Answers To Your Medical Questions

Medical Questions

Answers provided by Annette Lee, M.D., IVF New Jersey, Somerset NJ USA

Biographical Sketch

Annette Lee M.D., is a Phi Beta Kappa graduate from Cornell University, where she studied genetics and biology, Dr. Lee graduated with honors from Hahnemann University School of Medicine in Philadelphia, PA. She completed her residency in Obstetrics ad Gynecology at Winthrop University Hospital in Mineola, NY. There, her interest in infertility and assisted reproductive techniques led her to a fellowship in reproductive endocrinology at Oregon Health Sciences University in Portland, OR. Dr Lee has worked at the Center for Reproductive Endocrinology at Morristown Memorial Hospital. She then joined Drs. Darder and Treiser at IVF New Jersey.   In July 2000 she joined Reproductive medicine Associates in Morristown New Jersey. Dr. Lee moderates INCIID's Donor Gametes and General Infertility Forums.

 1.        Can I “kill” my wife if I give her an injection in the wrong location?

No.  However, it is possible to hit a blood vessel which could cause bruising or decreased absorption of the medication or to hit a nerve which would be painful. For this reason, intramuscular injections should be given in the upper outer quadrant of the buttock and when giving any injection, you need to "pull back" on the plunger. If you see blood flowing into the syringe, simply remove it and choose another spot. You are very unlikely to seriously injure your wife by giving an injection improperly.

2. How important is it to take my injections at the same time every  night?

Most of the medications can be given ABOUT the same time each day (a few hours later or earlier will not make a difference). 

3.         What happens if I cannot find anybody to give me an injection and I cannot give it to myself?  What should I do?

You can find an urgent care center or "drop-in clinic" or you can call your doctor and ask if you can delay your shot. Or you can attempt to give it to yourself. Intramuscular injections can be given in the buttock, the front of the thigh, or the upper arm.

4.         How soon after a failed cycle can I recycle?

Depending on whether there any residual follicles left on the ovary, you may be able to start immediately. Some clinics prefer to have you take one cycle "off" depending on your stimulation protocol.

5.         Why is a cycle canceled?  Is there anything I can do to decrease the  chance that my cycle will be canceled?

            Sometimes the cycle is canceled because the response to the medication is not what the doctor expected, i.e., more eggs than expected, or less, hormone levels rising too fast or slow. At a certain point, your doctor may decide that the best option is to stop everything and start again from scratch with a different protocol.

6.         If my cycle was canceled last time, does that mean that I have a  higher likelihood of having my next cycle canceled?

            It depends on the reason why it was stopped. If it was do to an inadequate response (too few eggs) then there is any increased chance of a poor response again despite changing the protocol.

 7.        I'm 41 years old.  I have a normal Day 3 FSH.  What are my chances of  getting pregnant using my own eggs?

Even with a normal FSH level, the age related decline in egg quality must be taken into consideration. In general, in the normal population, about 60-70% of women will be fertile at age 41. In a population of women complaining of infertility, of course this number will be much lower.

8.         I'm 41 years old and have a normal Day 3 FSH.  How do I decide whether  I am better off doing an IVF procedure or an IUI procedure?

            In general, over age 40, most Reproductive Endocrinologists will tend to become more aggressive earlier. That is, since time is of the essence, they will try at most 6 cycles of IUI before moving on to IVF. Whether to go directly to IVF depends on many other factors such as the status of the tube, insurance coverage, sperm count, etc. You should sit down with your RE for a consultation to discuss the pros and cons of each option.

9.         How do I know when it is time to leave my OB/GYN?

            In general, once you have had the "basic workup" including an HSG, semen analysis, day 3 hormone levels, post-coital test and/or endometrial biopsy, you should consider seeing a reproductive endocrinologist. Also, if you workup reveals any abnormalities that either you or your doctor feel need the attention of a specialist. Finally, if you feel that it is time to "become more aggressive" or feel frustrated with the care that you are receiving, it may be a good idea to see an Reproductive Endocrinologist.

10.       What’s the best tactic for me to try to persuade my clinic to treat me uniquely rather than putting me through a “cookie cutter” approach?

            Your clinic should take into account all of the various aspects of your case. Your age,  your level of urgency, your insurance coverage. I would be very wary of any clinic that follows the same workup or treatment for everyone. During your initial consultation, you should feel that your doctor has considered the circumstances of your case and outlined a treatment plan that you are comfortable with. If this is not the case, you should seek a second opinion elsewhere. On the other hand, if you visit several RE's and they all give you the same recommendation, then it may be that the options are clear-cut, even if you do not like what you are hearing.

11.       What's the optimum number of embryos to transfer?

            It depends on the "quality" and the "age" of the embryos. In general, the more developed the embryos (day 5 vs. day 3) and the better quality, the higher the implantation rate. Therefore, it would make sense to transfer fewer. Most transfers will be 2-6 day 3 embryos or 1 to 3 day 5 embryos (or blastocysts).

12.       What lifestyle restrictions are there after I have my embryos transferred?

It is recommended that you avoid any strenuous activity for 48 hours. Of course avoid caffeine, tobacco and alcohol until after the pregnancy test.

13.       Can I fly while I am taking the medication prior to retrieval? 

Yes. If you cross time zones, try to stick to the same schedule as your "home" time.

14.       Can I fly after the embryos are transferred but before I have had my pregnancy test?  Yes.

15.       Can I fly after a positive pregnancy test but before the end of 14 weeks?

            Yes as long as everything is going well but we recommend that you avoid any unnecessary travel until the 2nd trimester.

16.       Can I use hair dye while I am taking the medication prior to retrieval?  Can I use hair dye after the embryos are transferred but before I have had my pregnancy test?  Can I use hair dye after a positive pregnancy test but before the end of 14 weeks?

Hair dye has not been definitively tested so we recommend avoiding it if you can stand it until the second trimester

17.       Can I exercise while I am taking the medication prior to retrieval?

Yes, but as the ovaries enlarge or if you become bloated, we recommend avoiding any high impact or intense exercise.

18.       Can I exercise after the embryos are transferred but before I have had my pregnancy test?  Can I exercise after a positive pregnancy test but before the end of 14 weeks?

            Swimming and walking are OK. We suggest avoiding impact exercises or getting your heart rate above 120.

19.       In the time between the transfer and my pregnancy test, what signs indicate that I am likely to be pregnant?  (e.g..  Tender breasts, abdominal cramping, vaginal discharge) What signs are likely indicators that I am not pregnant?

Because you will most likely be taking progesterone which causes the SAME symptoms as pregnancy, you will not be able to tell if you are pregnant or not by how you feel.

20.       I am worried about taking fertility medications.  Am I at increased risk for getting ovarian cancer?

            The theoretical concern that fertility drugs could increase the chance of ovarian cancer has caused a great deal of concern in the medical community. Many studies have been done and NONE have shown that fertility drugs cause a statistically significant increased risk. One problem with doing these studies is that infertile women are at increased risk of ovarian cancer EVEN IF THEY NEVER TAKE ANY FERTILITY MEDICATIONS. Also, women that never give birth are at increased risk. We suggest you discuss it with your doctor and decide for yourself if the small, undefinable chance of an increased risk is worth the potential benefit. Only you can make this decision for yourself.

21.       Are there any family history conditions that would make me more susceptible than other women to have adverse reactions because I am taking fertility medications?

            For women that have a history of ovarian or breast cancer in their families, the theoretical concern about taking fertility medications may be of more concern. This should be discussed with your physician. In some cases, your doctor may ask you to be tested for BRAC1, a gene that has been shown to increase the risk of developing breast or ovarian cancer.

22.       Can I begin a cycle of Clomid when I have a residual cyst? Can I begin a cycle of injectable medication when I have a residual cyst?

It depends. If the cyst is not too large and if it is not producing any hormones such as estrogen or progesterone, your doctor may decide to begin clomid or injectables.

23.       What do you think about combining a natural cycle with acupuncture or the use of herbal remedies?

            There is some evidence to suggest that acupuncture may have a beneficial effect, however there are no well controlled studies. On the other hand, herbal remedies such as St. John's Wort and echinaccea have been shown to impede sperm function in the laboratory.

24.       For what purposes and when should baby aspirin be used during a cycle?

            Baby aspirin is thought to "thin the blood" a little bit, thus perhaps increasing the blood supply to the pelvic organs and preventing the formation of very small clots. This in theory is supposed to improve the response to medication and decrease the chance of miscarriage. Again, this has not been definitively proven, but many clinics uses a baby aspirin (80mg) per day on an empiric or "can't hurt" basis

25.       I am taking Melatonin to help me sleep.  Can this have any adverse reactions on my cycle?

            Melatonin, in a "natural" cycle, may interfere with the release of LH and FSH, thus interfering with ovulation. Discuss it with your doctor, but in general, it is prudent to avoid any unnecessary medications.

26.       Can I have dental procedures while I am doing an IVF cycle?

            Yes, as long as you let the dentist know you are trying to conceive. In general, the use of novocaine is OK but nitrous oxide should be avoided and lead shields should be used to block x-rays to the pelvic area.

27.       What gauge needles work best to minimize pain for subcutaneous injections and for intramuscular injections.

            Use a 1/2 inch 27 gauge or higher needle  for subcutaneous (higher number = smaller needle) and 1.5 inch 22 gauge for intramuscular. If you run out of small needles, you can take subcutaneous medications intramuscularly, it will just be more uncomfortable.

28.       I have endometriosis and am planning to have it removed.  Is there a “window of opportunity” after removing the endometriosis during which I have a higher likelihood of getting pregnant?  What is that window? How aggressive should my treatment be during this time?

In general, once endometriosis has been removed at the time of surgery, there is thought to be a "honeymoon period"  of 6-12 months during which the endometriosis has not really grown back. Your doctor may want to be aggressive and give you fertility medications or do IVF during this time period.

29.       Please explain the relationship between endometrial thickness, endometrial structure (e.g. # of layers) and cycle outcome success. What is the range of acceptable endometrial parameters for cycle success?

            Studies in which the lining of the uterus has been examined prior to transferring embryos in IVF cycles have shown that implantation is more likely to occur when the lining is at least 6 mm thick and when it has a "triple layer" or "trilaminar" appearance (it literally looks like 3 layers, somewhat like a layer cake). Nevertheless, pregnancy can and does occur with linings that are "too thin" or that lack the "trilaminar" appearance.

30.       What is the relationship between cervical mucus quality and cycle outcome?  Is there anything that can be done to increase the quality of my cervical mucus?

            Cervical mucus acts as a reservoir for the sperm. Around the time of ovulation, it should be thin, clear and stretchy. If it is not, there may be a decreased window of opportunity for the sperm to survive inside the woman's body. One way to get around this is to have artificial insemination timed to coincide with ovulation. Some people also will use supplemental estrogen or Robitussin cough syrup in an attempt to improve the mucus quality however this has never been proven to work.

31.       Please explain what it means to be Board Certified or Board Eligible. How will my doctor’s status with respect to board certification or board eligibility affect: 1) his competence, 2) his insurance coverage, 3) his hospital privileges.

The American Board of Obstetrics and Gynecology issues "board certification" in both general obstetrics and gynecology, and in the subspecialty of reproductive endocrinology. If your doctor is "board certified" in one or both of these, it means he/she has passed and arduous written and oral examination and found to be competent by his/her peers. If your doctor is "board eligible" then he/she is eligible to take the exam but has not yet passed the exam. This most likely reason is that the board requires a certain number of years of practice before one can take the exam. Also, since the exam costs several thousand dollars and is given only once per year, your doctor may not have had the opportunity to sit for it yet. Board certification does not guarantee that your doctor will be "good" or compassionate, however, it does indicate that your doctor was examined and tested by experts in his/her field and found to be competent. By the same token, lack of certification does not mean your doctor is less competent, it merely indicates that he/she has not been examined in this way. Many hospitals and insurance companies may require a doctor to be board certified within a certain number of  years of becoming board eligible in order to qualify for privileges or in order to become a member of their panel.

32.       What is considered the normal range of fluctuation in FSH level From month to month?

            FSH levels can fluctuate from month to month, however evidence has shown that as women reach the end of their functional reproductive years (i.e. when there are only a few hundred eggs left in the ovary) the month to month variation increases. Evidence in large populations of women has shown that once the day 3 FSH is abnormally high even one time, the chance of successful pregnancy is very low (<5%) even if the FSH is normal during other months. For this reason, many RE's will recommend that once one elevated day 3 FSH has been found, the patient may want to consider the use of donor eggs

33. I know that FSH levels can be too high.  Can they also be too low?

In certain conditions, such as hyperprolactinemia (increased levels of prolactin in the blood which causes discharges of milky fluid from the breast and irregular or absent ovulation) or anovulation (very infrequent or rare ovulation) due to weight loss, the brain will shut down production of either FSH or the hormone that stimulates FSH release (called GnRH). In these cases the FSH will be low or on the low side of normal. A lack of FSH production is usually treated with injectable fertility medications containing FSH.

34.       How long can a sperm sample survive between being produced and being processed?  What's the best way to transport a sample from home to the lab?

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This page was last modified 06/02/03