Trying to Conceive 06/05/02: Amos Grunebaum, MD

By Amos Grunebaum
WebMD Live Events Transcript

The opinions expressed in this transcript are those of the health professional and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician.

Are you trying to conceive? Amos Grunebaum, MD, answers members' questions every week about conception issues and concerns of both fertile couples and couples dealing with infertility. The following discussion took place on June 5th, 2002.

Dr. Amos: Hello, everyone. Welcome to another pregnancy and TTC chat.

Member: With the jury still out on whether or not fertility drugs lead to an increased risk for cancer, I'm trying to decide whether to pursue more aggressive fertility treatment or give up. I'm 38, have possible endometriosis, one ectopic pregnancy (cervical -- had UAE as emergency procedure), ovulate on my own, and all tests were normal (including SA, HSG, saline, blood work) except endometrial biopsy (out of phase). I'm currently on a series of cycles with Clomid, HCG shots, IUIs, and progesterone suppositories. Is it time to move to IVF or quit altogether (too many contraindications)?

Dr. Amos: IVF is usually an optimal solution getting pregnant fast. With endometriosis and already one ectopic pregnancy, your chances of getting pregnant on your own are very low. IVF provides you with a perfect alternative and much higher success rate.

Member: I had a son about seven years ago, and after that the doctors told me that I had some kind of tumors and they froze them out. Now I'm married for the second time and we are TTC, unsuccessfully. We have had sperm counts done and the doctors say that my husband is fine. I have had many tests and the doctors say they don't know why I'm not getting pregnant. About a year ago, I had a cyst and had it removed. And now in the same place I have gotten four cysts. The doctors say that it has nothing to do with me conceiving. It has made me afraid for my life, thinking that something very serious could be wrong with me. Is there possibly something that we could do to get pregnant?

Dr. Amos: I usually suggest seeing an infertility specialist -- a reproductive endocrinologist -- when you have come to a point where you need more help. From the information you have given, it's difficult to know what's going on. While you mention that his sperm count is OK, you failed to mention if you ovulate regularly and if your fallopian tubes are open. These are usually tests done right away to find the cause of your problems getting pregnant. There are three major questions that should be answered:

1. Is his sperm count OK?
2. Are you ovulating regularly?
3. Are your fallopian tubes open?

It's very helpful to answer these three questions right away. And once you have done the appropriate tests to answer these questions, you know immediately where else to look and how to improve your chances of getting pregnant right away.

Member: My fiancé and I are trying to conceive. We are trying to decide the best time of the month to do so. I have tried calculating the best time with an ovulation calendar. Do you have any other tips?

Dr. Amos: Timing of sex is the No. 1 question on my boards, and I usually give the same answer: If you try timing sex exclusively on when you think you may ovulate, you probably decrease your chances of getting pregnant. This is because studies have shown again and again that ovulation can happen any time during the menstrual cycle, even when women have regular periods. The best time to get pregnant is if you make love the day of ovulation and the four to five days before. And because you rarely know exactly when ovulation will occur, it's suggested to make love regularly, two to three times a week, every week. Studies have shown also that couples that make love several times a week during every week of the cycle have a higher chance of getting pregnant.

Member: After several years of trying to conceive, I surprisingly got pregnant and had a baby this past February. I never considered infertility treatments. Now I'm wondering what my chances might be for lucking out with a second child. My age is 38 and my ob-gyn suggested I start trying to conceive in August. One issue for me is that I suffered from PPD and wanted to wait longer, but yet the clock is ticking for me. Your advice?

Dr. Amos: I agree with your doctor. If you are physically and emotionally ready to have another baby, go ahead. Losing time at your age will only decrease your pregnancy chances. At you age, there is an about 3% increase of infertility for every year that you wait.

Member: If I want to wait a few years for another, should I consider freezing my eggs?

Dr. Amos: That is an option that you should discuss with your doctor. If you freeze your eggs, you need IVF to get pregnant and that's something to consider. Good luck.

Member: Can low progesterone levels cause your post ovulation temperatures to stay low -- say, just above your coverline?

Dr. Amos: That's possible. I suggest you have your doctor check your chart to see if you ovulate in the first place. Most charts I have seen with temperatures at coverline actually do not show ovulation. In addition, you may want to get your progesterone levels checked about a week after ovulation. Those levels will provide you with much more specific information on the actual levels.

Member: I have the same problem. My temperature never goes up. It always stays low.

Dr. Amos: If it doesn't go up, then you may not ovulate at all. One would have to actually look at the chart to assess what's going on. Most, if not all, women who ovulate will have temperatures stay up at least about 0.2 degrees after ovulation.

Member: I assume that if you have your period every month that you are ovulating regularly. Am I correct in this assumption?

Dr. Amos: You are correct in assuming that if you have regular menstrual cycles then ovulation is highly likely.

Member: Do you need a special thermometer to start charting or will any one work?

Dr. Amos: A basic mercury thermometer that can distinguish one-tenth of a degree works very well. There are some fancy BBT thermometers out there, if you have some money to spare. And then there are digital thermometers, but mercury ones work well, too.

Member: I use OPKs and when I get a positive I don't see a shift in temperatures until about three days later. Does this have anything to do with progesterone?

Dr. Amos: What you are describing is totally normal. Ovulation usually happens within one to two days after the OPK first becomes positive. And your temperature usually goes up one to two days after ovulation. So that would be two to four days after the OPK first becomes positive.

Member: My husband has had a second vasectomy reversal (first failed due to scarring) and we're having trouble supplying a specimen. How can we improve his fertility, and how can we obtain a specimen for testing? There's not a problem with his normal emission, when we're making love. I think the cup intimidates. Since I'm 37, time is of the essence for us.

Dr. Amos: Practice, practice, practice. There is unfortunately no better way to obtain the specimen than masturbation. I don't completely understand the problem. But sometimes you could use a condom during intercourse to get the ejaculate. Just make sure it does not have any spermicides inside the condom that could destroy his sperm.

Member: I underwent infertility treatment once for about three years, conceived twice, and lost them both -- one at five months and the other at six months, at age 37. Now I am 41 with no health problems and with a regular cycle but sometimes I skip cycles. I am married again to a guy closer to my age with no children but we have decided to have a child. Do I have to undergo infertility treatment again?

Dr. Amos: Before you even consider treatment, you should go (no, run!) to see an infertility specialist. They can do some tests and evaluate your present condition. Not knowing exactly what infertility treatment you had makes it difficult to provide a more proper answer. But seeing the RE right away allows you to not lose precious time.

Member: I had my right ovary and both tubes removed about six years ago. I was told that I couldn't get pregnant naturally, but I think I'm pregnant now. I need to know what the possibilities are. I still have my monthly cycle, so that means I'm still producing eggs. Can by some miracle I still get pregnant?

Dr. Amos: If your pregnancy test is positive despite having no tubes, you should see your doctor right away and let her know about the pregnancy. It's very important that she knows about it, because getting pregnant without tubes can be very dangerous and increase the risk of complication such as an ectopic pregnancy.

Member: What is an ectopic pregnancy?

Dr. Amos: An ectopic pregnancy is when the pregnancy implants outside the uterus. That's usually in the fallopian tube.

Member: I had a chemical pregnancy last month, so my doctor prescribed a fifth month of Clomid, IUI, and then Prometrium. I've read that a baby aspirin may be beneficial. Please explain how it works and if it is safe.

Dr. Amos: We don't know for sure if and how baby aspirin works. The theory is that it improves the implantation of the fertilized egg and also improves blood flow through the uterus. But there are no clear studies on this issues, and opinions whether to give baby aspirin or not with specific abnormal tests are different.

Member: Why baby aspirin, and not regular?

Dr. Amos: Baby Aspirin has about one-quarter the strength of regular aspirin. It's thought to be as effective but with fewer side effects.

Member: My husband and I have been TTC for three and half years, with no success. In the last two months, I have been to see two different ob-gyns for help. Both times I was turned away from fertility treatment because I was too young to need treatment (I am in my early 20s) and told it would happen on it's own, despite the fact that my BBT charts clearly show no ovulation most months (two out of the last three have been anovulatory, with no temperature rise at all). I have since made another appointment, with a different doctor, but am afraid I'm wasting my time. Is it normal practice to not treat women in their early 20s for infertility? What (besides my charts) should I bring to the appointment? Thanks for any advice.

Dr. Amos: You are correct. It's a shame you were turned away. If you want to get pregnant and you can't because you don't ovulate, then you should get treatment right away, whether you are 20 or 40. Without finding the cause of the anovulation, your chances of getting pregnant are slim if you don't ovulate.

Member: What is the normal course of treatment for Asherman's Syndrome?

Dr. Amos: There is no uniform opinion on how to treat Asherman's Syndrome. It's scar tissue inside the uterus. Many doctors will probably do a surgery by hysteroscope to cut out the scar tissue and right after surgery maybe put in a small catheter to prevent scar tissue from growing back again.

Member: Do you recommend staying on metformin through the first trimester?

Dr. Amos: There are no good studies showing that continuing metformin will improve pregnancy outcome. Many doctors probably recommend stopping it once you find out that you are pregnant.

Member: I'm currently on CD 34. I'm 16 and 19 DP IUI. I had a negative beta on CD 32. I took Clomid plus Profasi this cycle. I am currently taking progesterone supplements since CD 20. My beta was under 5 and my progesterone was under 6. I don't understand. My chart has been doing wonderful -- all above cover. What do you think my chances are?

Dr. Amos: There is one important word missing in your post. It's ovulation. Did you or didn't you? If you get treated to induce ovulation you must find out whether the treatment worked or not.

Member: I had four follicles on first IUI, and two on the second.

Dr. Amos: Four follicles doesn't mean you ovulated. Next time you should try finding out whether you ovulated or not. Not knowing the answer makes the treatment less effective.

Member: My chart indicated I did. Ultrasound as well.

Dr. Amos: If ovulation was longer than 14 days ago without a period, chances are usually that you are pregnant and the hCG should be positive. The only answer with a negative hCG is that you likely did not ovulate.

Member: I am trying to decide between moving on to IUI or IVF. I am 38, TTC for nine months, and the only identified problem is that my right tube is blocked. Since I only have one open tube, wouldn't IVF be my best chance?

Dr. Amos: IVF has a higher chance of getting you pregnant than IUI. That doesn't mean you have to go to IVF right away. Some doctors suggest to try IUI for several cycles and see whether you can get pregnant with IUI before moving on to IVF.

Member: Would tubal surgery followed by IUI be worth a shot? I'm concerned about losing time at my age.

Dr. Amos: Many doctors do not suggest tubal surgery to open up the tubes anymore. They feel it's major surgery, and much less successful than IVF.

Member: Wouldn't I need both tubes open for IUI to be successful?

Dr. Amos: One open tube is often enough to get pregnant.

Member: I've had two IVF cycles with ICSI. Got pregnant in the second cycle but ultrasound at 10 weeks showed no heartbeat. Should I have any other testing and how long should we wait before trying again?

Dr. Amos: Many doctors suggest a two to three month wait after a miscarriage before attempting IVF again, though there are no studies showing problems if you start trying earlier. Good luck.

Member: Would you suggest I chart before I go to the doctor to talk about possible infertility? I have been trying 10 months.

Dr. Amos: That all depends what your reasons are. Charting always helps you figure out much better what's going on with your fertility. Coming to the doctor with several months of charts will save you a lot of time explaining your ovulation pattern. And because ovulation problems are the No. 1 problem in women with difficulty getting pregnant, you are already several steps ahead. In addition, charting helps identify timing of intercourse. In about 20% of couples with difficulty getting pregnant there is a problem with timing. Either not enough or at the wrong time. I strongly suggest that all women chart their fertility signs to make sure they learn enough about their bodies and to improve their chances of getting pregnant.

Member: Is there a special chart that should be used for BBT or do you just make one up yourself?

Dr. Amos: There are several websites out there which allow you to save your chart on the web and which are very helpful evaluating the day of ovulation and other fertility signs.

Member: Is charting better than the kits?

Dr. Amos: They are different. Charting gives you a much, much clearer picture of your fertility. You can still use the LH kits in addition to charting. Most electronic charts allow you to enter the LH information so that you can easily correlate temps with LH surge.

Moderator: We have to wrap up for today. Thanks for joining us. If Dr. Amos wasn't able to answer your question, check our live event calendar for his next TTC chat, or try posting in his TTC message board . Bye for now!

Dr. Amos: Thank you very much for visiting today.



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