Fertility Treatment: Do not be Distracted
When contemplating options for fertility treatment with your own eggs, it always boils down to continue frequent intercourse, ovarian stimulation / ovulation induction + IUI or some form of IVF. During consultation or when weighing your options do not lose perspective of the big picture. Many suggestions may present themselves and serve to distract you. Men and Women load up on these distractions from the web, friends, primary care physicians or the couple themselves. Some of these recommendations are harmful because they shift the focus to non-proven interventions and most notably cause delay consultations with a reproductive endocrinologist and completing the infertility workup or starting treatment if needed.
Do not be distracted by these arguments
I am Healthy
Many women in America consider being healthy as being fertile. The media also bombard us with photos of beautiful women in their forties with babies. Truly many women, are in great shape with ideal body weight, exercise regularly, have no medical problems and feel great about themselves.
Fertility though speaks to a specific set of factors related to the ovaries, fallopian tubes and quality of sperm. Healthy women can have low egg reserve or blocked fallopian tubes or their partners have low sperm counts. Hence their fertility could be impaired. On the other hand, women not leading a healthy lifestyle or having a medical disorder can be very fertile if all fertility factors (tube, ovary, sperm) are functional.
I did not try enough
If you do not use birth control pills or condoms and you have having regular intercourse, then you are trying, irrespective of your conscious intentions. If you are you had regular intercourse for one year and are younger than 35 years or six months and 35 or older, then you have tried. Regular intercourse means two to three times a week. If you had intercourse with reasonable frequency for 6 months to a year and you are not pregnant consult with a fertility specialist. There is a strong relationship between the length of trying and pregnancy rate. The longer that you have been trying, the lower the chance for spontaneous conception.
I did not time my ovulation
Timing your ovulation is not required at all if you are trying to conceive. Actually timing your ovulation maybe harmful to your chance to conceive. Because the methods you would use to time ovulation (cervical mucus, ovulation prediction kits, basal body temperature or intelligent thermometers and apps) are not accurate, you may miss valuable time and have intercourse. Moreover, you cannot get higher odds for getting pregnant above and beyond having intercourse three times a week because sperm will be available all the time when you ovulate. Several studies failed to show any increase in pregnancy rates using many of these timing methods.
My progesterone level is not optimal
For almost all women, low progesterone level is not a cause for infertility. In natural cycles, progesterone starts to rise after ovulation. Levels of 3 nanogram/mL or more indicates ovulation, Optimal levels to maintain the lining of the uterus are 8 to 10ng/mL. Levels less than 8 (luteal phase defect) may lead to miscarriage because progesterone is not adequate to maintain the lining of the uterus but it is not a cause for not getting pregnant (infertility). Progesterone is monitored, and supplemented if low, during fertility treatment but in itself low progesterone is not a cause for infertility.
On Clomid & Letrozole
Clomiphene is widely used as initial fertility treatment. This use is commonly not appropriate because
a) clomid is used without infertility workup (checking ovarian reserve, sperm analysis and fallopian tubes)
b) clomid is used without performing basic tests related to the safety of getting pregnant (infectious disease and genetic screening)
c) clomid is used by women that are not likely to benefit from it e.g regularly ovulating women with low ovarian reserve and unexplained infertility. Women that are most likely to benefit from clomid are women with chronic anovulation e.g women with polycystic ovary syndrome (PCOS).
d) clomid is commonly used with no monitoring using ultrasound. If you do not get pregnant, one would not know if you did ovulate or not. 10-20% of women do not respond to clomid. If you do get pregnant, there is a possibility that you have many eggs developing in the ovary because you are unduly sensitive to the medicine which makes you at risk for multiple pregnancy
e) clomid is commonly use for extended periods of time while the majority of pregnancies take place in the first 3 months.
f) IUI is preferred to intercourse only, in clomid cycles because it can cause the cervical mucus to be thick. IUI bypasses the cervical mucus and deposit the sperm into the cavity of the uterus
g) Letrozole is similar to clomid regarding the use and indication but there is evidence that pregnancy is higher after letrozole compared to clomid.
Use clomid or better ltrozole for the right indication, with monitoring and for 3 (max 6) months only.
On Setting Time Limits
For each fertility treatment step: intercourse, ovarian stimulation + IUI or IVF define the number of cycles you will try before proceeding to the next step. Statistically, these treatments are more likely to succeed in the first three treatment attempts. Subsequently, the chance for getting pregnant diminishes and you and your physician should consider moving to another fertility treatment.
Do not loose track of your age and ovarian reserve
You have normal fallopian tubes and partner sperm and you ovulate every month. Younger women are encouraged to try (have regular intercourse). The duration of trying on your own should be guided by ovarian reserve tests and age. Younger women with good reserve can try a bit longer than older women or women with low reserve. This recommendation should be based on scientific information not general perception. Do not accept the advice ‘ keep trying’ from any one without considering you age and without performing the tests for ovarian reserve (vaginal ultrasound, AMH and FSH on day 3). Female age is the most important factor in occurrence of a healthy pregnancy and should be the prime consideration even if ovarian reserve tests and other factors are normal.
There is a plethora of low quality information, recommendation and advice out there. Women accumulate them from multiple sources or just using there simple logic. They can lead to delay in fertility testing and fertility treatment that could be detrimental to future fertility.
Amr Azim, MD, FACOG is a reproductive endocrinologist and a fertility specialist with special training in treating simple and complex fertility problems. His areas of expertise are assisted reproduction and preservation of fertility.