by Fred Licciardi, M.D.
Today I have answered the more interesting questions over the past few months.
What do I think about cervical mucus? This is tricky question. I would not make any treatment plans based on cervical mucus. Some women have “normal” mucus and others have mucus that is a little thicker, and for some it gets thin only for a short amount of time. Most infertility doctors do not look into mucus problems because no studies have shown that thicker mucus is bad. No studies have shown that trying to fix "mucus problems" does anything. There are some infertility doctors who take their time and really work with mucus and have some pregnancies. However most of us understand that some women seeing fertility doctors do get pregnant on their own and that dealing with the mucus may be immaterial.
Can you have both hypothalamic amenorrhea and polycystic ovaries? The answer is that there are some women who have polycystic looking ovaries and do not ovulate, but do not have other criteria for PCO. In some cases it is hard to distinguish if the underlying problem is PCO or hypothalamic amenorrhea. However, treatment is usually similar in that we use the same medications to induce ovulation for both problems.
I am not familiar with endometriosis causing fevers. Some more rare autoimmune diseases may present with fever, but I am assuming that if you have any suspicious findings would have been tested for those things.
Is a HSG the best test to see polyps? It depends. If your baseline ultrasound and HSG are totally clean, a sonohysterogram is probably not indicated. However if the first 2 tests give ambiguous or conflicting results, a sonohystergram would be the best test to diagnose polyps. Of course it always depends on who is doing the scan.
What if your first FSH is 20? You need to have the level repeated. Strange things happen every day.
What if you get regular periods and your ultrasound is normal, but the doctors cannot do the HSG because they cannot ”get in”? Get another opinion, someone else may be better at doing the HSG.
What if you do a donor egg cycle and the donor performs in a much less positive way than she has in the past? For example, she may have produced fewer eggs, or the fertilization rate was lower or the embryo quality may not have been as good? Unfortunately, this happens occasionally. We usually do not have an explanation for such an occurrence. We hope that after the transfer the pregnancy test is positive, but we understand that the cycle was a big disappointment and a financial burden as well. Pregnancies from marginal looking embryos happen every day.
What if hydros (hydrosalpinx) are seen on HSG but not on ultrasound? This is the usual scenario. The tubes need to be especially large and damaged to be seen on ultrasound.
If you have proximal tubal occlusion, what are your options? One important option is tubal recanulization via a special HSG. The other option is laparoscopic surgery. I usually recommend the HSG because it is less risky and less invasive. Plus there are cases where the patient shows up for recanulization only to have the first part of the test (repeating the hsg) show normal open tubes, therefore obviating the canalization part. There may have been a little tubal spasm during the first test keeping a tube closed, when in fact it was really open. However, all doctors have their own ideas so speak to your caregiver.
What if the sperm is moving but slowly? It depends on how slow. If it is a little off, there is no problem. If your doctor says the sperm is moving very slowly, that is more cause for concern and you may need to get to IUI or IVF sooner.
What if your lining is surprisingly thin? This is another tough one. I can say that you want to be sure your HSG and sonohysterogram (not just the sonohysterogram) are normal.
Will reflexology help? We are not sure but if it improves your quality of life and helps you get through the infertility saga, then I encourage its use. We had a nurse practitioner who performed reflexology and was very well received.
Does DHEA work? It sounded great when the information was first published but like many things in medicine, further good studies showing success have not been published. I do not recommend it, however I have patients who use it, so far without noticeable success.
If you are 30 and your FSH is 11, your odds of hyperstimulation are low. You may need to be more aggressive with your stimulation, but you need to discuss this with your doctor.
What if you have become pregnant with IVF, but only once despite multiple attempts and good embryo quality? Does this mean that many of your embryos are bad and more likely to result in a malformation or miscarriage? Should you not temp fate? It may mean that there is some unknown problem with your eggs, sperm or embryos that is causing you difficulty in reproducing. It is possible that there is a relationship between infertility and poor pregnancy outcome. Some of the science behind these theories is very preliminary but the ideas are very interesting. For instance, there may be women who have very subtle genetic problems that cause infertility, and these same genetic abnormalities may cause problems with fetal development. At this point, however, there are no tests for this. I understand and your concerns and they may be valid, however I have not had a woman decide to stop treatment because of these potential problems.
What if your doctor uses Lupron for most IVF cycles? I do not use much lupron. If however, you are with a program that has excellent pregnancy rates and uses Lupron, that’s OK, it’s what they do and it works out well for them and their patients. I suspect that over time they will slowly see the benefits of getting away from Lurpon. Without Lupron there are fewer injections and none of the flare reactions than can delay cycles. Plus, I believe that in some women, primarily poor responders, lupron suppresses the response a bit.
Does stress affect FSH levels? It probably has no effect at all. However, if there were an effect the FSH levels would decrease not elevate.