Trying to Conceive 03/26/03 -- Amos Grunebaum, MD -- 03/26/03

By Amos Grunebaum
WebMD Live Events Transcript

Are you trying to conceive? Amos Grunebaum, MD, joined us on March 26, 2003 to talk about conception concerns, discuss treatment options, and to answer questions from both fertile couples as well as couples dealing with infertility.

The opinions expressed herein are the guest's alone and have not been reviewed by a WebMD physician. If you have questions about your health, you should consult your personal physician. This event is meant for informational purposes only.

Grunebaum: Hello! Welcome to today's TTC chat.

Member: I have endometriosis. Six months prior to conceiving my first child I had a laparoscopy and had lesions removed from my uterus. During the surgery my doctor also checked my tubes, they were clear. My question is if I will have trouble conceiving again without another surgery? I weaned my daughter two and a half months ago and have been trying to conceive since. Also what would you say the average time is for a woman to start ovulating again after having stopped nursing? Thank you.

Grunebaum: Endometriosis can affect your fallopian tubes. When it affects the tubes it either closes the tubes or prevents normal movements. This prevents the sperm from joining the egg, or it prevents the fertilized egg from moving along the tube. At this point your choices are to either try or see if you can get pregnant, and then get examined when you have been unsuccessful for a while, or you can ask your doctor if there is still endometriosis present. The best test to find out about it is a laparoscopy.

Member: Can you explain what endometriosis is?

Grunebaum: Endometriosis is when the inside lining of the uterus, the endometrium, grows outside the uterus. It can grow abnormally on different places including the tubes, ovaries, uterus, or even the bowel. Endometriosis is a major cause of "tubal infertility" which is infertility due to fallopian tube problems.

Member: I am getting differing readings as to when I ovulate between my OPK and BBT. I have had a consistent BBT reading of 95.5 from CD 6 through CD1 1. On CD 12 I dropped to 97.2 and on CD 13 dropped again to 97.1. Then on CD 14 I zoomed up to 97.8 and have had that reading today, as well (CD 15). Based on that, I'd presume that I ovulated on CD 13. But my OPK had a positive read on CD 14 (indicating that I'd ovulate in 24 to 36 hours. Which would you presume is correct? Thanks.

Grunebaum: I cannot read temperatures without also looking at the chart. Charting your curve makes more sense and gives a better picture of what's going on. As you are now only on CD 15 it's likely too early to interpret your chart. Before you read too much into it, I suggest waiting another week or so before you try making sense of it.

Member: I want to know about folic acid, I looked for some the other day but couldn't find just folic acid is it in a multivitamin form? Also how does it help to take before pregnancy?

Grunebaum: Another word for folic acid is folate. It's a vitamin in the B-class. It's suggested to take 400-800 mcg of folic acid starting one to two months before conception to decrease the risk of fetal malformations. There is a more than 50% reduction of many fetal malformations if the mother takes folic acid during the first two to three months. Taking folic acid has no effect on your fertility.

Member: My cycle varies from each month. Some months it's 26 days and others it's 28 days. How do I calculate the best time of the month to try to conceive? Also is it possible to still have a cycle, but not ovulate?

Grunebaum: Cycles that vary less than 30 days are usually considered normal. The time between ovulation and the next period is usually 14 days or so. And with a 26-28-day cycle ovulation is expected between cycle days 12-14. Doing a fertility chart will help you significantly identify better what's going on. And making love daily (if his sperm count is fine) during the five to six days prior to ovulation and the day of ovulation is suggested when you are trying to conceive.

Member: Dr. Grunebaum, when exactly does implantation bleeding occur and how do you know it is implantation bleeding. Recently I wrote you describing how my menstrual flow has been changing and you mentioned two things, one being Asherman syndrome and I can't remember the other. Can this be confused with implantation bleeding?

Grunebaum: Implantation occurs on average seven to nine days after ovulation. Most pregnant women do not have implantation bleeding. And many women with bleeding at that time are likely not pregnant. So if you have spotting around that time you cannot be completely sure what it means. Women with Asherman syndrome (scarring inside the uterus) have usually a lighter menstrual bleeding flow or none at all. Asherman syndrome is not usually associated with spotting seven days after ovulation.

Member: Embarrassing question: We're in our second month of trying to conceive and I just started charting Sunday. How is it you check your cervix position? I'm a little confused on that.

Grunebaum: There are many ways to check your cervix. You usually do it by inserting a finger into the vagina until you feel a hard "end" of the vagina. Some women have difficulties doing it, and you may want to try different positions. Some women do it while squatting, others lying on their back with knees bent, and still others check the cervix lying on the side. Maybe some of today's visitors who check their cervixes can now send in their own way to do so.

Member: I have luck checking my cervix while sitting on the toilet and spreading my legs wider than usual. But the best way for me is to squat on the floor.

Grunebaum: Should also comment to make sure those checking their cervix have washed their hands.

Member: Why is it important to check your cervix position?

Grunebaum: The cervix is usually checked as part of fertility charting. It becomes soft as ovulation approves and then harder afterwards. In addition, at that time many women get a sample of cervical mucus to check for typical ovulation changes like egg-white cervical mucus (EWCM).

Member: Does it change if you get pregnant?

Grunebaum: No, there are no typical early pregnancy changes of the cervix. Only well after you miss your period and the pregnancy test is positive does it become softer.

Member: I felt my last IUI worked until one day I suddenly felt sad and blue (like I experienced a loss). Is there anything I can do to increase implantation or do you think it is a chromosome problem? One IUI lasted five weeks, a total of seven failed, one failed IVF.

Grunebaum: Chromosome problems are the number one reason for a miscarriage. nfortunately, the rate of successful pregnancies with IUI is less than 40% on average. With IVF you can significantly increase your chances of having a successful pregnancy.

Member: I am still nursing my 11-month-old baby. I'll be 37 this year, would I be able to conceive while still nursing?

Grunebaum: If you are ovulating, then you can get pregnant while nursing.

Member: I have been off the pill for two months, have not had a period and have not tested positive for ovulation. I have endometriosis. How long should I wait before I get concerned?

Grunebaum: It can take normally two to three months after the pill to start ovulating again and then eventually get your period. If you haven't ovulated three or more months after stopping the pill you may want to let your doctor know and find out if there is a reason for not ovulating.

Member: There is so much information on what I can do to increase my chances of conceiving but what about for my husband? Is there anything that he can do, too?

Grunebaum: You first should find out if he is fertile or not. His sperm count is your best information about his fertility. I usually suggest that every man get a spermanalysis when they start trying to concieve. About 50% of infertile couples have a "male" problem. And it's a good idea to know about it before you lose unnecessary time.

Member: Is sperm count always the best measure? We were told my husband's count was fine and went through four IUIs. When we moved on to IVF and strict morphology was performed, he had only 2% in the normally shaped range, putting him into the subfertile category. Had I known this, I would not have gone through four IUIs.

Grunebaum: Morphology is a major part of the spermanalysis. If you go to a reputable center they will always do the morphology as part of their analysis.

Member: My husband already has a child. Would we still need a SA on him, or would he still be fertile?

Grunebaum: If he made the child within the last months then it's likely that his sperm count hasn't changed that much.

Member: I finished four months of Lupron in January after having surgery for endometriosis. I'm still having the side affect hot flashes. I've had two light shows of bleeding but I don't think I have ovulated; no line appears on the kits. When should the side affects go away and when should I start ovulating again?

Grunebaum: Lupron is often given as a depo injection. That means it can be around for many months after you last received the injection. You should discuss with your doctor how much you received and how long this specific amount was expected to last.

Member: Does the amount of time you take birth control have anything to do with the amount of time it will take you to conceive? I was on Depo-Provera for two years and then switched to Ortho-Tricyclen for five more years. I have been trying to conceive for one year now.

Grunebaum: The pill is usually out of your system right away and it should normally not take longer than two to three months after you stop the pill for ovulation to return to normal. If you are now ovulating regularly, then your problems trying to conceive have nothing to do with the pill or the depo.

Member: I have completed three cycles of Clomid 100/IUI. Should I go for a fourth or move onto injectibles? Or should I talk to my RE about increasing the Clomid to 150? I have an elevated FSH (9.3) problem.

Grunebaum: Both options seem acceptable. Every RE has their own protocol on how much Clomid to give and how long to give it for. I defer to your RE in making that decision.

Member: I have had two miscarriages (September 2002, February 2003). I have shorter cycles, 24-25 days, and ovulate usually on day 11. Could this early ovulation be causing immature eggs, which make me miscarry?

Grunebaum: Ovulation on CD 11 is rarely a problem, unless you don't make love before CD 11. Many women who ovulate on CD 11 start making love late, only after CD 10. And making love too late or after ovulation rarely if ever gets you pregnant.

Member: Is it normal to have mild pains during ovulation?

Grunebaum: Many women describe mild pain shortly before and after ovulation. There is a German word for this called mittelschmerz, which translated means "pain in the middle."

Member: This month I had very strong ovulation pains on both sides, instead of just one side. Does this mean I possible ovulated more than one egg?

Grunebaum: It's possible to ovulate from both ovaries. If you look at twin incidence, about one in 100-150 pregnancies happen to be twins because of double ovulation.

Member: How good are chances with frozen embryos?

Grunebaum: There is no absolute number I can give you for this method. The chance depends on your indication, age, and other circumstances. In addition, every IVF center has its own statistics.

Member: During testing for recurrent miscarriages, we found an elevated DHEAS level. However, I show no other indications of PCOS. Could this be an issue in recurrent miscarriage, and what treatments are available? Thanks.

Grunebaum: There is a lot of controversy around an elevated DHEAS level. Many doctors do not think it's a major issue and don't know what to do with an abnormal result. A high DHEAS level usually means an increased male hormone level. But in and by itself without other findings it's unclear what it means.

Member: Last year in May I lost my baby while I was 30 weeks pregnant. Since then my periods are not normal, kind of prolonged one, and I was diagnosed with PCOS. I tried taking progesterone, and birth control pills but my bleeding did not stop. Please advise, thanks.

Grunebaum: I am so sorry to hear about your baby. What you are describing requires a thorough medical examination and testing to find out what's going on. If you are trying to get pregnant, then birth control pills are not necessarily the right treatment. You need medication to help you ovulate, and birth control pills will not help. I suggest you see an infertility specialist, a reproductive endocrinologist. They are usually best trained to help you find out what's going on and help you improve your chances getting pregnant.

Member: Does an RE stay with you through the pregnancy process and deliver babies or just help you get pregnant?

Grunebaum: An RE only helps you get pregnant. Most REs will then refer you to an ob-gyn for the pregnancy and delivery.

Moderator: If Dr. Grunebaum wasn't able to answer your question, try posting in his TTC message board, or join us again next time. You can also find dozens of archived Grunebaum chats in our Live Events archive, which can be found on our boards and chats page, Member Central.

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