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Infertility/Fertility/Ovulation Induction: something we're doing wrong?

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QUESTION: Hi Dr Ramirez,

I'm currently having Ovulation Induction due to secondary amenorrhea, and so far I've been through three cycles. Each time, the procedure has worked as intended: one follicle grows to the correct size, and ovulation definitely occurs (after using a trigger injection).

The only problem is, I'm still not pregnant! My period arrives 1315 days after the trigger injection each time, so I know I don't have any luteal phase defects.

I know that, with OI, once I'm ovulating I'm pretty much at the same stage as a "normal" person and therefore my chances of getting pregnant are just as likely as with a "normal" person. But with timed intercourse I really thought (hoped!) it would have worked by now!

Is there anything I could be doing wrong, or should be doing to help improve our chances? My husband has slightly low sperm morphology (about 2%), so I wondered if that could be an issue? Would sperm washing be recommended for people like us? (The hospital has mentioned it but so far hasn't recommended it.)

Thanks for any advice you can give!

ANSWER: Hello Mish from the UK.

This is a question that you should be discussing with your fertility doctor rather than on the internet.   If your doctor is not open to such questions, then you should find a better one.

Now that you are ovulating with medication, you are essentially begin made "normal" and therefore have the same chance of pregnancy as other women in your age group.  I don't know how old you are so can't give you the statistics for your age group, but in women under 30 years of age, the chances of pregnancy per month is 20% and the chance of pregnancy per 12 months of trying is 85%.  Most women will take 8-12 months to achieve pregnancy, but of course the range is  1 month - 48 months.  So, that means that three cycles is insufficient to evaluate if there is something else going on that is preventing you from getting pregnant.  Getting pregnant is not easy in humans.  Keep in mind that ovulation induction and intercourse is only completing 3 of the 10 steps your body has to go through in order to achieve a pregnancy, so timed intercourse still leaves lots of things to not happen, AND the human body does not work perfectly each month.  If just one step fails to function correctly then you don't get pregnant that month.

Certainly, the sperm issue could be signficant, because the analysis is not just about numbers but more importantly, it is about sperm function.  If there are any abnormalities in the analysis, we have to assume that there could be a functional problem i.e. that the sperm cannot fertilize an egg.  This is further compromised by having only a small amount of normally formed sperm.  I would recommend that you use IUI instead of timed intercourse because of this problem.  You should achieve pregnancy within 4 months of trying if you ovulated up to 3 eggs per month.  Your doctor should strive to get 3 eggs per month to ovulate with each cycle.  Your chances of pregnancy would be increased to 25% per month.  If you don't get pregnant by four attempts, then you should move to IVF based on statistical chances because that indicates that the sperm are impaired.  In that case you should do ICSI with IVF for a 71% chance of pregnancy (my clinic rate).

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

---------- FOLLOW-UP ----------

QUESTION: Thank you very much for the advice!

My husband had another sperm test, and this time, the morphology was normal. The doctor said this kind of thing can fluctuate a bit.

I know that OI is essentially making me "normal" (and that each cycle has a relatively small chance of working for any normal person), but I'm just wondering if there's anything I could or should now be doing to increase the chances of fertilisation, implantation, etc.?

Do diet/exercise play any sort of role, outside of ovulation, for example? Or vitamins, stress, travel...!  I'm 32.

Thanks again!

Answer
Hello Again,

Certainly a good diet, exercise, being healthy and reduced stress can help but there is no documented benefit or advantage to use these as "medical treatment" or "medical recommendations."  In studies, stress has been found to contribute to a reduction in pregnancy rates with IVF patients but that is not a blanket statement, meaning it does not necessarily apply to all.  Just trying to be healthy in all ways is a good rule of thumb.

Please keep in mind that donations are allowed and accepted if you plan to continue with multiple questions or to use me as your consultant.

Good Luck,

Dr. Edward J. Ramirez, M.D., FACOG
Executive Medical Director
The Fertility and Gynecology Center
Monterey Bay IVF Program
www.montereybayivf.com
info@montereybayivf.com

Monterey, California, U.S.A.

for additional information check out my blog at http://womenshealthandfertility.blogspot.com check me out on twitter with me at @montereybayivf and facebook @montereybayivf.  Skype and internet comprehensive consultations now available via my website for those who want a more extensive evaluation that this site can accommodate.  I also now provide an Email Concierge Advisory Service with a 1 year subscription for patients that want easy access to me to answer questions along their journey (women's health, infertility, pregnancy).  Contact me at ejrmd@montereybayivf.com if you are interested in continuous access to me.

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Edward Joseph Ramirez, MD, FACOG

Expertise

I am a specialist in infertility and advanced gynecological care. I can answer questions about infertility, gynecology related ills, menopause...virtually anything that affects women's health. PLEASE tell me where you are writing from as I am always interested.

Experience

I have been practicing as an Ob/Gyn and Infertility Specialist for over 23 years. Gynecology, advanced laparoscopic surgery, basic infertility, IUI's, IVF, reproductive surgery, and ovulation induction are all areas of my expertise. I am Board Certified. I have been doing In Vitro Fertilization in my clinic for 19 years.

Organizations
American College of OB/GYN, American Board of Obstetrics and Gynecology, American Society of Reproductive Medicine, Society of Assisted Reproductive Technology, American Association of Gynecologic Laparoscopists, Fellow of The American College of Obstetricians & Gynecologists,Resolve-National Chapter, Open Path - Northern California, Board of Directors Monterey Medical Society

Publications
American Journal of Obstetrics and Gynecology, Wall Street Journal, Monterey Herald, SERMO, Women's Health and Fertility Blog

Education/Credentials
Medical Degree from Stanford University, Residency at Tripler Army Medical Center, Reproductive Training at Pacific Fertility Center, San Francisco

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