Been There, Done That.

What Questions To Ask If You Think You’ve Done It All

December 5, 2006 - Tuesday
1:12 PM to (EST)
Guest Speakers: Shaun Williams, M.D.
Connecticut Fertility Associates

Categories
Acupuncture • Donor Egg • Endometriosis • IUI • IVF • Male Factor • PCOS • Pregnancy

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S_Williams	Hello.
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S_Williams	Hello Everyone...
S_Williams	I will hope my computer will be functional all night...it seems to be working.
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S_Williams	Hello Dan.
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susannealia	hi people, this is me, susanne.
S_Williams	Hello Susanne!
susannealia	hi S_Williams
Moderator_Daniel_Becker	Well I guess it is time to Welcome Dr. Shaun Williams
S_Williams	Hello all. I am happy to be here tonight.
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Moderator_Daniel_Becker	The topic tonight is "Been there, done that. What questions to ask if you think you've done it all." However, all questions are welcome!!!!
Moderator_Daniel_Becker	Dr. Williams please tell us about yourself!
Moderator_Daniel_Becker	And to all those that have joined, please feel free to just jump in!
S_Williams	I am a Board Certified Reproductive Endocrinologist in Connecticut. (Fairfield County).
jneencruz	I am 34 years old, I have one biological daughter (happy unplanned pregnancy). Started trying 4 years ago for second and was diagnosed with pcos along with blocked tube. doctor tried clearing tube during laporoscopy. had two rounds of ivf with failure. planning on trying again with new doctor but wanted to know if there were other meds besides gonal-f, and also if there is any way to improve eggs if this is the reason for failure to implant.
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S_Williams	I have been with my group, Connecticut Fertility Associates, for 2 years now.
Moderator_Daniel_Becker	Hi Dee Welcome to tonights Chat - with Dr. Williams of Conn Fertility Partners
S_Williams	www.ctfertility.com
Moderator_Daniel_Becker	Great
S_Williams	jneen--It is frustrating to have gone through two cycles without success. If your doc thinks it is egg quality and ultimately embryo uality that was the issue, that is sometimes difficult to overcome. But sometimes different medications or stimulation protocols can imporove embryo quality. Did you have many or few eggs?
S_Williams	Women with PCOS usually produce many eggs, and at times, too many eggs can lead to higher than desired estrogen levels. Some think this may lead to poorer quality eggs.
S_Williams	But some women respond very poorly to the stimulation meds, and this can be a sign of poor ovarian function/poor egg quality. Again, different stimulation protocols can increase the number of eggs available.
jneencruz	the first round there were 10 but only 2 were fertilized. second round there were 16, 11 were mature, but only 3 fertilized and we did icsi with all the eggs the second round, the first time they only did it on half
jneencruz	what other drugs would you recommend me looking into?
S_Williams	That is fairly low fertilization. Any sperm issues prior to the cycle?
Moderator_Daniel_Becker	Anyone else have a question -- don't be shy we are in cyberspace
jneencruz	no, there was never a test done for him and when we first started we were trying just insemination and the doctor thought that his sperm looked great
Dee_Dee	Any headup concerns one should have if one is planning on using a new egg donor, that is an egg donor that hasn't donated before?
jneencruz	do you think we should have his sperm tested
S_Williams	Well, the two most used drugs are Gonal-f and Follistim--both are identical, but many docs have preferences. An addition of Menopur to the Gonal F or follistim may improve outcome. This is called a mixed protocol. But your second stimulation produced a good number of mature eggs for your age.
Moderator_Daniel_Becker	Dee well that is a loaded question - how old is your new donor?
maddie1702	Hello Dr. Williams, I am moving on to donor eggs after 4 ivf attempts. I have moderate endo . I had my 2nd laparoscopy this past summer. Should I have another lap done before I use a donor? I would like a clean slate . Thank you
Dee_Dee	The donor we are looking at is 25 years old. Her profile indicates she has one child and had one abortion.
S_Williams	Jneen--at this point there are few good sperm tests that can be helpful. Some tests look at DNA structure, but if ICSI is done, we have no way to know which sperm are more or less normal at the DNA level.
Moderator_Daniel_Becker	Dee so I take it this is not an anonomous donor
jneencruz	so based on the very limited information i have been able to give you, would you suffice it to say that continuing with another round of ivf is the only possible solution besides going with egg donors
S_Williams	Dee-Dee--most studies have shown no difference in response or overall outcome between new donors and those that have donated before. We are sometimes more comfortable with an experienced donor, as women tend to respond to medications similarly.
Moderator_Daniel_Becker	If you have posted a question and have not seen an answer, please post it again - it is difficult for the DOC to type and read at the same time
Dee_Dee	We only know the first name of the donor. We found her at Conceptual Options based in Poway, CA (San Diego area). We are located in Orange County CA.
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waitingformyblessing_	I wanted to find out what medications I can take to become pregnant quicker if we are trying to conceive naturally.
Moderator_Daniel_Becker	Did you enter into an Donor Egg Agreement
Moderator_Daniel_Becker	Welcome Udfirefly
S_Williams	Maddie--it depends on your age and the possible reasons the first attempts were unsuccessful. Some studies have shown that treating endo can improve the uterine environment, but if egg quality was the main issue during ivf, then the donor egg should overcome that.
Dee_Dee	We haven't signed an Donor Egg agreement yet. Plan to do it before the end of the year, in order to use monies from my Health Savings account. Any thoughts?
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waitingformyblessing_	How important is cervival mucus to a successful preganancy ?
Moderator_Daniel_Becker	I look at a Donor Egg agreement as a kind of wish list that I would like a donor to do or not to do
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Moderator_Daniel_Becker	Dee, if there are specific issues that you would like addressed it can and should be incorporated into the agreement
S_Williams	jneen--if the quality of the embryos was good, but you just had few to work with, using a donor egg with the same sperm might not be overcoming the problem. It is hard to know if using younger eggs would be the best step--34 is still very young. Without knowing everything about the embryo development and the stimulation it is hard to say if another ivf attempt is the best way to go. It is always our best way to help you quickly using your own eggs.
Moderator_Daniel_Becker	Welcome Hopeandpray
susannealia	hi there~ I have PCOS, and am obese. I took metformin while on VLC diet for 10 mths - lost 80 lbs, but got heavy complicatiosn from kidney + gallstone blockages, infections etc. Since my gallsbladder removal, I have had very severe side effects from any dose of metformin, unrelenting after 4-6 months trying, which ease immediately I finally stop taking it, more or less. - anything at all that I eat produces them.
Dee_Dee	In regards to the Donor egg agreement, we thought it was pretty straight forth as to what was set up by the agency. Is there anything we should add to the Donor egg agreement?
S_Williams	Dee-Dee--as a physician, I would be comfortable with that donor.
Moderator_Daniel_Becker	Dee I am not familiar with your agency but I am familiar with these agreements - it depends on who wrote it and who is reviewing it
Dee_Dee	Okie dokie ... and what should we be looking for in the donor egg agreement?
S_Williams	Waiting--cervical mucous is important in normal intercourse cycles. Once treatment begins, and IUI can eliminate any cervical mucous abnormalities. We have no good tests to assess cervical mucous, nor do we know how much is enough.
susannealia	.. now we are trying with a donor egg, and some doctors strongly suggest we try to keep on metformin - but as time goes by, I really feel totally ill from side effects - should I really be so stoic and stick it out ? The main doctor in mind himself has crohns, and in his opinion, finding a loo a few times a day fast is a small price to pay for being pregnant.
Moderator_Daniel_Becker	Dee a good agreement should set forth the duties and responsibilites of the parties to the agreement
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Dee_Dee	Thanks for the info
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Moderator_Daniel_Becker	Dee, it should also speak to what behaviors are acceptable and/or not acceptable, for instance, some folks do not want their donor to drink caffinated beverages while others do not want their donor to spend anytime in an environment where first or second hand smoke is present.
Dee_Dee	Good to know
Moderator_Daniel_Becker	kjs and motmot - welcome to AFA's chat with Dr. Williams of Conneticut Fertility Partners
S_Williams	Susannealia---with PCOS, metformin can improve overall outcome and possibly decrease the likelihood of miscarriage once pregnant--some studies suggest women with PCOS have more miscarriages. But about half of the women who start that drug stop because of the side effects. There are other insulin sensitizers that have been used during fertility therapy--Avandia and Actos--which have very few side effects, but if you have any liver or kidney issues, those might not be the best. Ask your doc about his experience with the other insulin sensitizers.
waitingformyblessing_	I wanted to find out what medications I can take to become preganant quicker if we are trying to conceive naturally
Moderator_Daniel_Becker	Dee - will you and your donor have seperate attorneys to review the agency donor agreement?
S_Williams	Susannealia--have you been ovulating during treatment? Why donor egg?
hopeandpray	I have had several IVF's and a few medicated IUI's. I always make lots of eggs, the embryos look good, with little fragmentation, and nothing implants. My FSH is typically 6 or so on day three of my cycle. I have had a myomectomy to remove fibroids and recovered well. Because of my age, mid 40's, I have been referred for donor egg. I would like to continue trying with my own eggs until I am no longer producing. I am now doing natural methods- chines herbs, acupuncture, and recently went to a group called "Clear Passages" to have physical therapy on the abdominal region. Do you think I am crazy for continuing to try with my own eggs and are several medicated IUI's better than one more IVF?
Dee_Dee	We will have the same attorney, is that ok?
Dee_Dee	Another related question ... Is it possible to have progestrone supportories instead of progestrone injections for the egg donor cycle? Did a mock cycle and had progestrone injections. Another person, who had a sucessful egg donor baby, only had progestrone suppositories. Any thoughts
S_Williams	Waiting--some have used meds to make the cervical mucous more "watery" to allow sperm to swim through it more easily (guaifenesin). but thisisn't always going to give you a better chance.
Moderator_Daniel_Becker	Better to have different attorneys so that there is no possible negative inference - although some people are comfortable with signing waivers in this regard - in my practice I rather the reciepient couple just pay the extra cost for the donor to have seperate and independant counsel.
kjs25	My husband has azoospermia. Using a regimen of Arimidex and vitamins, his count improved to a couple hundred thousand sperm. We have done 2 cycles of IVF/ICSI. The 1st didn't work and the 2nd ended in a chemical pg. Even though we have frozen sperm as back-up (which resulted in the chemical pg last cycle), our doctor feels that we should be even more aggressive and do TESE for our next cycle. If we have a few motile sperm without doing anything invasive, why would TESE yield better results?
Dee_Dee	Thanks for the info
Moderator_Daniel_Becker	Dee am not a doc but it should not matter to any significant degree - depends on the doc and what he/she preferes
hopeandpray	Did the moderator receive my post.
S_Williams	Hopeandpray--The most frustrating thing we see is egg quality issues, and we know that in the mid-40's, egg quality is just much poorer than is usually necessary to allow pregnancy to happen easily.
Dee_Dee	Thanks again
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S_Williams	Hopeandpray-But, doing IVF or IUI's is giving your ovaries more oppotunities to release a good egg, one that con lead to pregnancy, but it is not successful very often, even if many eggs are produced during an IVF cycle.
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Moderator_Daniel_Becker	tcreed and jessicab welcome to AFA's chat with Dr. Williams of Connecticut Fertility Partners
jessicab	thanks.
Moderator_Daniel_Becker	hopeandpray - were you asking me a quesition or was it directed to Dr. WIlliams ??
waitingformyblessing_	What is the success rate of IUI's ?
S_Williams	Some times, genetic testing of embryos (pre-implantation genetic diagnosis) can be helpful if you produce many eggs. The chromosomally normal embryos can be identified and transferred. Many times, all embryos are normal. My group had a 43 year old undergo IVF, jproduce 44 eggs, and have only 3 normal embryos with this procedure. She did get pregnant, but many times we have only 8-10 embryos to work with, and the likelihood of a normal embryo is low.
Dee_Dee	What can one expect being preganant as an older mother that would be different if one is younger?
S_Williams	But, using a donor egg definitely overcomes that issue. But it is another level of acceptance, that many don't want to consider until trying with your own eggs. But these attempts are usually limited by costs.
waitingformyblessing_	Hopeandpray what did you think of clear passages and would you recommend it?
maddie1702	Did the 43 year old deliver the baby full term?
motmot	More tests? I am 41, and had a D&C 3 weeks ago at 8.5 weeks, when the heartbeat stopped. The pregnancy resulted from our first ivf/icsi with single gene pgd. The karyotype showed trisomy 21. My RE is recommending only an HSG before trying ivf again in january. Would it make sense to do any other tests?
S_Williams	Dee-Dee--some studies have shown no difference among the progesterone methods--vaginal or injections. Many docs though don't want to try something new, especiall with something as important as an egg donation cycle. I ahve used only vaginal progesterone, and I saw good results. The other docs in my clinic are not quite so sure about it, so all our cycles use injections.
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Dee_Dee	Thanks for the info
Moderator_Daniel_Becker	Dee - when my wife cycled she did both - injections a little painful - suppositories a little messy
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Moderator_Daniel_Becker	KJS - the azoospermia is caused by???
S_Williams	kjs25--Some studies suggest that some abnormalities may arise as the sperm spends time in the vas deferens, which they all do for several day before ejaculation. However, if you had good fertilization and good embryo quality, the TESA may not improve upon that. Ask your doc this as well.
Dee_Dee	By using both injections and suppositories, is the injection needle smaller? I got pretty black/blue bruses from the injections. I'm rather small framed person.
jneencruz	what is TESA
Moderator_Daniel_Becker	TESE is Testicular Sperm Injection
jneencruz	thanks
Moderator_Daniel_Becker	jneen - know this well having done it more times than I would ever like to admit
S_Williams	Dee-Dee--there are a few more risk with pregnancy as women get over 35, but these are manageable. Being a mom in the 40's is a bit different than being a mon in the 20's or 30's, but not necessarily more difficult. It may be much easier for you to be a mother after all you have experienced up to this point.
hopeandpray	I just finished Clear Passages. It is too soon to tell whether what they did will be helpful for me too conceive, however, I did have a positive response to the treatment in terms of blood flow and other signs that the area was invigorated. I would recommend them.
S_Williams	The 43-year old is still pregnant.
kjs25	Thanks for your response. We had poor fertilization and mediocre embryo quality our first cycle with fresh sperm and good fertilization and good embryo quality with the frozen sperm, so I guess that's why the doctor wants to do TESA for our next cycle? He doesn't think egg quality is an issue since I have no abnormal test results and I'm under 35.
Dee_Dee	Thanks
waitingformyblessing_	Thanks
jneencruz	so sorry to hear that. can't even imagine and I have injected myself many many times
hopeandpray	Does anyone know who the oldest woman was who conceived with her own eggs?
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Dee_Dee	you mean concieved with her own eggs, without any down's syndrome or other problems... right?
S_Williams	TESA--can be a biopsy of testicular tissue to retrieve sperm or an aspiration with a needle of the tubules outside of the testicle to retrieve sperm. It does not mix with any seminal proteins or other fluids that make up the semen...some think that those things can adversely affect sperm.
maddie1702	sarah in the bible she was aprox. 70 yrs old
jneencruz	doctor, what is your feelings on acupuncture
hopeandpray	Yes, I mean concieved with her own eggs without major problems.
Dee_Dee	Sarah, in the bible, had alot of God's help.....
hopeandpray	What about in modern day lif?
maddie1702	I would say so !
christalp	I had a post-colital test last week. My dr said that my mucus was to think and that there were rare sperm in the specimen. If I don't conceive this month, he suggested IUI. What is the success rate with this?
S_Williams	kjs--we are imperfect at selecting the most normal sperm, and if doing a testicular biopsy can be helpful, then you should consider it. It will be at least as good as the frozen sample, possibley better quality, but discuss this more with your doc to get his experience with this option.
jneencruz	and your husband!
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Moderator_Daniel_Becker	Remember the AFA is FREE MEMBERSHIP with the No Barriers Program
jneencruz	sorry, i just can't see my husband agreeing to that, he can't stand the idea of me injecting the medication, never mind someone using needles on him.
S_Williams	Dee-Dee--for the progesterone injections to be useful, they need to be in the muscle--deeper than all the other meds we use. It is uncomfortable, but that oil is not absorbed from the fat layer above the muscle very well. If you are thin, then a shorter needle can get into the muscle, but it is the intrmuscular aspect that makes it uncomfortable.
Moderator_Daniel_Becker	Miriam - Welcome to tonight's chat with Dr. Williams and RE with Conneticut Fertility Partners
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Moderator_Daniel_Becker	welcome back Waiting
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jneencruz	Thank you very much for all your information and help. Good luck everyone, I wish you all the best.
Dee_Dee	How long does one do the progestrone injections? I understood it could be 4 to 6 weeks into the egg donor cycle. Is that correct?
Moderator_Daniel_Becker	Dee - Ice the area until you can't feel the cold and then do the injection and it will be less painful and also less brusing
S_Williams	jneen--I think acupuncture can be great at relieving some of the stress of the process, and if that can be helpful, then I'm all for it. I don't know if it actually improves outcomes by direct means, but I don't think it hurts. If a couple wants to try this, I encourage it, but I don't think it shold be billed as something that need to be performed to increase one's chances.
Dee_Dee	Sounds good. Thanks for the "ice" tip
susannealia	I regularised periods with cylcic prometrium. With rare erratic periods, I presumed I was not ovulating, but we now realise you can ovulate regardless of clockwork periods, given 4 spontaneous pregnancies ! Original dx of blocked tubes, we expected only to get p with IVF. Then... pathology from curettage done to evaluate PCOS treatment showed I was pregnant at exam time. 2 mths later, I aborted remains of another calcified 2"embryo ~ the hydrosalping completely disappeared after this event, so we expect that was an old ectopic p. 42-44 years, we did 5 IVFs with ICSI, 4 with PGD - some good embryos, but no implantation. In between some IVFs, I also got p spontaneously 2x, mc at w9 (no hearbeat), and w13 (heartbeat, limbs..).
S_Williams	I have seen two 43 year old become pregnant with IVF. But I have many more that were unsuccessful. But I have also seen 49 year olds deliver healthy babies spontaneously, so it can happen if a good egg is released inthe right month. We just can't make that happen very effectively.
Dee_Dee	oh gosh
susannealia	so this is why we are now moving on to donor egg, as I'm 45 now... time goes fast when you are having fun ! (or IVF !
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S_Williams	Dee-Dee--the injections can last from 4-6 weeks after your positive test..or until 8-10 weeks of pregnancy age. Sometimes the dosing can be decreased to every other day, or every third day, depending on the progesterone levels and your docs comfort with that.
Dee_Dee	okie dokie... I'll become friends with ice ...
Moderator_Daniel_Becker	WE HOPE YOU DO TOO
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S_Williams	Sussanealia--that is quite a journey. With a possible hydrosalpinx and tubal problems, it is difficult. Miscarriages also increase as women get over 35, again related to egg quality issues primarily. I hope your next steps will be rewarding..
Moderator_Daniel_Becker	It's still not too late - there is still time to ask another round before we're done for the night
Miriam	Is there much research on miscellaneous anarobic or aerobic bacteria as a cause of infertility or mc? I recently stumbled on the work of a NYC doctor who seems to specialize in this...
Moderator_Daniel_Becker	Hi Patricia welcome to the AFA's chat with Dr. Williams of Conn Fertility Partners
kaylalunaava	Also, I found that applying warm compress and massaging the area of injections and walking around while massaging it will make the PIO shots absorb better and also less bruising.
maddie1702	Thank you ,have a great night everyone !
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motmot	More tests? I am 41, and had a D&C 3 weeks ago at 8.5 weeks, when the heartbeat stopped. The pregnancy resulted from our first ivf/icsi (male factor and my age) with single gene pgd. The karyotype showed trisomy 21. My RE is recommending only an HSG to check for scarring before trying ivf again in january. I had good progesterone levels (and a sore butt!) Would it make sense to do any other tests first given the trisomy diagnosis?
Dee_Dee	thanks for the tip of warm compress after the injection.
S_Williams	Miriam--many bacteria have been studied, from chlamydia to ureaplasma and others. It is not well proven that any single bacteria can cause fertility problems, unless it has caused scarring of teh tubes such as chlamydia is prone to do. Vaginal colonization with various bacteria does not represent uterine colonization, and some studies have suggested that uterine colonization can be a risk. It is hard to sample the inside of the uterus easily though.
susannealia	As we are expecting to go for a donor egg transfer January / Feb 07, does it make sense to target weight loss - significantly cut calories and so on (10-1200 cals), at this stage, - as doctor Crohn's has suggested - or should I just generally try to overall improve fitness with moderate diet control (like 14-1600 cals per day for example)? I am looking forward to donor egg, it seems a lot more hopeful a thing for us. We believe tubes are indeed patent and fine since the mass I aborted, confirmed by all imaging, plus laporoscopy, etc...
S_Williams	More studies are needed of course, but I can tell you that many antibiotic treatments have been tried, in an attempt to rid women of these bacteria, and none have been very successful when studied.
patricia	I will be undergoing ivf in January....1st iui resulted in trisomy 11, 1st ivf unsuccessful, 2nd ivf called off due to too big of a differencde in egg size. Took a break for 3 months cuz hair was falling out due to the drugs. anything I can do to help the process inJanuary?
Dee_Dee	Patricia - which drug made your hair fall out?
S_Williams	motmot--No other tests ae necessary. Many problems that can cause recurrent miscarriage lead to an earlier loss. Unless you have had other miscarriages, I would not reccommend any other tests. The Trisomy can lead to miscarriage--not all Trisomy 21's lead to delivery.
patricia	not sure..I was on gonal f & menopur
Miriam	From what I've read, ureaplasma is hard to diagnose. Is that why my RE prescribed a dose of antibiotics before starting IVF? What diagnostic tests are available for the less common forms of bacteria aside from the standard blood tests?
motmot	Thanks! Nice to have a second opinion.
S_Williams	Susannealia--if you are heavier than average, then modest weight loss and a good diet is better, with excercise etc. I would not drastically try to lose large amounts of weight by then--it might be detrimental over the next 1-2 months.
Moderator_Daniel_Becker	Wow - on behalf of the American Fertility Association, I can not express enough gratitude to Dr. Shaun Williams a distinguished RE from Conn Fertility Partners for being with us tonight, it is this kind of dedication to the community that makes the AFA a strong advocate for education and support.
susannealia	Great ! Thanks very much for your input and feedback !
Moderator_Daniel_Becker	As our time is drawing to a close, I want to thank everyone for particpating in tonights chat - I have been doing this for some time but am always amazed how much there is to know and how much I still need to learn.
Dee_Dee	Yes, thank you for all your insight!!
Moderator_Daniel_Becker	Rember KNOWLEDGE = POWER
S_Williams	Patricia--hopefully your docs will look at the stimulaitons, and try to maximize your response to expect good egg development. The hair will come back--the hair follicles have jsut been synchronized to all fall out at the same time by the hormones. Soon, they will all be in the growth phase at the same time also.
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patricia	Thanks-I figured a break was ok even though i am 43
Moderator_Daniel_Becker	Again on behalf of the AFA, thank you Dr. Williams for "chatting" with us tonight - we've all learned alot
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S_Williams	miriam--only uterine biopsy samples are effective at identifying uterine infections, but other routine cultures can be done for many bacteria also. I have not seen any good evidence to test for any single bacteria routinely (except chlamydia and gonorrhea), but your doc might have personal experience that can be helpful.
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Miriam	Thank you.
Moderator_Daniel_Becker	Good night everyone
S_Williams	Thank you all for logging on and joining me tonight. I hope I typed fast enough without too many mistakes...!!
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S_Williams	Good luck to all in your journeys. Be well.
Moderator_Daniel_Becker	You did GREAT and we look forward to having you again!
Dee_Dee	::rolleyes , yes Good night, thanks a bunch
S_Williams	Thanks Dan and Thanks Dee-Dee. I hope this was helpful.
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S_Williams	Thanks again.
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S_Williams	Good luck Susanne...
susannealia	thanks everyone, and dr. Williams, cheerio all.
S_Williams	Good bye...
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