Not all patients are successful on their first try but that doesn’t mean they will not conceive in subsequent treatments or even on their second attempt. Couples struggling with infertility are always trying to increase their chances of pregnancy. If you’ve ever experienced the disappointment of a negative pregnancy test, you’ve probably wondered, ‘is there something I can do to increase my chances of conception on my next try?’
The physicians at Shady Grove Fertility have the same goal as all of our patients, to increase the chances of pregnancy and ultimately take home a baby. When a patient’s cycle is unsuccessful our doctors review, in great detail, the plan used for that particular cycle and ultimately the results to see if any modifications can be made to optimize the patient’s next attempt.
From the careful monitoring and constant tailoring of individual cycles to extensive collaboration and innovation, the physicians at Shady Grove Fertility are always asking themselves how they can improve outcomes.
Collaborative Community
“The nice thing about working in such a large practice,” says Stephen J. Greenhouse, MD a reproductive endocrinologist at Shady Grove Fertility’s Fair Oaks, VA office, “is that the physicians come from many backgrounds and have been trained in different places, so everyone brings something different to the table.”
Shady Grove Fertility fosters an environment of teamwork on every level of patient care. Physicians frequently consult each other for feedback and recommendations whether it is in a formal meeting or through an E-mail. “When I want feedback on a patient, I can send an email to all 24 doctors within Shady Grove Fertility. Having an electronic medical record system allows all of our physicians the ability to review patient records and my notes to provide an in-depth assessment at any time.”
Physicians also attend formal weekly meetings to review complicated patient cases anonymously, the most recent fertility research and studies, and establish changes in the way they care for patients to increase everyone’s chance of success. Journal club, where internal and external research studies and findings are discussed, are not only attended by the providers, but by the embryology department, nursing department, and other groups such as NIH fellows and Georgetown Residents. “We find our meetings and journal club help give us a unified approach to the care our patients receive.” says Dr. Greenhouse.
An additional resource for Physicians with patients undergoing IVF is our embryology staff. Their prospective is unique since they see several thousand IVF cycles a year and can provide valuable information and insight to any treatment cycle.
Getting it Right from the Start
Getting the best results starts at the very beginning – with choosing the treatment plan that best suits each patient. “My decisions about which treatment plan and medication dosage to choose come from the results of the patient’s pre-screening tests,” explains Dr. Greenhouse. “Each test is a small piece of the patient’s puzzle and we can learn a lot from 3 rather simple tests, the patient’s age and her fertility history.”
The first test we start with is the blood work done on the 3rd day of a patient’s menstrual cycle, frequently referred to as “Day 3 blood work.” This test looks at the patient’s E2, FSH and LH. E2 refers to the estrogen level, the main female reproductive hormone which is secreted from the ovary. FSH is the acronym for Follicle-Stimulating hormone. This hormone is released from the brain and stimulates the ovaries to mature an egg. LH refers to ‘luteinizing hormone,’ which is integral in the final maturation and release of a mature follicle. Day 3 blood work along with considering the patient’s age is one of the best indicators we have for a patient’s potential success.
Although the blood work is important, it does not tell the entire story for each couple. We also analyze the partner’s sperm in a test called a semen analysis(SA). Three distinct indicators are measured in a SA – the count, or number of sperm in the sample, the motility, which is the sperms movement, and the morphology referring to the shape and sperm’s ability to penetrate an egg.
The last test we look at is the Hysterosalpingogram, or HSG. This test indicates if the uterine cavity is a normal shape, void of any obstructions such as polyps or adhesions that may cause miscarriage and the condition of the fallopian tubes. Physicians also look for hydrosalpinx, a condition that occurs when the tubes are filled with a fluid that can leak into the endometrial cavity at the time of implantation and decrease pregnancy and implantation rates by 50 percent. For patients with no open tubes or the presence of a hydrosalpinx , frequently IVF would be the preferred course of action. To successfully treat a patient using an IUI there would need to be at least 1 open tube.
Any single piece of the puzzle does not tell the entire story but when you put all the pieces together along with factors like the patient’s age and fertility history, including failed or cancelled cycles, physicians can select the most appropriate course of action to successfully treat a patient. Sometimes there are more than one option for patients whether it be IUI, IVF, or the use of Donor eggs. Selection of the right method is often the patient’s decision.
Monitoring and Tailoring
The first step in any treatment cycle is the stimulation phase, where prescribed medications, administered both orally or by injection, help grow and develop follicles. Along with daily medication, patients will also frequently monitor at their local office. The number of monitoring appointments will vary based on the type of treatment cycle, IUI cycles patients usually have 3-6 monitoring appointments where as in IVF cycles they have 5-8 over a 2 week period.
In each monitoring appointment, patients will have an ultrasound and blood drawn to be tested which determines how the cycle is progressing. The resulting blood test will tell the physician how the cycle is developing and how the patient is responding to the medication. “I’ll look to see how the egg follicles are developing and what the estrogen level is. If a patient is responding too fast to the medication, for example, we will lower the medication dosage. If we see that she did a previous cycle and her eggs weren’t mature, we will try to push the stimulation phase an extra day.” Frequent monitoring appointments allows physicians to closely track the progress of each cycle and optimize the treatment plan to result in the most desired outcomes as possible.
The second part of the monitoring is the ultra sound. Physicians look for 2 things in this step, the number of follicles and their size which indicates their level of maturity. The ideal number of follicles differs in an IUI cycle than in an IVF cycle. IVF provides greater control of the final number of embryos transferred where as an IUI cycles if there are more than 2-4 follicles the chance of multiplies increases drastically and frequently will lead to a cancelled cycle. When a cycle is cancelled, the patient stops their medication and abstains from intercourse until she gets a period and thus is able to start another cycle.
Patients have the ability to monitor at any Shady Grove Fertility office because of our electronic medical records system that enables every doctor to access a patient’s chart and medical information. “Each day that one of my patients comes in for monitoring, regardless of which office they visit, the results of their bloodwork and the images from their ultrasound are entered into the system, and I can review them,” says Dr. Greenhouse.
Monitoring results is another way Shady Grove Fertility physicians are able to work together on each patient’s cycle. There are always two doctors – the patient’s primary physician and another member of the medical team – who review monitoring results and sign off on the patient instructions. “If I’m not physically there for the patient’s monitoring,” says Dr. Greenhouse, “the doctor who is present will add notes into the chart for me to read about what they saw and their recommendations are for the patient.”
Under the Microscope
In the case of IVF treatment, the data keeps coming in after the egg retrieval and fertilization. Each subsequent day up until the embryo transfer, both the doctor and the patient get an update on the status of the embryos.
Our physicians often consult with the embryologists to get more unique information. “I will call them or even walk into the lab to talk to them in person,” Dr. Greenhouse says. They often make suggestions on the development of a patient’s embryos, if they are progressing in a normal fashion, whether to transfer of day 3 or day 5 and what is an appropriate number of embryos to transfer.
Discussing Next Steps with Patients
After the completion of a treatment cycle, if a patient’s beta (pregnancy test) comes back negative, physicians review the last cycle in detail. “When a patient has a failed cycle, the most important thing for me to convey is that she didn’t do anything to prevent the pregnancy,” says Dr. Greenhouse. After the cycle physicians now have so much more information that can be added to the puzzle to determine what the next move should and will be. “We have to respond to what the cycle is telling us, make adjustments and try again.” says Dr. Greenhouse.
After a thorough review by a patient’s physician, and potentially several others, patients are encouraged to meet with their doctor to discuss what was learned from the last cycle and what that means for the next cycle. Deciding how to proceed is ultimately up to the patients, but the goal is to arm patients with as much information about their options moving forward.
Something most patients wonder about is how many times it’s reasonable to try a particular type of treatment, like IUI, before moving on to something different, like IVF. Dr. Greenhouse says that to answer this question, he looks to his cycle review but also to success rate statistics. “It’s true that after three to four attempts the success rates go down. That factors into the decision, it’s another piece to the puzzle. We also have to be aware of the emotional toll of multiple treatment cycles. Patients can get discouraged by trying the same thing over and over without success.”
All of our physicians work to set expectations about the number of cycles we would try before we start a new treatment. Dr Greenhouse tells patients for example “I’m comfortable with trying IUI three times before we talk about possibly moving to IVF’. It’s better for the patients, I think, to have a sense of where we’re going from the beginning, so that if they do get a negative result, they know that we still have options left.” Most importantly, Dr. Greenhouse tries to give his patients support, perspective and a hopeful outlook about continuing treatment.
