“Social Egg Freezing: Why is it trending?”
TRIO’s Answer Featuring: Dr. Dan Nayot
Google and Apple’s decision to include social egg freezing as part of their employee benefit package has thrown the spotlight onto the evolving practice of fertility preservation. Before the corporate world inserted itself into the fertility equation, women who pursued egg freezing in hope of securing their future fertility were already sparking a debate. Whether you advocate for reproductive ‘insurance’ or believe that the practice of social egg freezing is simply playing into a fear-mongering industry, you will still need to be informed on why social egg freezing (or oocyte cryopreservation) is now a mainstream cocktail conversation. For the pros and cons of egg freezing please see “Pros and Cons of Social Egg Freezing”, but this post will focus on why social egg freezing is a real viable option for women in 2015.
Egg Freezing: Then and Now
Just as takeoff and landing are the biggest threats on board an aircraft, the act of freezing and then thawing an egg are the most dangerous parts of the process. The potential for sharp ice crystals to form inside the egg is a real concern and potentially lethal to a fragile egg. As well the freezing, process may harden / thicken the shell of the egg (known as the zona pellucida), making it more difficult for sperm to penetrate and thus fertilization becomes tougher.
Early egg freezing techniques (not that long ago) basically froze the egg in a slow and steady process, putting the egg through a lot of stress (ice crystals; shell hardening, etc). There have been major advancements, including a rapid freezing technique (vitrification) that minimizes the exposure of the egg to the dangerous ice crystal formation temperature zone. As well, the availability of injecting a single sperm directly into the egg (ICSI) after thawing has improved outcomes.
Thanks to research, current egg freezing technology is seeing over 90% of eggs survive and pregnancy rates from frozen eggs are similar to those of fresh eggs. As a result, all three major fertility societies (CFAS, ASRM, and ESHRE) have removed the “experimental” label from egg freezing. Mind you, “not experimental” is not equivalent to a full on endorsement, as there remains many aspects to be addressed. The key, as always, is to match the right patient with the right procedure. In 2015 egg freezing is a valuable tool with impressive results, which is why its already part of mainstream media.
“I’m on the birth control pill and have regular cycles. I should have no fertility issues when I come off the pill… right?”
TRIO’s Answer by: Dr. Dan Nayot
You can’t completely judge a book by its cover, but it does provide important insight to its content. In medicine, many external signs and symptoms (eg. a global rash of itchy red spots) are an expression of an underlying issue (eg. chicken pox). In the same manner, the menstrual cycle (a complex and highly regulated hormonal orchestra designed for reproduction) provides a lot of information about a woman’s endocrine system. Even non-gynecologists are well aware that any significant irregularities in the menstrual cycle signals a deviation from the norm and must be further investigated. Of course here are some extreme examples to highlight this point…
- A 16 year old girl who has never had a menstrual period (primary amenorrhea) may have been born without a uterus (MRKH syndrome) or may even be genetically a male (46XY).
- A 22 year old woman who hasn’t had a menstrual period in several months (secondary amenorrhea) may be pregnant or have a hormonal imbalance (eg hypothyroidism).
- A 44 year old woman with constant vaginal bleeding (metromenorrhagia) may have a uterine polyp or she may be transitioning into menopause.
The point is that a detailed analysis of your menstrual cycle can be very informative about your general health. However there is a substantial proportion of reproductive-aged women that are taking some form of hormonal contraception to regulate their menstrual cycles. Regardless of the form of hormone (eg pill, patch, ring, IUD, etc) it has an impact on your endometrial lining (eg. you can bring on your menses whenever you choose). So while having a “regular” (usually meaning every month as you would naturally expect) menstrual cycle while on hormonal contraception suggests that the external hormones are working as they should, it is masking your internal hormones.
Please be clear that this is not a knock against hormonal contraception, but just a disclosure that having a regular menstrual cycle while on external hormones is falsely reassuring – it may mask the true irregular cycles that would have be present if no medications were taken.
In a fertility practice it is common to see patients who have stopped taking the birth control pill and then experiencing infrequent menstrual cycles. Although the patients are initially surprised by their new irregular cycle pattern, the majority of time the same pattern was present prior to starting the pill (and actually was the main reason for starting the pill in the first place), it has just been unmasked once again.
One major concern that fertility doctors have is that hormonal contraception can also mask a declining ovarian reserve, and thus delay or miss the diagnosis. For example a woman in her early 40s may have already transitioned into menopause (generally diagnosed with the absence of cycles and symptoms of low estrogen such as hot flushes) but would never be aware since hormonal contraception would ensure she continues to have regular cycles with a normal estrogen level. A woman can even go through premature ovarian failure (defined as menopause prior to age 40) and she would never know until she stops taking her hormonal medications at a later date!
Whether women should occasionally stop their hormonal contraception to assess their natural cycles is a more complicated question, since it would put them at a higher risk of unwanted pregnancies and a flare up of the underlying condition they were treating with the hormones initially.
However it is perhaps wise to intermittently check one’s ovarian reserve, for example with an AMH blood test (See: AMH: Is It Really An Ovarian Fuel Tank Gauge?) that can be done even while on hormonal contraception (but must be interpreted appropriately). Next time you’re scheduled for a general well-being check up, make sure your reproductive health is on the checklist – don’t be misled by your fine-tuned regular menstrual cycles.
“Heard about Augment on NPR News. Would like to know more about it i.e. what is the criteria for going on the treatment. Thanks”
TRIO’s Answer Featuring: Dr. Dan Nayot
Augment has been getting A LOT of media attention…and for good reason.First TCART, and now TRIO has been involved from the very early stages in both the research and clinical aspect of this exciting new technology from Ovascience (based in Boston). In fact, we are currently the only clinic in North America to offer Augment to our patients. First some fertility basics to help you understand what makes Augment so innovative:
- Fertility and Female Age: It is well known that both egg quality and quantity decreases as women get older. Not only is getting pregnant more difficult, but also staying pregnant (the miscarriage rate increases as well). The main reason for this age-related decline in fertility is because the embryos have an abnormal number of chromosomes (aneuploidy). A healthy growing embryo has many cells that are quickly dividing, and each time a cell divides the chromosomes have to duplicate and divide perfectly. As you can imagine, this take a lot of energy for the process to be completed flawlessly.
- Mitochondria and Egg Health: Mitochondria are little organelles that are inside every cell in your body, and are the “powerhouse”, providing the energy…or as we like to say “the battery in the flashlight”. It is believed that older eggs may not have sufficient energy to divide properly (and produce 2 sets of balanced chromosomes with each division). Therefore if we can increase the energy in each egg, then perhaps we can improve its quality and ability to result in a pregnancy.
- Source of Mitochondria: The Ovascience team have found a method to isolate healthy mitochondria from egg precursor cells found in the covering of the ovary. So at the time of ICSI (sperm injection into the egg), the isolated healthy mitochondria can also be injected into each egg. The egg precursor cells are found along the cortex or surface of the ovary, so an ovarian biopsy (obtained by a minor surgical procedure called laparoscopy) must be performed before starting an IVF/ICSI cycle.
For more information about the procedure please contact Tina Giachetta at TRIOtinag@triofertility.com
Since Augment is designed to improve the egg quality, it may be potentially beneficial for all IVF/ICSI candidates, but currently there is no clinical data to support its use for all patients. The TRIO Fertility experience with Augment has been in patients that have previously failed one or more IVF/ICSI cycles or had a poor embryo development. Of course there are several other clinical variables, such as your ovarian reserve and age, that we must take into account before deciding if Augment is the right procedure for you. If you think you may be a candidate for this procedure, speak to your doctor for further details.
“We have been trying to conceive for the last 2 years and now we’ve been advised to use some fertility medications. Truthfully I’m hesitant to use these medications – I’m afraid they may lead to some form of cancer in my 50s or later on. What do you think?”
TRIO’s Answer Featuring: Dr. Anat Klement
This question is frequently asked by our patients… and we suspect even more patients are too afraid to ask and are hesitant to repeat a treatment cycle, fearing that the fertility medications might be a factor in their future risk for cancer.
Since breast cancer and gynaecological cancers (eg. uterus / endometrium) are reported to be correlated to the female’s hormonal levels (most commonly her estrogen exposure level), the medical research community has repeatedly tested this question – do fertility medications, which we know increases estrogen levels, increase the risk of breast and gynaecological cancers?
Fertility treatments have become so common and spread around the world that additional studies addressing this troubling question are published each year. So far no convincing evidence has been reported to support a causative connection between fertility medications and these malignancies. Certain patient populations are considered at high risk for developing these cancers (eg. BRCA carriers = Breast Cancer) and for these specific groups this possible association is not yet finalized…
The reassuring information regarding the lack of causative role of fertility treatments and cancer arises from multiple epidemiological papers. Even when you combine all the data (meta- analysis) there does not seem to be an increased risk of cancer.
Currently, the only concern arises from a possible increased risk for borderline ovarian tumours in sub-fertile women treated with IVF and from patients that were repeatedly exposed to multiple cycles of clomiphene citrate (Clomid) and have not conceived. The association between female sex steroids (e.g., estrogen levels) and the risk of melanoma (skin cancer) have also been suggested, but a recent large-scale study provided reassuring data against this association.
We must emphasize that even breast cancer survivors are not necessarily advised against fertility treatments as long as the required cancer treatment has been completed and a sufficient follow up indicates a disease free condition. In fact, we recommend fertility preservation (e.g., egg or embryo freezing) to breast cancer patients at the time of diagnosis, since this will not affect the disease course and will enable them to complete their treatment knowing their gametes or embryos are preserved for future parenthood.
“Which method is used for oocyte cryopreservation?”
TRIO’s Answer Featuring: Dr. Paul Chang
For oocyte cryopreservation, TRIO uses ‘vitrification’.
Vitrification is defined as rapidly cooling of a solution by transforming it into a mirror-like state without crystal formation.
You are made of 50-60% water: your oocytes are also made of water. In the past, the method used to cryopreserve oocytes was ‘slow freezing’ which caused water crystals to form. Crystals are sharp and can damage the delicate oocytes, negatively impacting on their thaw-survival. With vitrification, not only can we cryopreserve oocytes safely but also embryos and other human tissues.
“Read about augment and wonder if you offer this and do you have an age restriction?”
TRIO’s Answer Featuring: Dr. Dan Nayot
TRIO is proud to offer Augment to its patients. Actually, not just to our patients…since we are the only clinic in North America offering Augment we are providing care for patients all across Canada and the US. For details about how the Augment procedure works, please visit: http://www.tcartonline.com/augment and have a quick read of the previous post. We know that older women develop more abnormal embryos (aneuploidy) since the chromosomes do not separate properly at each cell division. Many suggest that the reason for this is that older eggs have less energy to allow for this energy-dependent process of cellular division (you can only imagine how many times a 2 cell embryo has to divide in order to develop into a full pregnancy). So ideally ,Augment should be most beneficial to older women… but you must consider the following:
- Egg quantity – As women age, not only does egg quality decrease, but so does egg quantity. Therefore older women have fewer eggs to perform the Augment procedure on. This is a very important clinical variable that you must consider before embarking on this innovative technology. Too few eggs may substantially decrease the chance of success.
- Clinical Data – As of now the TRIO clinical experience with Augment has only been on women under the age of 40. Although the results have been impressive, it would be unfair (and inaccurate) to extrapolate this data to older women. We currently have numerous patients older than 40 in the process of undergoing Augment at TRIO… stay tuned to find out their outcomes (of course this will be anonymous).
So back to the question – Is there an age restriction to enroll in the Augment procedure? At TRIO Fertility, there is no strict age cut off, but age is a very important variable. We must also consider your ovarian reserve and the anticipated number of eggs that will be retrieved. Of course the details of your previous IVF cycles is vital as well. Remember, success is in the details…
“Just wondered how the results were with the two women's studies—one with placebo and other with cq10. I am considering trying it and read your study. Any info would be appreciated. Thank you.”
TCART’s Answer Featuring: Dr. Bob Casper
In our CoQ10 study we compared the effects of pre-treatment with CoQ10 versus placebo for two months prior and during an IVF treatment on its outcome. Despite our best efforts we were not able to meet the required number of participants. The analysis done with about half of the target number had shown an improvement in the number of chromosomally normal oocytes and an improved pregnancy rate. This findings did not reach statistical significance, likely because of the sample size and possibly due to the short duration of treatment.
“I am starting an IVF treatment and was offered to freeze all the embryos and transfer them later. I am a little concerned about my chances to get pregnant with frozen embryos and wanted to ask about your opinion.”
TRIO’s Answer Featuring: Dr. Anat Klement
Many patients share with us their concern about freezing embryos; fearing that the process of thawing might damage the embryo or if the embryo survives it might possibly reduce the chances for a successful implantation. In recent years two reassuring factors have been introduced to improve the frozen embryo transfer success rates… so much so that in some clinics, based on their local statistics, patients are recommended to withhold a fresh transfer and instead to aim for a frozen transfer from the very beginning of the cycle (the ‘freeze all’ attitude).
- The first significant factor is the freezing technique. As opposed to the ‘old’ slow freezing technique that was practiced for many years, we are now using a flash freezing method known as ‘vitrification’. Many studies have supported higher survival rates of embryos with vitrification and the method has actually revolutionized our ability to freeze and thaw unfertilized eggs, which was somewhat limited before this method’s introduction. Most labs are so confident with vitrification that they easily freeze and thaw embryos more than once without compromising the survival and the pregnancy rates.
- The second factor is the knowledge gained that the matching of the embryo and the uterine lining is potentially more in sync when a ‘frozen’ transfer is implemented. In other words, the hyper-stimulation environment of the IVF cycle (fresh cycle), which involves extremely high levels of estrogen (produced by the numerous growling follicles in the ovary), might interfere with the synchronization between the uterus and the embryo that is transferred.
For both these reasons I think you can be reassured that the frozen embryo transfer will not reduce your chances to get pregnant, and may even be beneficial. Furthermore, having a frozen transfer can sometimes even protect the patient from an adverse outcome of reproductive treatments called OHSS (ovarian hyperstimulation syndrome). Of course it is important to discuss fresh vs. frozen embryo transfer with your medical team to personalize your care, and the decision can be reviewed once more at the time of your egg retrieval.
“I’ve done several IVF cycles, with one successful pregnancy. I’m pretty sure my issue is egg quality. I’m interested in the Augment treatments, but am curious if this becomes more expensive than a typical IVF cycle, or if the typical drug protocol would be any different.”
TRIO’s Answer Featuring: Dr. Dan Nayot
Augment is a new technology that is aimed at improving egg health and therefore embryo development. Here is a quick general summary on what makes Augment an exciting and innovative breakthrough.
- Cell division is critical for embryo development. After fertilization (egg + sperm = zygote), a 2-cell embryo quickly divides and reaches several hundred cells at the time of implantation.
- When a cell divides it requires a lot of energy to duplicate the chromosomes and then allow them to separate perfectly. Any error during this process can cause chromosomal abnormalities and lead to an unhealthy embryo that won’t implant.
- The main energy source for cell division comes from the mitochondria.
Therefore, perhaps if we can increase the energy source (mitchondria) in the eggs, then we can allow for better cell division and less chromosomal abnormalities in the developing embryo.
So how do we increase the energy source in the eggs? This is where the breakthrough technology comes into play. The OvaScience team (based in Boston, MA with some of the research done here at TCART, now TRIO) have discovered that there are many egg precursor cells in the cortex (outside layer) of the ovary, and more importantly that they are filled with healthy mitochondria.
So, by performing an ovarian biopsy (prior to starting an IVF cycle), we are able to isolate the mitochondria from the egg precursor cells. Then, at the time of ICSI (sperm injection) we also inject the extra mitochondria into the mature egg with the hopes that the extra energy will allow a healthy embryo to develop.
“Do you offer Natural Cycle or mini-IVF?”
TRIOs Answer Featuring: Dr. Dan Nayot
Yes, TRIO offers both natural cycle IVF and “mini” IVF. However, prior to initiating any type of IVF protocol, it’s important that you discuss it with your physician, because it’s critical that you pair the right protocol with the right clinical scenario.
In a typical IVF cycle, the ovaries are stimulated (with gonadotropin injections) to allow a large number of follicles to grow. Once the follicles have reached a certain size, they are drained in order to retrieve the eggs from within. The general idea is that by stimulating more follicles, more eggs can be retrieved, and the more likely a healthy egg (that will lead to a pregnancy) will be among them.
In mini IVF, less stimulation medications are used, so you can anticipate less follicles to grow and less eggs to be retrieved.
In natural cycle IVF, no stimulation medications are used at all and therefore only a single large follicle (which grows every month in women who have regular cycles) will be drained usually resulting in a single egg.
Although a traditional IVF cycle is generally the most effective treatment for the majority of patients, it does have some drawbacks.
- Clinical Data – As of now the TRIO clinical experience with Augment has only been on women under the age of 40. Although the results have been impressive, it would be unfair (and inaccurate) to extrapolate this data to older women. We currently have numerous patients older than 40 in the process of undergoing Augment at TRIO stay tuned to find out their outcomes (of course this will be anonymous).
- There is an inherent cost to the medications used for stimulation, and depending on the dose and duration required, this expense may accumulate quickly. So, in terms of cost natural cycle or mini IVF are considerably cheaper than traditional IVF.
*However, just because a cycle is cheaper, doesn’t mean it’s more cost-effective. For example, if you require several cycles of natural IVF to reach the same success rate as traditional IVF, it may be more expensive in the long run.
- There is some research suggesting that too much ovarian stimulation can negatively impact the quality of the eggs. So although traditional IVF maximizes the quantity of eggs, it may slightly impact the quality. Perhaps decreasing the stimulation (mini IVF) will optimize the quantity and quality equilibrium?
“I find the trans-vaginal ultrasound to be extremely inconvenient. Is it possible to ask for an abdominal ultrasound, especially now that I am doing cycle monitoring and have to perform the tests repeatedly? “
TRIO’s Answer Featuring: Dr. Anat Klement
Trans-vaginal ultrasound is the most common mode of ultrasound monitoring during fertility treatment cycles. The different qualities of the trans-vaginal probe as compared to the abdominal probe (and also its closer proximity to the pelvic organs) enable us to get excellent imaging of the cervix, the uterus and the ovaries. Trans-abdominal ultrasound can provide with relatively good pelvic imaging, but the image quality is more affected from the abdominal wall (muscles) and therefore commonly requires a full bladder in order to provide a satisfactory study. The fact that nospecific preparations are required for trans-vaginal ultrasound (actually its even easier to see with an empty bladder – much more comfortable for the patient), as well as the high quality images provided, make it the favourable diagnostic tool in reproductive studies.
We do use the abdominal approach to better define the general anatomy of the pelvis, especially when it’s your first study (for example to measure the length of the uterus and to determine what position it lies in), and in special cases of an unusual pelvic anatomy (for example if you’ve had previous surgeries). We also use the abdominal ultrasound to help us perform several procedures such as egg retrieval and embryo transfers.
If you find the vaginal ultrasounds to be extremely uncomfortable then an abdominal scan can be considered; this of course involves a full bladder prior to the test to provide us with good images. If the monitoring was already started through vaginal probe then it is probably better to carry on with the same modality – this way it is easier to compare the tests and identify a trend.
Thank you for the question. You have brought up two major issues that are (unfortunately) commonly faced by women being treated at fertility clinics – secondary infertility (difficulty conceiving after having a child) and recurrent pregnancy loss (miscarriages). We will focus on recurrent pregnancy loss on this post.
Firstly, miscarriages are common, and are estimated to occur in 15-20% of all pregnancies. Many women are unaware that an occasional late period they experience is actually a “biochemical” pregnancy – meaning an embryo had implanted into the uterus, but stopped developing shortly afterwards. However, only a small proportion of women (about 1%) experience three or more consecutive miscarriages.
There are numerous potential reasons why someone may be experiencing recurrent miscarriages, and a complete investigation is warranted. For the sake of simplicity I’ve highlighted the major categories that should be looked into by your physician (but of course each case is unique and should be treated as such).
It is important to note that even with a full work up, the majority of patients don’t have a specific cause identified (although there are “empiric” therapies that may still be of benefit to them in their future pregnancy).
The chromosomes of both partners (and even of the early pregnancy loss) can be tested with a blood sample.
Some women are born with an anatomical variation of their uterus (congenital anomaly), while others can have an abnormality develop throughout their lives (acquired anomaly). There are several ways to properly assess the uterine cavity, such as a 3D ultrasound or an MRI.
Rarely, an underlying infection can be a contributing factor to recurrent miscarriages. This can be screened for by taking a simple swab from the vagina and cervix.
Some women are more prone to developing clots within their blood vessels, and this may inhibit the invading placenta from developing properly. A blood test can look for both inherited and acquired thrombophilia.
The endocrine system is a complex system that maintains our body in a delicate balance. Any extreme imbalance, such as thyroid function, prolactin levels or insulin resistance can increase the risk of miscarriages.
Pregnancy is a unique state of “immune tolerance”. It is remarkable that the mothers body accepts an embryo (that is only 50% genetically similar) to grow and develop within the uterus. Therefore any significant issue with the mothers immune system can increase the risk of miscarriages. Immunology testing is relatively new, and no specific tests have been well established to truly diagnose this issue.
Yes, abnormal sperm is also a contributing factor to recurrent miscarriages. More advanced testing, such as a DNA fragmentation index can shed more insight into this possible cause.
“Could you please tell me who is an appropriate candidate for the Augment procedure?”
TRIO’s answer Featuring: Dr. Dan Nayot
The AUGMENT procedure refers to the innovative technology developed by OvaScience. It is an autologous (meaning the tissue is from the same person – the patient is both the donor and the recipient) mitochondria injection into each oocyte at the time of ICSI. The “fresh” mitochondria are retrieved from tissue derived from an ovarian biopsy performed prior to your IVF/ICSI cycle.
The rationale for injecting additional mitochondria into each oocyte is aimed at improving the quality of the egg and subsequent embryo (recall that the egg and embryo are dependent on mitochondria for the energy to develop and divide properly).
For more details about the AUGMENT procedure please refer to a previous post (March 23 2015) or visit our our Augment Page.
So who is the appropriate candidate for the AUGMENT procedure?
Truthfully, we are still working tirelessly to pinpoint the patient population that would benefit the most from this new technology. We suspect that patients who have previously failed an IVF cycle due to poor embryo development would be ideal candidates. In fact, the initial trial at TCART ( now TRIO) focused on patients aged 40 or younger who have failed one-to-three IVF cycles and had poor embryo development. For updated results from our AUGMENT experience, please visit Ova Science’s Website.
Perhaps other patient populations may benefit from AUGMENT as well – for example older patients? Or patients that have experienced recurrent miscarriages? Currently there is not enough clinical data in these specific patient populations to help answer this question, but as more people opt to use AUGMENT for their IVF cycle we will have more information as to who is the best candidate.
“My husband and I are preparing to do an IVF cycle. Do you recommend acupuncture on embryo transfer day?”
TRIO’s Answer Featuring Dr. J. Fitzgerald
Acupuncture is increasing in popularity as an alternative or support to IVF. There have been several studies done on acupuncture for pre and post embryo transfer which show promising results. While the results of the studies vary, none of them show a detrimental effect on embryo transfer or pregnancy rate, and most show a statistical increase in IVF success rate and pregnancy outcome.
Acupuncture on transfer day appears to minimize patient stress and anxiety, create an increase in blood flow to the endometrium to support implantation, relax the cervix to make the embryo transfer procedure easier, minimize any contractions post transfer (contractions may cause expulsion of the embryo from the uterus), and increase the rate of pregnancy.
Acupuncture is also useful throughout the IVF cycle. For example, it can be used for endometrial lining support, to normalize/balance hormones, to increase the response to IVF medications, and reduce side effects of treatment.
Conceive Health Clinic is pleased to provide on-site acupuncture to TCART patients for embryo transfer, as well as before and during medicated cycles. For more information, check out our website at www.conceivehealthclinic.com, contact us via email at firstname.lastname@example.org, or book an appointment through TRIO reception.
“It seems that my haemoglobin is normal, but my ferritin levels are consistently low. Is that common in women trying to conceive? Any recommendation on how to boost my ferritin levels? “
TRIO’s Answer Featuring: guest blogger Dr. Tracy Malone (Conceive Health)
Low ferritin levels is something that many women will encounter during their reproductive years.The amount of ferritin in the blood (serum ferritin level) is directly related to the amount of iron stored in your body. Ferritin is an essential part of red blood cell production, and can impact ovulation, and the endometrial lining.Normal ferritin values range from 10-150 ng/mL for females. Ideally I like to see patients between 50-70 ng/mol when trying to conceive.
There are several reasons for declining ferritin levels including: heavy or prolonged menstrual periods, gastrointestinal malabsorption, insufficient dietary intake, and intestinal bleeding. In most cases low levels are due to a combination of these factors.
When a patient’s levels come in below 20 ng/mol I typically recommend supplementation with an elemental iron at a dosage range of approximately 150mg daily, taken with 1000mg of vitamin C. The acidity of the Vitamin C will improve the absorption of the iron. The red blood cell life cycle is approximately 120 days, and so the duration of supplementation should last between 4-8 months before it will significantly impact serum ferritin levels.
Many Ferrous (iron) salt supplements have a number of unwanted side effects including nausea, vomiting, epigastric pain, and constipation. Because of these adverse effects, many users stop taking their supplements prior to their levels coming into normal range. My favorite brand of iron supplement is FerraMax 150, it is an elemental iron enveloped in a polysaccharide, it is easy on the stomach and provides an effective dose with just one capsule daily. It is important to note that all iron supplements should be taken away from calcium, as it will impact the absorption of iron.
“I am 40 and had one round IVF and was planning to use PGS testing. However, none of the embryos made it to blasts. I will be doing IVF #2 and will probably not being doing PGS as if I have any blasts it will probably be a small number. I am treated in Texas and they recommend PGS for everyone my age, but I am not sure it is the best for me now that I know I will be lucky to have any embryos make it to day 5-6. I am desperately searching for your complete study that I have found online. Where can I get a copy of this full article? It looks like your team took part in the study. What year was it completed? Thanks. “
TRIO’s Answer Featuring: Dr. Dan Nayot
I believe the article you are referring to is:
Trophectoderm biopsy for aneuploidy screening using different platforms and conflicting test results, N. Esfandiari, Y. Bentov, A.M. Sultanm D. Dela Cruz, A. Gokturk and R.F. Casper. University of Toronto, TCART, OB-GYN, Toronto, Canada
This was an abstract that was presented in October 2013 at the ASRM (American Society fro Reproductive Medicine) and in September 2014 at CFAS (Canadian Fertility and Andrology Society) by our very own clinical team. The abstract has never been published as a full manuscript, but can be found through the Fertility and Sterility scientific journal.
This small pilot project carried out at TCART ( now TRIO) comparing the accuracy of different PGS testing methods of cells derived from blastocysts (trophoectoderm biopsy). Essentially donated blastocysts were biopsied into 4 samples and sent to two centers that routinely perform PGS. One center uses the CGH technique and the other center uses the SNP microarray techniques. We were surprised to find that 3 of the 10 embryos that were reported as “abnormal” (aneuploid) at one center, were reported as “normal” (euploid) by the other center. Even within each center, only between 30-60% of the time (depending on the center) did the 1st and 2nd sample results match (keep in mind these were biopsies from the same embryo).
This abstract suggests that more studies are needed to compare the validity of each of the commercially available PGS tests. PGS technology is continuing to evolve, and in fact next generation sequencing is now available at TRIO.
“How can I survive the 2 week wait with my sanity intact? “
TRIO’s Answer Featuring: Dr. Erica Berman, Fertility Counsellor
Often the time between embryo transfer and finding out if one’s IVF cycle was successful is intensely stressful. While every 2 week wait can provoke anxiety, the stakes are higher when doing IVF due to the high financial, emotional and time commitment. Keep in mind that everyone is anxious and don’t get caught up in stressing about stress. Ultimately, there is no consistent evidence that anxiety reduces your chances of conceiving through IVF.
Its helpful to try and relax, but only so your experience is not miserable. I recommend that patients take the opportunity to pamper themselves: binge watch your favorite tv show, take a weekend getaway with your partner, or go out and have a nice dinner and movie night. If you have a hobby or activity that gives you great pleasure like reading, painting, writing, etc., make time for it, because it will help you pass the time. Most importantly, stay present. Don’t anticipate the worst case scenario. There is really no way to know if the cycle was successful until you do the pregnancy test. Try to wait for the blood test at the clinic as testing to early with home pregnancy tests could give you a false negative. If you do get a negative, don’t assume IVF will never work for you, it just didn’t work for that cycle. Staying hopeful is important – again, not because how we think effects the outcome, but because it will help you cope with disappointments.
“I’m a smoker, and well aware on its negative impact. I’m trying desperately to stop, but having difficulty. What is the effect of nicotine replacement on fertility and pregnancy?”
TRIO’s Answer Featuring Salman Hashim
We know smoking has considerable negative effects on both heart, lung, and overall health, and that definitely includes fertility health. In women who smoke, achieving pregnancy usually takes a much longer time compared to women who don’t smoke; and moreover in those pregnancies, there is an increased chance of miscarriage. We also know that the ovarian reserve of eggs tends to diminish much quicker in women who smoke. Similarly, in men who smoke, a lower sperm count and lower sperm function has been documented. So it is always advisable for people who smoke, especially those who are trying to get pregnant, take a step back and think about quitting. Yes, easier said than done, but the importance is maintained.
Nicorette and other Nicotine Replacement Therapies (NRTs), such as gums, lozenges, inhalers, and nasal sprays, are very useful substitutes in people trying to quit smoking. There is no evidence that NRTs have a negative effect during the pre-conception process. It is thought that because the harmful chemicals of cigarettes are not present in NRTs, it may be beneficial for people trying to get pregnant for those who want to quit smoking.
It is extremely important that smoking be discontinued while pregnant. The dangers of cigarettes include: increased risk of still birth, low birth weight, preterm delivery, and a number of congenital (birth) defects, including heart and lung problems, and learning disabilities. Unfortunately, the effects of Nicorette and similar substances in pregnancy is unclear. Some studies have shown a decreased risk of preterm delivery and low birth weight in pregnant women who use nicotine replacement compared to those who smoke. However this does not relieve nicotine replacement of its side effect profile. Studies have shown that prolonged exposure to nicotine can result in impaired organ development, particularly of the brain, in fetal mice. There is very limited information on its effects in human fetuses; it is recommended that prolonged nicotine exposure be avoided, and if it is absolutely necessary for the person, the use of nicotine lozenges and gums are preferred over patches and inhalers.
“I’ve been going through infertility treatments for the last two years in the U.S. I was diagnosed with premature ovarian failure at age 31. I’m currently 34 and will undergo my third attempt at IVF in three weeks. Approximately how long does IVF with the Augment procedure take? “
TRIO’s Answer Featuring: Dr. Dan Nayot
The logistics of an AUGMENT procedure (autologous mitochondrial transfer) is similar to a standard IVF/ICSI cycle, except for the need of an ovarian biopsy.
The biopsy is taken from the cortex of the ovary and is performed by a minimally invasive technique called a laparoscopy. During a laparoscopy (which you will be asleep for – general anesthesia) your doctor will also be able to visually assess your pelvis and look for other possible contributing factors to your struggle with fertility – eg. endometriosis, scarring around the fallopian tubes, uterine malformations, etc. Once the biopsy is performed, the tissue is sent off to the lab at TRIO to be processed. In the lab the egg precursor cells are then isolated from the tissue sample, and then broken down to allow for the mitochondria to be collected. The mitochondrial sample is then frozen in anticipation for injection into the egg at the time of ICSI.
The ovarian biopsy is a performed as an out-patient procedure, and the whole surgery typically lasts less than an hour. Like all surgeries, you will require some time to fully recover (and so will your ovaries). We generally recommend waiting 1-2 cycles before starting your IVF/ICSI cycle after an ovarian biopsy. So the whole AUGMENT procedure can be performed in under 3 months time. Generally there is enough mitochondria isolated (and frozen in storage) that if you required a 2nd IVF/ICSI cycle you would not need a 2nd biopsy, so there would be no delay for another attempt.
“Question: Could I be a good candidate for Augment if I have a low ovarian reserve? I’m going to be 39 yrs old this year. I’ve previously undergone 1 IUI and 3 IVF cycles, each of which resulted in a miscarriage.”
TRIO’s Answer Featuring: Dr. Dan Nayot
The rationale for injecting mitochondria into the egg (at the time of ICSI) is to provide more energy for the early stages of the developing embryo. As cells divide they require a lot of energy to duplicate their chromosomes and separate perfectly into two daughter cells. If this process is not completed flawlessly chromosomal abnormalities arise, and ultimately embryos stop developing or result in biochemical pregnancies or early miscarriages. By adding mitochondria we are aiming to improve embryo quality by allowing cell division (mitosis) to be optimized as a single egg develops into a blastocyst containing hundreds of cells.
However, it is important to remember that we are injecting mitochondria after the egg is retrieved – and at this stage of development it is a mature egg (M2) and has already gone through two cell divisions (meiosis 1 and meiosis 2). So if the mature egg (M2) is already chromosomally abnormal (aneuploid) at the time of injection, then mitochondrial supplementation is unlikely to be beneficial. In other words, mitochondrial injection is aimed to help chromosomally normal eggs continue to develop into healthy embryos.
It is well known that egg quality (and quantity) diminishes as women age. So as a woman gets older the proportion of her eggs that are abnormal (aneuploid) at the time of collection increases. On the flip side, younger women have a higher proportion of normal (euploid) eggs at the time of collection.
Therefore in younger women, even a low ovarian reserve (as in low quantity, but high quality) will result in some normal mature eggs that may benefit from the Augment technique. In fact we currently have several clinical pregnancies in younger women with diminished ovarian reserve who have used Augment (for more details please visit Ova Science’s Website).
It’s also important to note that a diminished ovarian reserve refers to the quantity of eggs that are expected to be collected per cycle. To overcome this, women with diminished ovarian reserve can undergo several IVF cycles to accumulate the eggs collected (serial egg banking) before the Augment technique is performed.
As a reminder, the initial clinical experience at TCART focused on patients aged 40 or younger who have failed one-to-three IVF cycles and had poor embryo development. It is always advised to speak to aTRIO physician to better understand if you are an appropriate candidate for Augment.
“Question: I have been unsuccessful with IVF because of thin uterine lining, presumably due to Asherman’s from prior D&C’s. Even my periods are much lighter than they have ever been before—is there any treatment for this other than surrogacy?”
TRIO’s Answer Featuring: Dr. Anat Klement
Uterine factor is one of the most challenging issues in our practice; though tremendous breakthroughs have been registered for male factor infertility and for egg related infertility, we still struggle in treating endometrial lining issues.
Unfortunately, intrauterine adhesions are a well-known complication from previous uterine procedures such as curettage of the uterine cavity (for example after a miscarriage) or a manual removal of the placenta (for example after a delivery).
Diagnosing intrauterine adhesions is relatively easy, as it can be suspected through several tests such as a sonohysterogram (also knowna as a saline ultrasound) or a salpingohysterogram (HSG), but hysteroscopy (a small camera placed inside the uterus) is the best modality, as it provides both diagnostic and therapeutic options. The use of hysteroscopy enables visualization of the adhesions and allows for their safe resection, though sometimes more than one session is required. The success rates of the procedure are very high in terms of resuming menstrual flow (70-90%), but vary tremendously for achieving a pregnancy and live birth. However, even after a successful hysteroscopic treatment that is able to restore the normal uterine cavity and even resume a menstrual flow, the lining of the uterus may still not function sufficiently to support an implantation.
My initial recommendation (in case you have not already done so) is to undergo a hysteroscopy, because, as mentioned, it will confirm the diagnosis and carries a significant success rate. If the endometrial lining is still ‘resistant’ (thin, irregular) after hysteroscopic management, there are different medical protocols that may be worth trying to improve your endometrial lining growth. Some of these protocols try to increase the endometrial blood flow (such as Viagra, blood pressure medications, and aspirin), others try to create a pro-inflammatory process that will lead to lining regeneration (such as endometrial scratching or G-CSF infusion) while some try to change the cellular characteristics of the lining, making it potentially more receptive to the embryo (such as letrozole). Different response rates have been reported to each of these modalities and the management, like many other treatments we offer, should be individualized. If the lining is still not responsive to any of the above treatments then a gestational surrogacy should be considered.
Furthermore, reproductive naturopathic physicians have other beneficial options to manage resistant uterine linings and it’s certainly worthwhile consulting with them for a complete approach.
“Hi, I would like to know if antral follicle count is useful in case of Premature Ovarian Failure when the trans vaginal ultrasound reveals no follicle seen in both ovaries. How can a woman determine day 3 FSH when there are no periods. Thanks”
TRIO’s Answer Featuring: Dr. Dan Nayot
When we (reproductive endocrinologists) are trying to estimate the ovarian reserve, there are several tests that can help shed light into the matter. In terms of blood tests, the more common ones include FSH (follicle stimulating hormone) and AMH (anti-mullerian hormone).
FSH is generally tested on the 3rd day of your cycle (or between day 2 to 4). It is recommended that an E2 (estradiol) blood level be drawn at the same time, because a high E2 can lead to a “normal” FSH, which we would classify as falsely reassuring. If a patient does not have regular cycles, she can either opt to wait for her natural day 3 (which may take weeks…), or artificially bring on her period with hormones (eg. birth control pills or progesterone supplementation and then stopping the medications to bring on a period, also known as “withdrawal bleed”). A high FSH (or high E2) may suggest that your ovaries are starting to show some resistance. For example, in menopausal women and women experiencing premature ovarian failure, the FSH levels are generally very high,
On the other hand, the AMH blood test can generally be taken at anytime in the menstrual. However there are some factors that may effect your AMH levels, such as being on the birth control pills. Unlike FSH, a high AMH suggests a good ovarian reserve. Women in menopause or experiencing premature ovarian failure may have undetectable AMH levels.
Besides a blood test, the antral follicle count (which is just the total number of small follicles in the ovaries that can be seen on ultrasound) can also help determine your reserve. For example, women with PCOS tend to have a large number of antral follicles, and subsequently they tend to respond well to ovarian stimulation and this results in a large number of eggs retrieved during an IVF cycle.
It is important to keep in mind that all of the above tests are generally aimed at evaluating the quantitative component of your reserve (eg. how many eggs will be collected at the time of IVF?), rather than the qualitative component of your reserve (eg. will this egg lead to a pregnancy?). For example a 27 year old female with a low ovarian reserve (low AMH and small number of antral follicles) is still expected to have high quality eggs (due to her young age), and therefore has a good chance of becoming pregnancy with IVF treatment.
In general, in premature ovarian failure, you would expect elevated FSH levels, very low AMH levels and a small number of antral follicles. There are cases that have been diagnosed with “premature ovarian failure”, but surprisingly a normal number of antral follicles are seen on ultrasound. In this situation it is possible that the main issue is an FSH receptor mutation, which results in the ovaries being unable to respond to the FSH hormone. There have been some pregnancies recorded in this unique situation using the IVM (in-vitro maturation) technique – removing the eggs from the small follicles and maturing and then fertilizing them inside the lab.
“Why has the medical team asked me/us to see a counsellor?”
TRIO’s Answer Featuring Erica Berman, PhD
Anyone using third party fertility methods (egg/sperm/embryo donor, gestational carrier) are required to do one preparatory counselling session. This is to ensure you are going into the process fully informed about what is involved. The discussion includes information about how to choose a donor/carrier, when and what to tell your child later on down the road, legal requirements, how to negotiate your relationship with known donors or carriers, etc. The emotional implications are also explored, as many individuals and couples grieve/feel a sense of loss when they discover they must create their family using third party fertility strategies.
Patients doing IVF also benefit from seeing a counsellor prior to starting their treatment. While infertility is stressful, the IVF process is another stress due to the financial, time and emotional commitments. The session helps prepare patients for IVF by letting them know what they can expect from a logistical and emotional perspective. If there are other issues a patient is struggling with (family, health, work, etc.), than the counsellor recommends coping strategies in order to ensure patients get through treatment as seamlessly as possible.
Counselling sessions are not about evaluating patients for their suitability to become parents or screening them out of the treatment process. Counselling is for the benefit of patients to minimize distress and maximize comfort with the fertility treatment process.
“I had a hysterectomy in 2009. I still have one ovary. Is it possible to produce healthy eggs?”
TRIO’s Answer Featuring Dr. Dan Nayot
Great question! Although the ovaries and uterus are interconnected and work harmoniously to achieve (and maintain) a pregnancy, each reproductive organ can also function independently. Many women have undergone a hysterectomy (removal of their uterus) for numerous reasons – eg uterine cancer, symptomatic fibroids, etc. The surgical decision to also remove your ovaries (oophorectomy) at time of your hysterectomy is an important discussion point to have with your Gynaecologist prior to your procedure. Sometimes it’s a simple decision, but many times it’s debatable with valid arguments for and against removing the ovaries. In general, the younger you are at the time of hysterectomy, the more important it is to keep your ovaries – as you will need the natural estrogens released by the ovaries to maintain a long and healthy life (specifically your bones, brain, and heart health).
So if you don’t have a uterus, but you still have an ovary, can you produce a healthy pregnancy? Well, you certainly can’t carry the pregnancy yourself (you would need a surrogate for that), but you may be able to produce healthy eggs that would contribute to your future genetically-linked child. You would simply require an IVF procedure, that is, hormones to stimulate your ovaries, and then a procedure to remove the eggs from within the growing follicles inside the ovaries. Once the mature eggs have been retrieved, you can either freeze them (for future use), or with the addition of sperm (your partners or a donor) you can generate embryos that can then be transferred to your designated surrogate.
It would be important to see your REI to assess your ovarian function before embarking on this path. Your ovarian reserve generally depends on your age, and a serious of tests (ultrasound and bloodwork). Based on your ovarian reserve, your REI can better counsel you about how many eggs (and their potential quality) you can expect to retrieve, and therefore your overall chance at success of achieving a pregnancy.
Your natural menstrual cycle pattern (frequency, duration, flow, etc) can tell you a lot about the health of your reproductive system. For example, if you have monthly periods, you can generally be reassured that you are ovulating every month. However, if you’ve had a hysterectomy – and therefore no longer have periods – then even if you ovulate regularly it would be difficult to know. The take home message is that (depending on several factors) you can still produce healthy eggs that can lead to a healthy pregnancy using a surrogate. I would recommend you reach out to your REI for a more personalized evaluation.
We’re sorry to hear about the results of your recent embryo transfer. Fortunately it appears you still have several frozen embryos! Can you have them shipped toTRIO? But of course – this quite a common scenario.
We generally recommend that you come in for a full assessment to review your particular situation. As you can imagine, different clinics have different protocols, so it’s always helpful to have your case reviewed from a new perspective. At your appointment you will likely be asked to undergo some preliminary investigations, and depending on the results, a personalized treatment plan will be created. We want to be sure that your reproductive system is “optimized”, before we transfer any further embryos.
In terms of physically transferring embryos from one clinic to another (whether it’s within the same city or half way across the globe), we use the expertise of several reproductive couriers. The couriers will work with your local IVF centre and TRIO to make sure all your embryos are picked up, transferred, and arrive safely. They will take care of all legal requirements, documentation and you will be expected to sign the appropriate consent forms.
To optimize the future success of your frozen embryos, the TRIO lab will request more detailed information from your local IVF centre. It is very important for us to know how many embryos are frozen, their stage of development (and grading), the freezing protocol used (including the culture media), and what the appropriate thawing procedure should be for that particular freezing technique.
The entire process generally takes 1-3 weeks, and you will be notified once your embryos have found their new home. Welcome to Canada.
“Our first IVF cycle failed. I am 34 with slightly low AMH and AFC for my age. Eggs retrieved were 13 with 100% fertilization rate (without ICSI). In the end only 2 embryos were useable (but 4 made it to the blastocyte stage). I was was worried I had a thin uterine lining but was reassured it was okay because it had “three stripes,” it never got above 6.7mm even with an estrogen level above 10,000. Am I a good candidate to try IVF again? What other medications/investigations might you recommend?”
TRIO’s Answer Featuring Dr. Dan Nayot
Whenever we review an unsuccessful IVF cycle (that least favourite part of our job), we try pinpoint the major issue – was it “the seed” (embryo) or “the soil” (uterus)? In reality, it’s far more complicated and likely has to do with a little bit of both, and other reasons as well (“the weather”).
In this post we will focus on “the soil”. To make it more clinically relevant, let’s assume you are reproductively young and your blastocyst embryos were biopsied for PGS and came back with normal results – in other words let’s make the assumption that issue is far less likely “the seed”.
How do we assess the endometrium, or know when it’s ready to receive an embryo?
Firstly we need to rule out any mechanical factor that may be inhibiting a high-quality embryo from growing. These are generally grouped into congenital uterine anomalies (something you’re born with) – such as a bicornuate uterus or a septum – or acquired uterine anomalies (something that develops as you age) – such as polyps, fibroids or intra-uterine scarring. There are several ways to assess these conditions, which include a Saline U/S, HSG, or hysteroscopy (for internal cavity assessment) along with 3D Saline U/S, MRI, or laparoscopy/hysterscopy (for both internal and external cavity assessment).
Although there may not be any discrete mechanical factors noted within the cavity, there still may be other contributing factors that negatively impact the endometrium, and therefore must be dealt with. Two common clinical examples are a hydrosalpinx (fluid in the fallopian tube) and endometriosis, both of which can limit your success regardless of how great the embryos are. In general we tend to remove a hydrosalpinx (surgery) and suppress endometriosis (medication) to optimize the uterine cavity.
We want to be sure that the endometrium is responding appropriately to hormonal stimulation. Recall that as the follicle grows, the granulosa cells from within produce more estrogen, and estrogen stimulates the endometrium. Therefore as the ovarian stimulation proceeds, and the estrogen levels rise, you should see a corresponding thickening of the endometrium. Although the endometrial thickness is a very important clinical variable, it must be taken into context – it would be minimalistic to think that such a complex process of embryo implantation can be reduced to a single number! Besides endometrial thickness, there are other was to assess how responsive the endometrium is to estrogen. For example, the specific pattern of the endometrium (“C” or “triple line”) suggests there is adequate estrogen stimulation.
Even more complicated, is evaluating how the endometrium responds to progesterone, and subsequently transforms into a receptive endometrium that accepts an embryo (window of implantation). Some common tests include ultrasound surveillance (endometrial pattern, uterine contractility), or endometrial biopsies (histology dating, presence of gene expression, etc). Of note there is growing evidence that perhaps the fresh IVF cycle is not the ideal time to have an embryo put back into the uterus, as the high levels of estrogen (from the ovarian stimulation) may have a negative impact on the endometrium – fresh vs frozen embryo transfer continues to be debated in our field.
In summary, after an unsuccessful IVF cycle it is very important to meet with your doctor to review the details. Remember that an IVF cycle is also diagnostic – we can learn a tremendous amount from a single cycle, and more importantly we can use this gained knowledge towards your future successful IVF cycle.
I have two questions:
I am currently taking Lupron which was prescribed a week ago and I am now experiencing spotting and cramping similar to just before I get my period. Is this just a symptom of the drug?
My other question relates to travel. Is it safe to travel while taking these medications and undergoing treatment?
TRIO’s Answer Featuring Dr. Dan Nayot
Here is my attempt at explaining the basic physiology of Lupron …
Lupron is a long acting GnRH agonist. It can be administered either by a daily, monthly or every 3 month injection. The role of Lupron is to suppress your natural FSH hormones. Recall that FSH is the “follicle stimulating hormone”. If you are not producing FSH, then your follicles don’t grow; and if your follicles aren’t growing then they are not producing estrogen (as well if your follicles don’t grow then you can also expect not to ovulate). Therefore Lupron essentially shuts down the hormonal activity originating from your ovaries and puts you in a pseudo-“menopausal” state associated with low estrogen levels.
Lupron can be prescribed for many different conditions. It is commonly prescribed to patients with endometriosis (recall that estrogen stimulates endometriosis, and so inducing a low estrogen state would be beneficial), fibroids and even in men with prostate cancer (also a hormonally sensitive condition).
Interestingly, Lupron has a short “flare” effect in the first few days after administration. This means that the FSH levels actually increase for the first few days (and thus estrogen is expected to increase as well) before they rapidly decrease. So, depending on when in your cycle you take your first injection (beginning, middle or end of the cycle) you may experience unexpected spotting or light bleeding for several days – this is generally related to the change in hormones (from the flare and subsequent down regulation effect of Lupron).
Unless specifically instructed by your doctor to avoid travel, there is no particular reason to delay your trip just because you are currently taking Lupron. However it always advisable to make sure you have adequate travel insurance and access to medical care at your destination if you should require it.
Why do I need a prescription for greater than 1mg folic acid?
TRIO’s Answer Featuring Dr. Salman Hashim
Folic Acid supplementation is an essential part of prenatal care. It plays an important roll in DNA synthesis in both mother and baby. Its use in reducing congenital defects, such as Neural Tube Defects (NTD), and the reduction of fetal loss is well documented.
The recommended dose of folic acid for the average woman considering getting pregnant is between 0.4mg and 1mg per day. For high risk women, such as those with previously encountered NTDs, women with diabetes, sickle cell disease, celiac disease, or those who are taking anti-seizure medication, it is recommended that 1-5mg of folic acid per day should be taken.
High doses of folic acid supplementation (5mg) may not be quite as therapeutic in low risk women. In healthy individuals, high dose folic acid supplementation can mask the effects of other vitamin deficiencies, such as B12 deficiency. Occasionally anxious mothers and to-be mothers will increase their dose of multivitamin to compensate for the low dose of folic acid contained in them, which can be more harmful than helpful. For example, high doses of fat soluble vitamins in multivitamin capsules, like vitamin A can be detrimental to both mother and baby.
To add to this, high dose folic acid is only recommended for a short duration even in high risk women. The suggested time frame to take it is: 12 weeks prior to conceiving, and only 12 weeks after conception (first trimester of pregnancy). After this point, you can continue to take folic acid.
at the over-the-counter dose of 0.4-1mg per day, as there is no added benefit to continue taking the high dose.
For these reasons it is recommended that women considering getting pregnant see their primary physician to assess their need for adequate folate supplementation, and that they receive a prescription should they need a higher dose of folic acid than what is available over-the-counter.
I am 41 years old and I have a 12 year old boy. I am trying to have another baby and after one year of unprotected sex with my partner, I have decided to see my family doctor and have some blood tests done to see the level of my hormones. I have done the AMH testing and it came out abnormally low 0.03. I have done an ultrasound as well and my uterus lining is normal, everything came out normal with the exception of a 2 cm cyst on my right ovary. The other blood tests I have done were the hormones, I believe FSH and TSH and the results came out abnormally low, post-menopausal levels. My last period was on several months ago.
Do I have any chances to still get pregnant if I didn’t have my period for the last 3 months and if so, what would be the best option for me, would hormone replacement therapy and ovarian simulation work. Please advise, your help is greatly appreciated. Thank you very much,
TRIO’s Answer Featuring Dr. Jigal Haas
The AMH test and the hormone profile (FSH and LH) provide us information about the ovarian reserve of any individual. Extremely low AMH and extremely high FSH reveal a situation we refer to as “low ovarian reserve”.
Unfortunately in your scenario, an AMH lower than 0.03, an abnormally high FSH levels and irregular menses is highly suspicious of perimenopause.
Perimenopause means “around menopause” and refers to the time period during which a woman’s body makes its natural transition toward permanent infertility (menopause). Although the average age of menopause is approximately 52 year old, many women start perimenopause in their 40s and some women even notice changes as early as their mid-30s.
During the perimenopause some of the menstrual cycles occur without ovulation. Recall that if you don’t ovulate, there will be no progesterone released by the corpus luteum, and this is the reason for the long time period between periods (instead of the regular monthly period that is seen with ovulatory cycles). As well, if you don’t ovulate, the egg will not be released and therefore there is no opportunity for fertilization by the sperm.
During perimenopause, the levels of the endogenous hormones (FSH and LH) are very high (think of it as ovarian resistance – the ovaries are not responding even to the high hormone levels) and therefore during this period, taking exogenous hormones (like many of the fertility drugs) for ovulation induction doesn’t help to induce ovulation and thus it doesn’t increase the pregnancy rate.
Generally we would recommend egg donation in this particular situation, but as you can appreciate every situation is unique. It would be best to schedule an appointment with your RE to review your options at this point.
But, there are high fluctuations in the FSH levels and one abnormal FSH test isn’t enough to determine that you are in the perimenopause. Therefore I advise you to test again the levels of your hormones (LH, FSH and estradiol), and if your menses will return to be regular, and your levels of FSH will decline then turn to a fertility clinic that will try to help you to conceive.
Our first IVF cycle failed. I am 34 years old with slightly low AMH (1.7) and AFC (11) for my age. I had 13 eggs retrieved with 100% fertilization rate (without ICSI). Four embryos made it to blastocyst stage, but only 2 embryos were useable. I was worried that I had a thin uterine lining but was reassured it was okay because it had “three stripes,” it never got above 6.7mm even with an estrogen level above 10,000. Am I a good candidate to try IVF again? What other medications/investigations might you recommend (I have had all the basic IVF work-up)?
TRIO’s Answer Featuring Dr. Dan Nayot
As a first impression, 13 eggs, 100% fertilization and 4 blastocysts in a 34-year-old woman sure sounds promising. As always, the (potential) answer is in the details… After a “failed” IVF cycle it is critical to review your cycle with your clinical and embryology team to see what can be learned, and hopefully what can be adjusted for your next attempt.
In terms of embryo quality, the development and morphological evaluation is key – at TRIO we can gain further insight into this by using a time-lapse machine (EEVA) to study the embryos evolution. However, even properly dividing embryos that results in high-quality blastocysts may have a chromosomal abnormality (aneuploidy) – at TRIO we can screen for euploid embryos using pre-implantation genetic screening (PGS) using the next generation sequencing (NGS) technology.
Do all euploid blastocysts results in a clinical pregnancy? Unfortunately not. The endometrium is another key aspect to consider. The most common variables that are used to assess the receptivity of the endometrium is the endometrial thickness and pattern. As you had alluded to, a three-line (also known as “C”) pattern is ideal. However even just using an ultrasound there are other variables to consider, like the location and size of fibroids, the presence of adenomyosis and even the uterine irritability – at TRIO we are currently studying the effectiveness of using an ultrasound prior to an embryo transfer to assess how uterine contractions impact the implantation rate. In your case, with a lining <7mm, it would be worth while to review your old cycles (even previous natural cycle monitoring) with your team to see how thick the lining has reached in past cycles. We have found that occasionally prolonged exposure to estrogen may actually hinder the endometrial growth. In summary, there are many aspects to consider before embarking on another IVF cycle, but from the information you have provided it would seem that you are a great candidate for another IVF cycle. Best of luck!
Is it possible for a person to become pregnant in one month?
TRIO’s Answer Featuring Dr. Dan Nayot
Yes, it is very much possible to get pregnant in your 1st month trying. In fact, just as there are some people that struggle with unexplained infertility (where all tests are completely normal), there are others that one the other side of the spectrum and are “hyper-fertile”.
As you may know there are many important clinical variables that effect your chance to conceive (eg your age). But even a young, perfectly healthy couple can expect to be trying a few months. I would estimate that about 30-50% of couples are fortunate enough to conceive within the first 3 months.
I have been referred to your clinic by my family doctor. What should I expect during that first visit?
TRIO’s Answer Featuring Dr. Dan Nayot
Thank you for trusting TRIO Fertility Partners with your reproductive medical care. The initial visit is a very important one. You will likely meet several of our team members along the way – administration, nursing, and medical. We are an academic institution so you may even meet some of our clinical fellows, residents and medical students as well.
At your first meeting, your medical team and you will have the opportunity to sit down and review your case. We believe the details are critical, so expect to be asked numerous questions that will help shed further insight into the underlying issues. Your doctor may also decide to perform a quick physical exam if they deem it necessary. Generally after the first meeting, your medical team will arrange some preliminary investigations.
The investigations may include bloodwork (eg. hormonal profile performed on the 3rd day of your cycle), imaging (eg. an internal ultrasound to count the number of follicles within your ovaries), and further testing such as a semen analysis.
You will have ample opportunity to ask any questions that may arise (or that you have been waiting to ask the fertility specialist from the very beginning). Once the initial investigations have been completed, a review meeting will be arranged to go over the results and formulate a personalized treatment approach to help you reach your reproductive goal. Welcome toTRIO!
Hi, I have read your clinic’s excellent paper on the effect of long-term combined oral contraceptive pill use on endometrial thickness and wonder how you manage cases of reduced endometrial thickness in these cases, particularly in cases where increasing doses of estrace seem to make the problem worse?
TRIO’s Answer Featuring Dr. Chang
A resistant endometrium is a difficult problem to solve. Over the years we used multiple approaches to increase endometrial thickness that included the use of aromatase inhibitors to sensitize the lining, endometrial washes with G-CSF or growth hormone, endometrial scratching, vaginal PDE5 inhibitors, and others with individually changing levels of response.
Hello, I have had 2 failed IVF cycles. Both cycles I get 10-12 eggs. One thing which I noticed was my LH blood levels were consistently low. Does that play a factor with embryo development? And the he quality of the eggs? Will increasing the LH levels result in better eggs/embryos that will be able to reach a blastocyst stage?
TRIO’s Answer Featuring Dr. Jigaal Haas
It is known that gonadotrophic hormones FSH and LH play separate but complementary roles in the regulation of the ovarian follicle, leading to synergistic actions in stimulating follicular growth and maturation. FSH – like its name, follicle stimulating hormone – is the major hormone required to stimulate the follicles to grow. LH plays an essential role in the final stages of follicular maturation. Therefore, LH may play an essential role in determining oocytes maturity and development potential in IVF cycles.
However, over many years of experience in inducing multiple follicular growth have shown that ovarian follicular growth proceeds normally even in the presence of very small quantities of endogenous LH. Endogenous LH (in the presence of pharmacological doses of FSH) allows adequate follicular steroidogenesis, even when in very low serum concentrations.
There are a few studies that have demonstrated that serum LH levels don’t correlate with the number of oocytes retrieved, fertilization rate, or pregnancy rate.
So should women with low LH levels get LH supplementation (eg. Menopur, Repronex, HCG, etc) during an IVF cycle to improve their outcomes? The verdict is not clear. There have been a few studies suggesting that LH supplementation in women with baseline low serum LH levels undergoing assisted reproductive technology may improve pregnancy rate, while other studies didn’t find any improvement in the pregnancy rate after LH supplementation.
It would be important to thoroughly review your 2 failed IVF cycles with your doctor. Perhaps it would be worthwhile to add LH supplementation with your next IVF cycle, if it has not been attempted in the past.
What is acupuncture and how is acupuncture different with Conceive Healthcompared to other acupuncture clinics?
TRIO’s Answer Featuring Melissa Lee of Conceive Health Clinic
Acupuncture has been used for various conditions in China for thousands of years. It involves inserting hair thin, sterile needles into specific points in the body; these points are referred to as acupuncture points. In traditional Chinese Medicine (TCM), these points are located along channels or meridians. When these acupuncture points are compared human anatomy, they fall along small nerve bundles and blood vessels lying among fascial tissue. These nerve bundles can be sensory nerves, motor nerves or both. When acupuncture points are needled, one will feel a sensation of warmth, pressure or tingling.
Acupuncture has recently gained popularity and has been clinically studied as an adjunctive therapy to infertility treatments. At Conceive health, the acupuncture system we implement is based on an individualistic approach which incorporates the two medical systems of traditional Chinese Medicine (TCM) and modern western medicine. We combine the principles and philosophies of TCM with updated clinical techniques and research to obtain the greatest treatment effect.
Acupuncture can be done as an adjunctive treatment during the following phases:
- IVF cycle
- IUI cycle
- IVF with ICSI
- Oocyte Retrieval
- Cycle Monitoring
- Preconception Care
- General Health
How does acupuncture increase my chances of success with IVF or IUI?
TRIO’s Answer Featuring Melissa Lee of Conceive Health Clinic
Recent research has indicated that the benefits of acupuncture can vary depending on the duration of treatment: short term or long term. Short term treatment refers to receiving acupuncture only during an IVF cycle, whereas long term treatment involves patients undergoing acupuncture treatments even before their IVF cycle.
In short term treatment, the benefits of acupuncture include: improved blood circulation to the uterus and ovaries, lowered stress levels and relaxation, and amelioration of side effects from the IVF medications (For example: abdominal bloating and discomfort, fluid retention, headaches and mood swings).
In long term treatment, patients notice benefits overall when receiving acupuncture from pre IVF, during an IVF cycle and into pregnancy. When acupuncture is received with the right treatment frequency and duration, it can induce regular ovulation through modulating the sympathetic nervous system, endocrine system, and neuroendocrine system. These treatments can also be beneficial for pre-existing conditions (endometriosis, PCOS, adhesions, ovarian cysts, or fibroids) and work synergistically with biomedical prescriptions.
Whether short term or long term treatment, one of the most significant benefits of acupuncture is its influence on the central nervous system. For instance, acupuncture given before and after an embryo transfer has been shown to decrease urinary adrenaline and noradrenaline. We also see lower serum levels of cortisol when acupuncture is given during gonadotropin stimulation in an IVF cycle. Overall we see a decrease in the concentration of stress hormones in the body and a subjective feeling of greater relaxation and stress reduction.
These benefits translate into increased clinical pregnancy rates and live birth rates in women undergoing IVF.
What is acupuncture’s role during cycle monitoring or its role in regulating the menstrual cycle?
TRIO’s Answer Featuring Melissa Lee of Conceive Health Clinic
In each menstrual cycle, there are main events that occur. These include:
Day 1- 5: Estrogen and progesterone levels are low, and the pituitary gland starts to make FSH and LH, promoting follicular growth.
Day 7: One of the follicles becomes the main follicle and grows while producing higher levels of estrogen.
Day 7-12: Higher levels of estrogen then stimulate the uterine lining to grow. Glands in the cervix create fertile mucous.
Day 12 and 13: High levels of estrogen induce an LH surge which stimulates the production of lytic enzymes and prostaglandins in the main follicle.
Day 14: Egg is released from the main follicle.
Day 15-25: The empty follicle becomes the corpus luteum and produces progesterone. Progesterone stimulates the growth of the endometrial lining.
Day 25-28: When fertilization does not happen, the corpus luteum dies and the estrogen and progesterone production drop, allowing the pituitary to produce FSH and LH.
Our acupuncture treatments follow the four phases: follicular, ovulatory, luteal and menstruations phases to facilitate these main events of the menstrual cycle. During each phase we use different combinations of acupuncture points with the overall goal of regulating the sympathetic nervous system, endocrine system, and neuroendocrine system. As these systems start to regulate, women notice slight differences such as: decrease in PMS symptoms (breast tenderness, moods, cramping), cervical mucous or menstrual flow.
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