Hi, thank you for doing this AMA!

What would be the advice you would give a couple trying to get pregnant, any basic thing to do / not to do that are generally overlooked?

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Hi u/leag63,

Great question. For many couples the best way to start trying is to make sure you are timing things with the woman's menstrual cycle. The easiest way is to plan to time sex every 2-3 days from when her period ends until she expects her next period. If her periods are unpredictable, this is reason to see a doctor rather than try for too long on your own. If she is over 35 it is a good idea to do some fertility tests even if you are planning to try naturally just to make sure all is well.

The basic tests are semen analysis, uterus and tube test (like an HSG), and ovarian reserve testing (such as AMH and ultrasound).

The most common thing people may not know is when to time sex especially when a woman's period is irregular.

Hi! Question 1: In regards to a 'normal healthy' woman, how many egg donation procedures can someone have before the risks of the procedure become unacceptable?

Question 2: What can a woman do to advocate for herself when she wishes to become sterilized? I've heard doctors won't provide this medical intervention without a husband's consent if the woman is otherwise healthy and less than 45 years old.

For more AMAs on this topic, subscribe to r/IAmA_Medical, and check out our other topic-specific AMA subreddits here.

Regarding NOA, are there any upcoming new treatments we might want to be aware of? TESA, mTESE unsuccessful, no known cause.

Hi u/MsGoogle,

Thanks for your questions!

Regarding question 1: There are different professional guidelines on how many times a woman can donate her eggs but the most common one is no more than 5 times.

For question 2: Laws and regulations regarding sterilization vary widely between different jurisdictions around the world. The most important thing to bear in mind is sterilization is not intended to be reversable and as such most doctors avoid offering it to younger women especially if they have not had children. As far as advocating for yourself, I would advise working with a doctot that you feel comfortable with and who is willing to listen to your concerns and weigh the pros and cons.

My sister has a genetic condition and is worried about getting pregnant and passing it to her child. Is there any fertility treatment that can help her?

Hello u/LucilleandCharlie,

Thanks for the question. NOA (non-obstructive azoospermia) is a common cause of sub-fertility. The causes can vary from genetic to hormone issues, chemical exposure and varicocele. This means the treatment options are best tailored to the underlying cause. Some cases can be treated with medication however not all. Even the best treatment may however only lead to a small amount of sperm production, just enough for IVF.

There are some studies looking into stem cell therapy, but this is not commonplace.

An alternative worth considering is donor sperm which may or may not be a direction you are comfortable with.

Thank you for doing this Dr!

Are there any significant lifestyle changes that either significantly increase or decrease chances of success via IVF?

(Couple, M39 and F31, UK)

Hi u/dangerWW,

I am sorry to hear about your sister's situation. The best advances in fertility treatments have been in the field of pre-implantation genetic testing (PGT). Using IVF, embryos can be tested safely for specific genetic conditions and then the unaffected embryos can be selected to have a baby without the condition. This is something many clinics including my own specialize in. Looking at my own clinic's data, we have a >85% pregnancy rate using PGT, so this is a very successful option to consider.

Hi,

I want to have kids someday but not yet-- I'm 29 and it's still not feasible with my income/ lifestyle. But and am really starting to worry about my "clock ticking".

But I keep finding contradictory information online. At what age does it actually become harder for women to conceive? Does the matter of conception (IVF or not) matter?

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You are very welcome u/Lt_Devil_Melon!

Lifestyle choices when you are trying to get pregnant is very important. High on the list of things to avoid are smoking and alcohol for both men and women. Being an optimum weight is also important as both underweight and overweight have been linked to poorer IVF outcomes. Also, if you have any medication conditions (such as diabetes or high blood pressure) you want to make sure your condition is under control prior to starting the process.

Regarding supplements, some studies have found a benefit for women taking Co-enzyme Q10 and DHEA supplements. For men, zinc and antioxidants have also been found to be important for sperm production.

Stress reduction is also important but hard to study scientifically.

Stress is the difficult one... I'm in the Armed Forces and my wife is an ITU Nurse! Ha ha...

But we really appreciate the advice. And thank you for helping so many people!

Does the risk of OHSS decline or end once period resumes after an embryo retrieval (and will go under FET protocol with oral intake of Estrace)?

My pleasure!

Is there any truth to the rumors that people are looking for non covid or vax sperm/eggs?

ERA (endometrial receptivity assay) for those who aren't familiar is a tool designed to determine the best time of the cycle to transfer a frozen embryo after IVF. The studies on ERA have sown benefit in some patients if they have had multiple failed embryo transfers. In my clinic, I specialize in PGT single embryo transfers. Our current pregnancy rate using PGT is >85% per embryo transfer and as such I haven't found much of an improvement using ERA for my patients. I would recommend anyone considering having an ERA, ask your clinic how much of an improvement they have seen using the ERA so you can make the most informed decision.

Thank you for your thoughtfulness and support in doing this AMA. It is greatly appreciated!

I’ve been to many doctors about plenty of my fertility issues. I didn’t go initially because—what woman wouldn’t want less periods (and pain monthly). Not until I got older I started to understand the negative sides of that. Is there any way to narrow down if my disorders are causing each other or they’re unrelated and just stack?

Diagnosis: PCOS, Low thyroid function, insulin resistance, sleep apnea, and whatever I can’t think of.

It’s like every year the doctor just tacks on something else I have that’s still causing me to have fertility issues….

Hi u/HaworthiaRYou

Great question. There are many ways to reduce OHSS, one of which is freezing the embryos and planning for an FET. This is a very effective option. In nearly everyone who is experiencing OHSS, the symptoms are gone by the time of your period. That being said, most doctors will still want to assess you before starting the FET cycle just to be sure.

Hello! Thank you so much for being here. What IVF retrieval protocol would you suggest for someone with endometriosis and who has the issue of dominant follicles? I have poor egg quality and have a hard time making blastocysts. Thank you so much!

Hi u/Iamatworkgoaway,

I haven't seen this in my clinic. That's not to say it isn't being asked elsewhere.

Hi u/SongBird2007

I am sorry to hear about your situation. Many medical conditions can have an impact on fertility, and it is often hard to find a balance. PCOS and insulin resistance are both very commonly linked to fertility problems. You ideally want to make sure you are working with a doctor you feel is addressing your needs in a supportive and productive way. Also be sure you are taking time for yourself!

Hi u/Harlan2114

Thanks for the question. The 2 main types of protocols are agonist and antagonist. There is data suggesting longer agonist suppression can help with early follicle growth, but this can also over suppress some follicles. The estrogen priming protocol is a nice blend of suppression with the added advantage of antagonist. I see a lot of patients with a similar situation. If you want to reach out to my office, we could set up a consultation to talk about your specific case. (email contact@caymanIVF.com)

Hi Dr! I'm a postgrad student doing clinical embryology and have a question about PLCzeta. Can we say it is the only factor that contributes to oocyte activation? If not, what other factors can we consider? If yes, to what extent?

Hello, I was misdiagnosed with PCOS when I had a far more serious illness. I am currently battling cushings disease. My endocrinologist has said he does not see a resolvable issue in regard to me later starting a family. I am skeptical of this.

What tests should I request in regard to fertility and what are the risks post cushings in regard to pregnancy?

Thank you

Hi - thank you for doing this AMA! What advice regarding protocol would you give someone with a normal AMH/AFC but elevated FSH (10.06) Is there any indication that elevated FSH will mean poor egg quality?

If a baby's head isn't going to fit through the pelvis and require an emergency c-section, is there any way to know this before it happens in the moment?

What are your thoughts on genetic testing of embryos?

Thank you for being here! I'm 34 and I'm looking at having my second child in a couple years. I heard the risk of health issues goes up after 35. Is this a significant risk (are we talking single digit odds or double?). Does IVF lower these risks? Are their natural ways such as diet that lower these risks? Thank you in advance.

Cool Thanks, just nice to get a straight answer to a stupid question that the stupid internet puts in my head from time to time.

If the overstimulation happened during the egg retrieval cycle how do you suggest that not doing a fresh transfer is an option to prevent it? I had ohss already by the time of my egg retrieval, and my doctor told me (accurately to my experience and literature) that ohss symptoms peak in days 3-7 from the procedure. So while sure maybe the transition to fresh transfer would make it worse, surely that doesn’t actually have any prevention success for OHSS that has already begun. OP sounds like she’s doing a FET already anyway.

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What’s your live birth rate? In the end, that the most important number.

Here is a medically reviewed article that you could share with your sister. Also, a lot of people with genetic concerns opt to use donor eggs or donor embryos, so they don't have to worry about passing that genetic concern on. But this article is a good place to start! https://www.fertilitywise.com/research/preimplantation-genetic-testing-pgt

You read my mind! It was the same for me. They were monitoring and were ready to freeze embryos and switch to an FET instead of fresh transfer, but I was already there... I know sometimes implantation can trigger symptoms to get worse, so maybe that's what he's implying??

I really like this article (and heck-the whole site because it's medically reviewed, not just someone's biased opinion, and the articles tend to be easier to read than ASRM or other medical articles) and thought you might find it helpful. Even though it's meant for getting pregnant via sex, it's got some good points about "how to optimize fertility" that you might find helpful! https://www.fertilitywise.com/research/getting-pregnant-via-sex

Here's a good medically reviewed article that might have some good insight for you. Overall, there's a lot of things people think impact fertility but ultimately don't really have any true weight behind them. Being healthy and making healthy decisions is the best thing you can do! https://www.fertilitywise.com/research/getting-pregnant-via-sex

Hi @sqic80,

Yes live birth rate is very important. With single euploid embryo transfers our current live birth rate averages 74% over the year.

Great question. OHSS does get worse shortly after trigger especially with an hCG trigger (vs an agonist trigger). The symptoms peak as you rightly said 3-7 days after trigger. The benefit of freezing embryo rather than fresh transfer is the reduce the severity of the OHSS while it resolves. I typically use agonist triggers and plan to freeze if I see any risks or signs of OHSS. Even in the best of situations however OHSS can still happen. I believe the most important way to address OHSS is to have an open discussion about the signs and symptoms and make a plan with my patient about how to proceed. That being said, I do very few fresh transfers and have seen very few cases of severe OHSS since moving to that approach.

Good follow up question! See my reply above but yes, hCG worsens OHSS. This is not only from an hCG trigger but also from a fresh transfer that implants and begins making hCG. This is the theory behind using agonist triggers and avoiding fresh transfers when OHSS is suspected.

Unfortunately not all OHSS can be avoided. We can just use certain approaches to lessen the duration of the OHSS and reduce the risk of worsening symptoms.

My pleasure!

Hi @rosegolddragon,

There are some risks of pregnancy as we approach our later 30s and 40s but a lot depends on your overall health status (such as high blood pressure, etc). The other risks we think of related to pregnancy over 35 are risks of genetic problems in the baby. The risk of having a baby with Down’s Syndrome for example is 1/1000 roughly at age 30 and is closer to 1/350 by age 35 and 1/100 by age 40. An unfortunate corollary to the increased chromosomal abnormalities is an increased chance of miscarriage. These risks related to the baby don’t seem to be reduced with diet or lifestyle but can be tested for using PGT.

If you have other medical conditions like high blood pressure or diabetes, lifestyle and diet can in some cases help reduce the risks associated with those conditions. Hope that helps!

Hi @strawberrywine5880,

Many of my patients choose to do genetic testing if embryos (PGT) for several reasons. For patients over 37, the odds of an embryo being genetically abnormal exceeds the odds of a normal embryo and this can mean lower pregnancy rates and a higher miscarriage rate. For others who are younger, especially those with PCOS or unexplained sub fertility, they often have a large number of embryos and use PGT as a tool to identify the chromosomally optimal ones.

Like all tests though, PGT is not 100% accurate. This can mean “normal” embryos may be discarded if the test inaccurately shows they don’t have the right number of chromosomes. There is also additional cost to PGT which is a factor.

Many patients I’ve spoken to have balanced the cost of PGT ($2000 in my practice) with the cost of a failed frozen embryo transfer (also $2000) and given the higher pregnancy rate and lower miscarriage rate with PGT tested embryos have stated they feel the cost is worth the benefit.

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Why do human females have menstrual periods when most female animals simply reabsorb their uterine lining if they don't become pregnant? I can't think of any evolutionary advantage to this often incapacitating process. Back in the prehistoric days, it would've hindered many women's ability to gather food, run from dangerous situations, take care of other offspring, and other things they'd need to do to survive.

Do you know about pois? Post orgasmic illness syndrome?

Thank you so much for sharing and thinking of us!

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Why would you expect a fertility specialist to be of any use in learning how to advocate for sterilization? They literally do the opposite of what you are asking after.

Seems like you are asking this question just to troll - "I've heard..." Not you've experienced, but you've "heard". As someone who did seek sterilization and was declined, the answer, as with any other medical issue, is to find a doctor willing to treat you in the manner in which you wish to be treated. Sometimes that's easier than others. But in all of my search, I never thought a fertility specialist was the correct resource.

What is your opinion on the use of Lupron in FET prep? Low dose (5-10 IU) is part of my FET protocol, but recently I’ve read some concerning information regarding possible long term side effects (arthritis, vision, hormone issues, etc) linked to the drug. Is there cause for concern at my dosage?

Is it true that up to 10% of miscarriages are caused by blood-clotting disorders? If so, why isn’t testing done for all pregnant women?

It's all about the quality of your eggs. Women's egg quality and availability diminishes with age. There are tests your OB-Gyn can run to check those levels to look at your egg reserves. Some wonen experience early menopause. There's no good "one size fits all" number when it comes to what age that hapoens. For some women it may be 25, for others it may be 40. You can always do egg freezing now, to retrieve your eggs and save them for later. Even if you waited to use them for 10 or 15 years, the eggs will be frozen in time and not age. Women can have healthy, successful pregnancies into their mid to late 40s, (I've even seen some women become pregnant at 52!) but your eggs won't stay good that long. Here's a medically reviewed article you may find helpful. https://www.fertilitywise.com/research/egg-freezing

What's your stand of nature vs nurture? Meaning, I hear all sorts of anecdotal cases about couples who struggle because they're busy working and thus appear completely infertile, change their lifestyle and boom, she's pregnant.

Of course, I know you work on evidence, but to what extent does having an excessively busy life affect your fertility? And do you ever advise clients to take a step back, before going for fertility treatments?

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Hi,

When do you think we will have the technology to bypass the need for egg and sperm by perhaps introducing the patient DNA into "host" egg or sperm of a donor like a vector?

Hi Dr! Thank you for doing this.

What advice would you give to a couple who are trying to have twins? Me and my soon to be wife, we both want twins and we're willing to get any help if necessary, any advice on what we should do and not do? We both absolutely love twins!

Does the flow, cramps, and length of a woman's period indicate anything about her fertility?