Fertility Treatment Questions? Texas Fertility Center Has the Answers.
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/GYN, 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.
The testing must be repeated every 12 months.
Cycle day one is the first full flow day of your period; we do not count light spotting.
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.
We prefer that you test between 12-3 pm every day.
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.
Injectable medications are typically started on Cycle Day #2 or 3.
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.
Our clinical staff tries to return all patient calls between 4:30 and 5:30 pm.
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.
A typical IVF cycle takes 6-7 weeks from the start of birth control pills until the embryos are transferred into the uterus.
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.
YES! Spotting or bleeding in early pregnancy is not unusual so you must take the pregnancy test as scheduled.