often also well treated through IVF.

A major risk for tubal compromise is low-grade endometriosis, but any source of pelvic scarring, including pelvic inflammatory disease from a previous STD like Chlamydia, a ruptured appendix, or other bowel surgery, all are risk factors for tubal compromise.

3. High quantity of low quality eggs

This situation is more complex. Many couples, particularly when women are over thirty-five years, increasingly worry about egg quality.

On the face of it, IVF would not seem to be all that beneficial; simply placing a sperm inside the egg does not increase its quality. Ninety-three percent of first trimester losses are related to embryo quality, 90% of which come back to egg. So, egg quality is a serious concern in any fertility setting.

The advantage that IVF can provide is this: Numbers. With high-dose fertility drugs, instead of the two to four eggs we will often encourage people to have intercourse or inseminations with, we would be aiming for ten, fifteen or twenty eggs with IVF.

And so it is a numbers game: If egg quality is a concern, and egg quantity is high, then IVF has a superb chance of being more beneficial than any other therapy for the shear advantages that come when ten to twenty eggs are fertilized at a time. It is like one to two years of trying naturally all focused into a single cycle.

And so when is IVF less successful?

Arguably, IVF is less successful when none of the elements above are present: If egg quality is a potential concern, but egg quantity is low, with all other parameters being normal, then IVF is unlikely to be of great benefit. When the issue is related only to uterine structure or implantation, IVF is unlikely to be successful, and if the issue is related to the couple’s overall health, IVF is unlikely to be successful.

IVF, therefore, may be our gold standard of therapy, but it is not for everybody. Still, if any of the three diagnoses above apply to your situation, and it has been a number of months of trying with other means, then IVF may well be considered as a reasonable option.

The post 3 situations where you’ll want to consider IVF appeared first on Fertility.ca.

Sperm’s ability to fertilize an egg is dependant on healthy DNA. But some sperm are fragmented.

Healthy DNA is arranged in a double-helix spiral bound by cross-bonds resembling a ladder. DNA damage means the bridges become unstable or broken causing instability in the DNA ladder.

That instability is referred to as fragmentation or damage of the DNA. If there is a high amount, you’ll likely see a reduction in male fertility, poor embryo development and lower rates of implantation.

Scientific literature shows that the extent of DNA fragmentation has little relevance to the basic semen quality parameters (concentration, motility, morphology, etc.) For example, a “good” sperm sample with high concentration, motility and morphology doesn’t guarantee you’ll get pregnant if there’s poor DNA Fragmentation Index (DFI).

Why is DNA Fragmentation important in the assessment of male fertility?

The test (flow-cytometry or TUNEL assays) is used to count the number of sperm cells per sample that contain suboptimal, damaged or fragmented DNA.

What are the values and what do they mean?

DNA Fragmentation Index (DFI) is used to quantify DNA damage in the sperm. DFI is inversely related to sperm’s ability to fertilize an egg and produce a viable embryo. DFI of less than 15% in sample is considered optimal. DFI between 16-29% is considered to be good or fair fertility potential. Sperm with DFI over 30% is considered to have poor fertility potential. Although exceptions do exist, these percent ranges have been established based on numerous scientific publications over many years of research.

What does testing mean for our ability to conceive?

• More accurate assessment of semen sample quality
• May explain previous failed attempts to conceive
• Determine suitability for IUI versus IVF/ISCI
• Assessment of efficacy of medical intervention or treatment of infectious diseases to improve
• Ultimately improve fertility potential of the male partner

What are the causes of DNA damage?

We don’t yet know all of the factors that lead to DNA damage. Most common ones we do know are chemical/toxin exposure, heat exposure, varicocele, age, infection, smoking, alcohol, radiation or testicular cancer.

The post What is DNA Fragmentation? appeared first on Fertility.ca.

However, there are some logistical challenges limiting choice. There is only one Canadian sperm bank: ReproMed, based in Toronto.

To allow for a greater variety of sperm available to Canadians, Health Canada has allowed for the importation of non-altruistically-donated sperm. Including ReproMed, there are three organizations that import sperm, the other two are Outreach Health Service and CanAmCryo. At our clinic we endorse Outreach and ReproMed.

When you choose sperm, Health Canada recommends that women who have never been exposed to Cytomegalovirus (i.e. “CMV negative”) should choose sperm that is also CMV negative. We test for CMV status for all women considering donor sperm.

When you make a purchase you’ll be offered washed and/or unwashed sperm samples. We re-wash the sperm regardless. From our perspective, there’s no functional difference which sample you’d choose to purchase. We see equal pregnancy rates from either approach.

When doing donor sperm inseminations, we ask that women trigger ovulation (usually with Ovidrel), to ensure that the timing of insemination is ideal. We use one sperm unit per cycle.

We’ll provide you with information on the count of the sperm being inseminated, and the average motility. Using fresh samples as a reference frame, we like to see at least 5 million sperm in the washed sample with 80% or greater motility. We won’t always see these numbers with frozen-thawed sperm: you may have a reduced success rate.

The success statistics that support the donor-sperm program are available from your clinical team and can be individualized to your specific situation by your doctor.

Next post, we’ll be covering guidelines for known donors.

The post We’re considering using an anonymous sperm donor. How does it work in Canada? appeared first on Fertility.ca.

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.

1. Oocyte (egg) quality

Implantation is more likely to happen when a healthy embryo is present, and the best predictor for a healthy embryo is a healthy egg. Egg quality is based on a number of factors.

2. Sperm quality

We now know that paternally imprinted DNA is disproportionately expressed in developing placental tissue. In other words, sperm quality matters a lot when it comes to implantation. For a successful pregnancy, sperm should have stable, well balanced DNA.

What you can do:

There are many ways that sperm quality can be maximized. Antioxidant vitamins are a popular intervention. We have more on sperm here and here.

3. Embryo quality

Embryo quality is a reflection of both egg and sperm. If you are doing an IVF cycle, embryo quality can be determined by grading systems. The embryos most likely to continue to develop will have 6, 7, or 8 cells by day 3 of development in the lab.

If you are considering a frozen embryo transfer (FET), embryo quality is also a reflection of the laboratory’s freezing-and-thawing success rates. In some labs, FET cycles have a pregnancy rate of one-quarter to one-half that of fresh cycles, but the rates vary by clinic and many of us are now seeing the same (and even higher) success rates with FET. Embryos may be frozen with the traditional slow-freeze protocols, but with the flash-freeze vitrification methods we are seeing better success rates.

Here’s what you can do:

Maximize egg and sperm quality before you start treatments.

Consider a repeat fresh IVF cycle instead of multiple frozen cycles.

4. The number of embryos transferred

There are some suggestions that embryos help each other to implant. In other words, the more embryos that you transfer, the greater the chance that each one will stick.

Be very careful with this one. The movement in our field is away from multiple-embryo-transfer, not towards it, because the risks associated with multiple pregnancy are very real. Some clinics even advocate for elective single embryo transfer. But if there are other impediments to implantation–say, embryo quality is a known concern–then our standard of care is to transfer multiple embryos in the hope that one will take.

We also find we have more success with blastocyst embryos transferred at day 5 rather than morula embryos transferred at day 3.

5. The woman’s overall health

An overall health screen tests many things, and usually includes thyroid function and prolactin levels.

Depending on your situation and family history, you may also be screened for other systemic diseases that can affect implantation. For example, we might look to rule out diabetes, autoimmune conditions such as elevated Natural Killer cells, a pre-disposition to hypercoagulability, markers for celiac disease…and many more.

If you and your immediate family are otherwise healthy, many of these tests are not routinely offered.

Here’s what you can do:

Eat well, exercise moderately, don’t smoke, and continue seeing your family doctor for annual check ups even when under active fertility care. If you have or suspect a specific medical condition, ask your doctor if further testing is warranted.

6. Shape of the uterus and fallopian tubes

Some women have an anterverted uterus, some women have a retroverted uterus. Both are fine: the terms simply refer to which direction your uterus tips. Of more importance, we need to confirm that the uterine cavity is a normal size and shape for implantation to be successful.

To check the structure of your uterine cavity, the gold standard of imaging is a 3-dimensional sonohysterogram. Hysteroscopy (surgery) is used when necessary for things like fundal polyps, impinging or submucosal fibroids, and/or a uterine septum extends 10mm or more.

The shape of your fallopian tubes should be confirmed by ultrasound, a hysterosalpingram, or (less often) surgery. We also screen for chlamydial antibodies, because a history of this infection can affect tubes. We know that dilated tubes (”hydrosalpinges”) may compromise implantation, and sometimes suggest that they’re surgically removed before IVF.

Here’s what you can do:

Make sure that you have all the imaging tests available to you updated before starting your treatments. If your doctor suggests uterine surgery, you may want to get a second opinion. But don’t be too hesitant: the surgery is often a day procedure, and the benefits can be profound.

7. Lining of the uterus

We look at the uterine lining itself, to judge whether or not implantation may be expected. The endometrial lining can be assessed in the following ways:

Appearance on the transvaginal ultrasound

An ideal lining will be at least 7mm thick on day of ovulation trigger (the day your HCG spikes). Ideally, it will also have a “triple line” appearance (an ultrasound finding that shows a good response to estrogen).

After ovulation, the endometrium compresses somewhat, and the triple-line pattern will be less distinct. These are normal findings.

Luteal endometrial biopsy

An endometrial biopsy is not part of every cycle, but it may be done in the luteal phase of a cycle before IVF, in an effort to confirm that the implantation window exists. Various markers for this implantation window have been identified, including histologic appearance and grading, specific findings seen only by electron microscopy, and the staining for various markers that are thought to be associated with implantation.

There are several tests which analyze endometrial biopsy further looking for markers of implantation. This is controversial, as it does not work as well as we would like, but some tests include Harvey Kliman’s Endometrial Function Test, the “E-tegreity Assay” for beta-3 integrin, and sending a biopsy specimen off for culture (this is most useful when intrauterine fluid is collecting and worries about infection persist).

We offer the EFT through our office in partnership with Dr. Kliman.

Here’s what you can do:

When endometrial thickness is low (the lining is never more than 6mm thick), you should talk to your fertility doctor, for management is highly individualized. Many authorities recommend a BMI of >18.5; a healthy lifestyle that involves no smoking and limited caffeine; and ask that you consider red meat to be part of your diet. Supplemental estrogen is regularly used and acupuncture may also be suggested. But again: you should really speak with your doctor.

If you have irregular cycles and a tendency towards a thick lining (>12mm), you might benefit from an endometrial biopsy to rule out hyperplasia.

Even if the EFT is limited, the very act of getting an endometrial biopsy may help with implantation. The proper studies have not yet been done to support this statement, but many smaller ones suggest that implantation may be boosted by as much as 20% in some cases.

8. Embryo transfer technique during IVF

In an IVF cycle, embryo(s) selected for transfer will be collected into about 0.020cc of fluid and inserted into the womb. The process of insertion is highly physician dependent: this means that it matters who does your embryo transfer. The following issues will be considered by your doctor:

(a) Transfer medications like progesterone, antibiotics, and steroids.

(b) Cervical preparation

(c) Use of a tenaculum

(d) Catheter type

(e) Ultrasound guidance

(f) Post transfer instructions

Here’s what you can do:

Work with a doctor and clinic that you really trust. Embryo transfer is very important. Some physicians even suggest doing a mock transfer prior to the IVF cycle itself. It has been our experience that the uterus is lying in a slightly different position every time. In other words, the mock transfer did not help as much as we would have hoped for. We now judge the value of a mock transfer on a case-by-base basis.

9. Luteal Support

We support the luteal (post ovulatory) uterine lining with progesterone whenever we are worried about natural progesterone levels. Progesterone may be taken orally, intramuscularly, vaginally, or rectally. Other medications that you may read about for the luteal phase, and into early pregnancy, include estrogen, ASA, dexamethasone, Fragmin, Lovenox, IVIG, HCG, and others. We are very cautious here: some of these medications have side effects that, in some circumstances, could be of real concern to you or your baby.

Here’s what you can do:

Definitely talk to your doctor. The medications that you take in the luteal phase, and into pregnancy, must be compatible with bringing a healthy child into this world. That said, the ideal balance will keep your endometrial lining stable. If you find that you consistently have your period before the planned pregnancy test day, your luteal support may need to be re-examined.

10. Lifestyle

You need to minimize caffeine, quit smoking, and avoid alcohol. Intercourse during the “two week wait”? We think it’s fine, but I would ask your doctor, as everyone has a different opinion on this subject.

Conclusions

To be successful, your clinic must focus on implantation. Many protocols and techniques are well standardized across fertility clinics, but implantation standards are not. Because of this, there are great differences in implantation success rates across both clinics and doctors. We hope this article will help shed light on some of the complications and what you can do to help achieve a successful implantation.

The post How do I improve my chances for embryo implantation? appeared first on Fertility.ca.

Toronto Public Health is very clear on its relationship to alcohol and pregnancy. Its May 2014 communique references these very clear key messages: There is no safe level of alcohol exposure at any time in pregnancy, and that when planning a pregnancy it is safest to stop drinking alcohol before becoming pregnant.

Without doubt, these are reasonable comments.

At the same time, it puts women who are trying to conceive over an extended period, in a socially very awkward position.

The challenge that I see is that women who are trying to conceive for a month or two are socially in an entirely different position to women who are trying for a year or two.

It can be incredibly awkward to need to refuse all alcohol, in all social situations, at all times, for years at a time, while awaiting a pregnancy that, in many circumstances, should be a private story, or at least not one that you would wish to be exposed in a new social setting. How awful to get raised and knowing glances from others around the table when you decline a social drink!

But I cannot state unequivocally that alcohol is safe and appropriate while trying to achieve pregnancy. For one, some people do self-medicate with alcohol for sleep and anxiety, to serious concerns for those who are in fertility clinics and trying to achieve pregnancy.

The evidence very clearly indicates that alcohol does not promote egg quality or the safety of embryos. Perhaps there are antioxidants such as resveratrol in reasonable doses from red wines from wet regions in the world. But if resveratrol were your goal, it can be found in tablet or dietary form and red wine is not required as part of the process.

But, what of other data that suggests people who drink one drink a day are more likely to live longer than people who abstain? It is possible that alcohol is a vasodilator and increases blood flow, including to the pelvis; but again, I have seen no study and heard no evidence that alcohol in any way helps promote better egg development or uterine lining.

Alcohol is part of the big four substances that people wrestle with in their personal lives, the other three being coffee, cigarettes, and marijuana.

In my clinic, I routinely advise that one cup of coffee a day is fine, cigarettes are to be avoided as the residues have been clearly demonstrated to accumulate within the follicular fluid that surrounds eggs, and there is some evidence that marijuana may reduce implantation rates by interfering with the natural receptors associated with stress and with implantation.

I don’t know what to say about alcohol.

I know if it were my wife who was trying, I would encourage her to have a social drink from time to time throughout the process. If she were drinking alone in the basement, that would be one thing, but light social alcohol in moderation with friends, if it is part of your lifestyle, is a lot to give up for years at a time.

Perhaps, if you want to justify it this way, you could remember that implantation itself does not occur until approximately five to seven days after ovulation. If you know when you ovulate, does that mean it is okay to drink before that moment? I do not know.

I would ask that you be kind to yourself throughout this process of trying to achieve pregnancy, and if you are deciding to abstain from alcohol, I hope you are able to reward yourself in some other fashion. I hope you are able to achieve the same sense of social connection to those around you which is usually why people reach for a glass in the first place.

The post Alcohol when you’re trying to conceive. appeared first on Fertility.ca.

When we retrieve eggs, a lot of them may look good under the microscope, but in fact not be functional. Not every IVF patient is the same but on average it takes four to five eggs to generate one blastocyst.

Blastocysts are the best developed embryos we have in the laboratory and will take five to six days to generate.

Blastocysts are associated with the highest pregnancy rates. Not every blastocyst is genetically balanced.

A blastocyst with the correct number of chromosomes is called “euploid”. For women that are thirty-five, on average 70% of blastocysts will be euploid; for women thirty-six to thirty-eight, it is closer to 50%; and over thirty-eight years, it is closer to 30%. By the time women are over forty-two, it is likely an even lower fraction.

Even euploid embryos may have smaller genetic or other irregularities such that it will be an approximately 80% implantation rate.

Looking at all the numbers above, then, for the average thirty-seven year-old patient, mathematically at least, we can expect pregnancy if there are three blastocysts to be transferred over one to two cycles. To generate three blastocysts, we would like to have generated fifteen eggs.

That is why our goal for IVF is to generate twelve to twenty eggs.

I have seen cases where there were only two eggs, leading to two blastocysts and an ongoing twin pregnancy. If you have a very low ovarian reserve, but every reason to believe you have extraordinarily high-quality eggs, it is reasonable to hope that IVF could work for you.

But for most women, if there are fewer than twelve to twenty eggs being generated through IVF, then there is a lower chance for success based on the math described above.

So why not more than twenty eggs? The answer is that over twenty-two eggs, there may be enough hormonal imbalances that pregnancy rates may start to fall again. With such high numbers, the current community standard is shifting to freezing all embryos and not completing the transfer at all, instead waiting for a future cycle when your hormones are likely to be in better balance.

The post Why do you want 12 to 20 eggs for IVF? Isn’t that a lot? appeared first on Fertility.ca.

Choosing the best embryo

The next day -day 1- each healthy embryo will still be a single cell, now at the two-Pro-Nucleii (2PN) stage. It is a black-or-white assessment, with little room for interpretation: either you have 2PN embryos, or you don’t. Most couples can expect 80-90% of the mature eggs to turn into 2PN embryos.

Embryos are rarely transferred at this point, because you really can’t tell which embryos of the group will be the most likely to continue to grow properly.

By day 2, the embryo should be 3-4 cells.

By day 3, the lab staff can finally grade the quality of the embryos by looking at them under a microscope. It is not a perfect science, but, it is our standard of care for the moment. The grading is done in two ways:

• We count cells. The ideal embryo has 8, 7, or 6 cells. More than this, and embryos may be growing too fast, using up the energy stored by the egg, and therefore more likely to burn out before they get the chance to implant. Slower than this, and the concern is that the embryos won’t continue to divide at all.
• As cells divide, they leave fragments behind…and too many fragments suggest that cells may not be dividing properly. We grade fragmentation on a 5 point scale, and ideally your embryos will be grade 1 or 2.

A perfect grading system would allow us to spot the ideal embryo every time. We’re working on that*, but in the meantime, to make up for our uncertainty, we usually encourage the transfer of more than one embryo.

For greater specificity in embryo selection , some doctors will encourage you to grow embryos along to day 5.

By day 5, listed in increasing order for pregnancy, we hope to see:

• morula
• cavitating morula
• blastocyst
• hatching blastocyst

A blastocyst will be about twice as likely to result in pregnancy as a morula.

Sometimes we will allow an embryo to grow to day 6 to become a blastocyst, but we won’t go further than that.

The pregnancy rate per blastocyst transferred is certainly higher than per day 3 embryo transferred, because the extra two days has allowed greater selection to occur. But in some ways, it isn’t a fair comparison. Perhaps pregnancy rates would have been just as good transferring 3 embryos on day 3 cf. 2 embryos on day 5.

In fact, doctors and laboratory staff will cite many factors when comparing day 3 to day 5, including patient age (some say >40y should always be day 3), optimization for freezing (historically better on day 3, but perhaps vitrification changes this equation), embryo health, the implantation window, uterine contractility…the debate goes on. Good people can disagree.

My advice would be to accept the day that your particular lab favours. In this way, you will be maximizing your chances as your work to the strengths of your particular group.

* Note that there are newer systems for embryo grading, include proteomics, metabolomics, and other variations in preimplantation genetic screening (PGS). I am happy to write to these topics, but they generally will not be offered in most laboratories in Canada or elsewhere.

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