Category — Operation Heads Up

IVF (FET or Frozen Embryo Transfer)
by Bea

Why Would You Be Having An FET?

1. Because you had extra embryos left after your fresh transfer cycle. There is a limit to how many embryos can or should be transferred at one time. This limit will vary from patient to patient, for both personal and medical reasons, and also according to the laws and guidelines in your region of the globe. Extra embryos of good enough quality can be frozen for later use. This cuts down the amount of drugs and treatment you need to have to achieve a pregnancy.

2. Because, although you made nice embryos, your fresh transfer was cancelled. This may be the case if you are at risk for ovarian hyperstimulation syndrome.

3. Because you are using donor embryos (which will usually be frozen).

What Can You Expect?

1. First, your specialist will decide on a protocol. In some cases, there is a clear reason for choosing one protocol over another – a post-menopausal woman, for example, will most certainly be prescribed a HRT protocol (see below). Other cases rely on a review of many factors, including cause of infertility, clinician and patient preference, and response to previous protocols. In other words, it’s very complicated and frankly, half the time it’s either hard to know what is best in advance, or it will make little difference to your chances of success either way.

At the basic end, you have the natural FET. You are monitored for ovulation and lining thickness, and embryo transfer is scheduled for several days after ovulation. The exact timing will depend on the age of the embryos at transfer. If you have frozen the embryos at day two, transfer will happen two days after ovulation. If you have frozen the embryos at day five, transfer will happen five days after ovulation, and so on. The idea is to mimic the natural process as closely as possible. As in the natural situation, the timing doesn’t have to be ultra-precise, with studies showing there is up to twenty-four hours leeway.

A natural cycle may be used with or without some form of luteal phase support. Commonly you will be given two or three hCG injections and/or progesterone supplements (pessary-style or injections). Again, protocols for luteal phase support vary wildly, sometimes starting before transfer, sometimes the day of transfer, some continuing until beta (and perhaps beyond if your test is positive), and others continuing only for a set number of days, no matter what.

If you don’t ovulate reliably on your own, your specialist may use an ovulation induction (OI) protocol, in which ovulation of a single follicle is induced (usually using FSH injections). You will either be monitored for a natural LH surge, or triggered with an hCG injection. Transfer and luteal phase support happens as per a natural protocol.

Hormone replacement therapy (HRT) protocols are favoured by some specialists, and for some patients. These use hormone tablets, patches, pessaries or injections to mimic the natural cycle, plus or minus a GnRH agonist/antagonist to shut off your body’s natural control. The simplest and most common protocol seems to be oestrogen tablets until the lining is thick and ready, followed by progesterone supplements, with transfer happening near the beginning of the “luteal” (progesterone) phase.

2. Prior to transfer, your embryo will be thawed out. Fifty to eighty percent of embryos survive the thaw. By thawing the day before transfer, the lab ensures plenty of time to thaw extra embryos if need be. It also gives a chance to see if the embryo will resume growth after thawing – those that don’t are very unlikely to survive inside the uterus.

It’s also possible to thaw a batch of embryos and grow them for a few days prior to transfer–for example, if you have decided to grow day two embryos to blast. An embryo can be thawed, grown, and re-thawed providing it remains of good enough quality.

3. The transfer itself is exactly like a fresh transfer. The procedure is similar to an IUI (which feels a bit like a pap smear) except it is performed in the hospital for easy access to the laboratory where embryos are kept and thawed, instead of in the doctor’s rooms. You are usually given a short period of rest, and your doctor will let you know if there are any other instructions. Some doctors prefer you to rest for a day or more, just on the off-chance this helps, although numerous studies show no benefit to restricting your normal activities for more than twenty minutes after the transfer is done.

Problems That May Arise And Ways To Trouble Shoot

1. Problems with giving medication. Please see trouble-shooting suggestions under subcutaneous injections, intramuscular injections or progesterone.

2. Cysts and other nasties. If a cyst is discovered at the beginning of your cycle, your doctor may want to treat it before going ahead with transfer.

3. Ovulation is not happening or the lining is not thickening. Most of the time, your specialist will simply prescribe extra drugs and continue monitoring. If the problem is severe, your cycle may be cancelled and a new protocol put in place for next time.

4. It’s a natural cycle and ovulation is missed. Your cycle will be cancelled and you will be monitored more closely next time, or placed onto a medicated cycle for greater control.

5. Embryos do not survive the thaw. From personal experience, it is possible to thaw four embryos, one by one, in the twenty-four hours prior to transfer, and almost certainly more, depending on how quickly each succumbs. This is, of course, wrenching in its own way, but as long as there are embryos left, you will not need to worry about your cycle being cancelled.

If none of your embryos survive the thaw, it’s possible to start a full cycle straight away. For example, if you usually start sniffing or around day 21 or so of the cycle prior to EPU, you can start your drugs within a week of your cancelled transfer day.

6. Unusual spotting in the middle of your cyle. If it’s happening in your luteal phase, your specialist may prescribe extra drugs to support the lining. If it happens prior to transfer, your cycle may be cancelled pending investigation – depending on the opinion of your specialist. Unusual spotting is very common, not always explanable or treatable, and can happen even in successful cycles. Having said that, please report it to your doctor immediately.

Personal Tips

A frozen embryo transfer is easier, physically and emotionally, than a full cycle. As you can see, problems do sometimes arise, but most people find things go fairly smoothly until beta day – so please try not to let the above list panic you! There is often some trial and error involved in finding the best protocol for your body. Good luck – and yes, FETs do work for many people!

Questions When Choosing a Reproductive Endocrinologist (RE)
by Cara

The best type of patient is a prepared patient! I was both excited and anxious for my first appointment with my RE. I find I function best when I know what to expect and I stay calm if I am organized. In order to help you through this potentially nerve-wracking first experience, I have prepared a list of tips, questions and expectations for your first appointment with your RE. If you are not satisfied with the answers from the first RE and clinic that you visit, I urge you to keep looking for one that is a better fit.

Tips for your first appointment:

• Bring your list of questions with you
• If possible, have someone accompany you to the appointment–2 sets of ears are better than one
• Take notes during the consultation
• Bring relevant medical records: surgeries, recent pap test, list of medications
• Bring copies of any fertility work up you or your partner have had completed with the OB
• Bring list of concerns/observations about your cycle. If you have a month or two before your first appointment, try charting your basal body temperature
• Do not leave your appointment until all your questions are answered to your satisfaction!

Questions, Questions and more Questions!

About the Clinic

• How long has this clinic been in business?
• What are your office hours?
• What procedures are performed on the weekend?
• Are the Clinic and Lab open 365 days a year?
• How much work should I expect to miss?
• Do you provide pre-natal care? If not when will I be released to an OB?

About Communication

• Who is the case manager?
• Who is available if I call with questions?
• Can I leave a message for my RE? Can I email my RE directly?
• How long will I wait to receive a return call/email?
• Is there a number for off-hours problems?

About the Reproductive Endocrinologist (RE)

• Where did you earn you degree?
• What is your training in infertility? Are you board certified as a reproductive endocrinologist?
• What hospital are you affiliated with?
• Will I always get to see you?
• If not, how many REs are part of the group?
• Will I always see the same nurse?
• Will all my treatment and procedures be performed by you?
• How often will I get to meet with you face to face?
• How open are you to discussing information that I have learned about from other sources?
• Do you recommend counseling?
• Do you have a counselor on staff? If not, can you refer me to one?
• What books do you recommend reading?
• What is your view on alternative treatments (acupuncture, TCM, vitamins)?

About Initial Evaluation

• What tests do you perform to evaluate me/us?
• How long will it take to diagnose my/our problem?
• What specific tests would you recommend to diagnose my infertility?
• How long will you wait from the time of diagnosis to starting treatment?
• What do you see as our first step in treatment?
• If that fails to produce a positive, where do you see us moving next?

About Treatment and Procedures

• Will my treatment be individualized or will you follow set protocols?
• What procedures do you perform at your clinic?
• Which do you perform on-site? Which in a hospital?
• How will you proceed if we have unexplained infertility?
• Do you monitor while on Clomid?
• What kind of monitoring should I expect for other types of medicated cycles?
• During a treatment cycle, how often will I have to come into the clinic?
• What are your office hours for different procedures (ie: Blood tests, ultrasounds)
• If we go to IUI or IVF, can I bring in sperm sample or does it have to be produced in the clinic?
• How long do you stick with a particular treatment before moving forward?

About the Lab

• Do you have a Donor Egg and Donor Sperm programme?
• Do you do Blastocyst transfers?
• Do you do Assisted Hatching?
• Do you do Intracytoplasmic Sperm Injections (ICSI)?
• Do you do Pre-implantation Genetic Diagnosis (PGD)?
• How long do blood tests and other results take to receive? What is the procedure for getting the results?

About Expenses

• Do you have a price list? Can you run through it with me?
• Do your fees include the medications? Injection Instruction?
• Is it possible to set up payment plans?
• Will my insurance pay for the testing and/or treatments?
• Will your clinic help me determine what my insurance will cover?

About Success

• May I contact any of your patients who have had similar treatments?
• What are your statistics for couples with our diagnosis?
• What are your live birth statistics for different procedures?
• How do your statistics stack up against national averages?
• What would account for these differences?

What you might expect from your first RE appointment:
You can expect your first appointment to last from an hour to two hours. You will meet with the RE and your primary care nurse. The RE will ask you about your medical history as well as your sexual history. Check your embarrassment at the door! The more honest you are with your doctor, the quicker he may be able to arrive at a diagnosis and treatment plan. Whenever I feel myself getting embarrassed about something, I think: no matter how weird/abnormal this seems to me, the doctor has certainly seen worse!

At your first appointment your RE will probably order blood tests to check for the following diseases: Rubella (female only), Chlamydia (female only), HIV antibody, Hepatitis B surface antigen, Hepatitis C antibody, RPR (syphilis).

Depending on where a woman is in her cycle, your RE may also take blood to check the following: Luteinizing Hormone (LH), Follicle Stimulating Hormone (FSH), Estradiol, Progesterone, Prolactin, Free T3, Free Thyroxine (T4), Total Testosterone, DHEAS, Androstenedione.

For women, the RE may also wish to perform a vaginal ultrasound to look for any abnormalities, measure ovarian volume and look at antral follicles. The RE will probably order a Hysterosalpingogram (HSG) to be done between days 7 and 10 of the next cycle.

Men may also do a semen analysis, even if they have done one or two before. Be prepared: abstain from sex 3-5 days before your appointment! If the man has had previous semen analyses with abnormal results, the RE may refer him to a urologist. The urologist will order blood work to look at hormone levels, and he may recommend a testicular ultrasound.

Postcoital Exam
by Melissa

Why would you be doing a postcoital exam?

It seems like doctors don’t use them very much anymore, but we had a postcoital exam to determine whether IUI was a good option or whether we should jump to IVF. A postcoital exam evaluates the cervical mucous and determines whether it is a good conductor for the sperm.

Thalia wrote in the comments (and I’ve added it here): There’s a reason why doctors don’t do these any more. The doctor I saw recently said, imagine a picture of a station after the train has just left. The postcoital test is like using that picture to estimate how many people got on the train. Enough said, in my opinion. If your doctor suggests one, ask why. If they insist, look for another doctor who has better kept up to speed with developments in fertility treatments [unless the test is being used to test the quality of the cervical mucous close to ovulation].

What to expect

Postcoital exams are conducted close to ovulation, when optimal cervical mucous is being produced. Simply put, the couple has sex (at home!) and comes to the clinic within a set period of time. A swab is inserted near the cervix to collect a sample of mucous. The mucous is analyzed and the couple is given a report on the quality of the cervical mucous. For the most part, the RE is looking to see how many sperm are still alive and moving in the mucous. And also the quality of the mucous (as well as quantity).

Problems that may arise and ways to troubleshoot

Except that you may not get to the RE’s office in time? There really aren’t many things that could go wrong with a postcoital exam. It’s a simple, painless test.

Personal tips

The worst part of the postcoital is that it’s embarrassing. In reality, all fertility tests and treatments are embarrassing, but this one is particularly blush-enducing since you just had sex prior to arriving at the RE’s office. Some women drink green tea daily from CD 1 until ovulation in order to produce larger quantities of cervical mucous. I’m not sure if this is even a proven result of drinking green tea, but it can’t hurt to down a cup or two a day in the days leading up to the test.

Diagnosis: Infertility Caused by PID Scar Tissue
By: Carolyn

What PID Scarring Means and Its Impact on Fertility

Many women who have suffered an attack of pelvic inflammatory disease (PID) also suffer from infertility caused by the infection. PID can be caused either by a sexually transmitted disease or bacterial vaginosis. An infection can cause scarring in the fallopian tubes or in the abdomen. Blocked fallopian tubes hinder an egg’s ability to travel into the uterus to be fertilized, and scarring in the abdomen can effectively cement the fallopian tubes in place (making it nearly impossible for them to “catch” an egg) and completely separate them from the ovaries.

PID is frequently misdiagnosed, especially if the patient does not test positive for a sexually transmitted disease. A bad attack causes severe stomach/abdominal pain and an infection that must be treated with antibiotics. If you suspect you have had PID, inform your OB/GYN or RE so they can complete further testing.

It’s important to note that any kind of abdominal infection or abdominal surgery can cause scarring that may lead to infertility. You should inform your physician if you have any cause to suspect that you may have scar tissue.

Diagnostic Process

Unfortunately, the only way to definitively diagnose infertility caused by PID scarring is through a laparoscopy. Your doctor may decide a lap is indicated if an HSG shows that your tubes are blocked, if you have a known history of PID or abdominal infection/surgery, or if an HSG shows that your uterus and/or tubes seem to be pulled into an awkward position. If scarring is found during a lap, your doctor will remove all that (s)he can.

Treatment Options

Since many women who suffer from infertility caused by PID scarring (or scar tissue in general) have blocked tubes, unblocking them is frequently the first step. This is typically done during a laparoscopy. The best treatment for scar tissue is to remove it, however, because the nature of scar tissue is to grow back, removal may only result in a short window (usually 6 months to 1 year) of fertility. Aggressive scar tissue can grow back even more quickly.

IUI may not be recommended for a woman who suffers from PID scarring if she has blocked fallopian tubes or tubes that cannot retrieve an egg once ovulation has occurred. In those cases, or in the case of a woman whose scar tissue has grown back aggressively after removal, IVF is the only option.

Personal Experience

I suffered from a bad attack of PID three years before my diagnosis. The initial infection was misdiagnosed by no fewer than three doctors, all of whom assumed that I had a burst ovarian cyst. My HSG was perfectly normal, though a later review of the films showed that one of my tubes was pulled in a suspicious direction. After 15 months of infertility, a new OB/GYN recommended an exploratory laparoscopy just to rule out any problems that could have been caused by the infection. Lo and behold, I had scar tissue everywhere. My fallopian tubes were thankfully clear, but my tubes and ovaries were completely cut off from one another, and my tubes were tied down by scar tissue.

Not every doctor thinks to perform a lap before labeling an infertile patient “unexplained.” I will forever be grateful that mine decided to take that step before we wasted time and money on IUIs that would not have worked. As grateful as I am to my doctor, however, I never would have found him if I hadn’t been determined to find a diagnosis for my infertility. In my case, getting aggressive was likely the only way for me to find a cause and to determine which treatment options were best for us.

Saline Sonohysterogram (SSH, saline sono, hysterosonogram, saline infusion sonogram)
by Kelly (she’s gaining on you, Carolyn! 🙂

Why would you be having a SSH?

This procedure is used to determine if there are any abnormalities (such as polyps or fibroids) of the uterine cavity that could interfere with pregnancy.

What you can expect

The physician will place a small catheter into the uterus and sterile saline will slowly be injected into the uterine cavity. This will slightly inflate the uterus so that most abnormalities (polyps or fibroids) can be visualized with ultrasound. After the procedure, the saline will slowly drain out of the uterus, so you will need to wear a pad to protect your clothing. You may experience some light spotting (bleeding) after the procedure also.

My personal tips/experiences

This procedure was worse for me than the HSG because my cervix is tilted. It was performed by the nurse who couldn’t seem to get the dye to go to the right place so they were never able to determine whether I had a polyp.

The worst part of this was that when I left I had the most horrible cramps that I have ever had – I think because she had injected so much dye (because she kept trying over and over again to no avail). I drove myself home from the appointment which was a big mistake – I would definitely suggest having someone come with you just in case yours goes anything like mine did. I almost had to pull over because the pain was making me nauseous (I only live about 10/15 minutes from my doctor’s office, but the ride felt like an eternity).

I came home from the appointment and lay down because my cramps were so bad. I think the best thing though is to walk around and let the saline drain out of you. Once it started to drain out, the cramps started to subside.

I would also suggest taking motrin or advil prior to going. They suggested this for the HSG for me but not for this procedure so I wasn’t prepared for the cramping.

Also, wearing a pad is a good idea because once the saline started to gush out (yes, mine did not slowly drain) I felt like I had peed myself (lovely picture, right?).

I did not have spotting immediately following the procedure but I did have it start a couple of days later. It was relatively heavy and lasted a good 4 days or so.

Honestly though, I think that this procedure goes pretty smoothly for the majority of women. Most women that I have heard from say that this procedure was much easier for them than the HSG so I definitely believe that experiences will vary greatly among people.