General

The fertility window is described as the most fertile period during a women’s menstrual cycle in which intercourse may lead to a pregnancy. This window is centered around ovulation and speaks to the egg’s short life span of 12-24hrs. When Shady Grove Fertility opened in the 90s, many infertility patients were using “old school” methods to determine whether ovulation occurred, such as Basal body temperature (BBT) charts. As of today, BBT charts are considered an unsophisticated measure, and have since been replaced with simple scientific tests that can quickly and more accurately predict ovulation. SGF Houston physician, Janet Bruno-Gaston, M.D., who see patients at SGF’s Houston – Memorial City and Houston – Texas Medical offices, provides facts about BBT and how you should be measuring your fertility.  

What is basal body temperature and is it accurate? 

Following ovulation, there is a characteristic change in a women’s BBT by 1°C. The most fertile period during the menstrual cycle occurs directly before ovulation. Using BBT requires patients to retrospectively outline when to be most sexually active. For those of you who have tried charting your basal body temperature, you know the routine. Tracking your basal body temperature can have some unrealistic expectations such as remembering to have a thermometer by your bedside, having an undisturbed night of sleep, or not going to the bathroom throughout the night.  

While charting your basal body temperature is sometimes suggested by some physicians or online “experts,” and a biphasic (demonstrated temperature increase) may indicate ovulation, the BBT method is inherently inaccurate and can be anxiety-provoking.  

What other methods are used to determine your fertility window? 

Prior to ovulation the brain releases luteinizing hormone (LH) that triggers the release of an egg from the ovary. The LH surge typically occurs 12-36 hrs before ovulation. This provides a more accurate assessment of the fertility window and informs patients when it is most important to be sexually active. The most common methods used to determine the LH surge are ovulation predictor kits and serum blood levels. 

Ovulation predictor kits

Ovulation predictor kits can be purchased over the counter and use urinary test strips to detect a rise in LH levels. We recommend that couples are sexually active on the day of the LH surge and the day after to optimize chance of pregnancy for that cycle. Additionally, your fertility specialist may monitor your cycle more closely with transvaginal ultrasound and laboratory testing to determine the maturation of a egg in your ovaries and ovulation using serum blood levels. 

Your menstrual cycle   

The menstrual cycle is an important vital sign that reflects the health of your reproductive system. For women with irregular cycles, ovulation predictor kits may not be reliable and I recommend early evaluation with a fertility specialist as you may need additional testing.  

“As I always tell my patients – when dealing with infertility, we might not always have a diagnosis and cure, but the testing gives us a direction to formulate a treatment plan to optimize the potential to become pregnant,” shares Dr. Bruno-Gaston. “Once your diagnosis is established, a treatment plan will be tailored to suit your personal situation. The recommended approach will depend on your age, diagnosis, the duration of infertility, any previous treatments, and your personal preferences.” 

Remember to always communicate with your physician, your nurse, and any of our staff with questions and concerns along the way. 

Technology within the fertility world has made great strides over the last 20 years and will continue to progress over the years to come. Our goal as doctors and scientists is to continue to provide improvements on old school techniques, like basal body temperature, to lead to higher success for you, our patients. 

Medical contribution by Janet Bruno-Gaston, M.D., MSCI

Janet Bruno-Gaston, M.D., MSCI, is board certified in obstetrics and gynecology and in reproductive endocrinology and infertility (REI). Dr. Bruno-Gaston received her medical degree from Morehouse School of Medicine, where she was recognized as a Community Health Honors Scholar for her work with health care disparities.  

At Shady Grove Fertility (SGF), we believe in a stepped-care approach to treatment, starting with the simplest, most affordable low-tech fertility treatment options first and moving up to more advanced treatments only if needed. 

More than half of all the treatment cycles we do are considered low-tech and many patients find success with this route. Oftentimes, it makes sense to start with the low-tech treatment, but when fertility treatment doesn’t initially work, it becomes a question of when to consider moving forward to advanced fertility treatment to increase the chances of conception?  

While IVF is one of the most successful fertility treatments ever created and has the highest per cycle success rate, many patients who pursue treatment at SGF will be able to achieve a pregnancy with less intensive treatment option. 

Dr. John R. Crochet Jr., M.D., an SGF Houston physician, who sees patients at SGF’s Houston’s Beaumont and Clear Lake offices, shares insights of when to take the next steps in your fertility treatment plan.  

“Many individuals and couples delay seeking fertility treatment because they are intimidated by advanced fertility treatments,” shares Dr. Crochet. “We want patients to know that low-tech fertility treatment options can be an affordable and effective first step for those trying to conceive.”  

When to seek help from a fertility specialist 

The first question most couples ask if they are having trouble conceiving is: When should we seek help from fertility specialist? The easiest way to answer this question is to look at the accepted guidelines based on the age of the female partner, in instances of opposite-sex couples.   

SGF recommends seeing a fertility specialist if a woman is: 

• Under 35 with regular cycles, unprotected intercourse and no pregnancy after 1 year 
• 35 to 39 with regular cycles, unprotected intercourse and no pregnancy after 6 months 
• 40 or over with regular cycles, unprotected intercourse and no pregnancy, more immediate evaluation and treatment are warranted 

If there are other known conditions or you are experiencing irregular periods, you should seek help from a fertility specialist sooner. LGBTQIA+ individuals and couples and those interested in pursuing single parenthood are encouraged to seek help from a fertility specialist when they are ready to learn more about their family-building options.  

Some patients will start by talking with their OB/GYN, but it’s also perfectly fine to schedule a consult with a fertility specialist.  

“When you start your fertility journey, we’ll begin with a basic fertility workup that includes testing for both partners,” shares Dr. Crochet. “From there, we’ll be able to chart a path for your fertility treatment that will optimize your chances of success and could likely begin by exploring low-tech fertility treatment options.”  

When to get started with Clomid or Letrozole  

Most patients have the option of starting with low-tech forms of fertility treatment. In fact, many patients start with oral medications (i.e. Clomid or letrozole) while still under the care of their OB/GYN. These treatments don’t have the high success rates associated with in vitro fertilization (IVF) but they are simpler and much more affordable. 

When oral medications are not working, though, it could be time to take another step in your fertility treatment journey.  

“If we look at the data, we see that after 3 to 4 cycles of oral medications, the success rates drop off dramatically, even if the woman is ovulating. If she is over 35 or the couple’s infertility is unexplained, the data show that they should move on even sooner,” shares Dr. Crochet. “In fact, it’s actually been shown that it is more cost-effective to switch to more advanced treatments like IVF rather than continuing with Clomid.” 

When to take the next step in your fertility treatment plan 

After oral medications or speaking with their OB/GYN, the next step is visiting a fertility specialist, but that doesn’t mean jumping right into IVF. Depending on the patients’ diagnoses and age, there are still several steps a fertility specialist might recommend before IVF.  

For example, patients might continue oral medications and intrauterine insemination (IUI) but add injectable medications. One thing that will change when you work with a fertility specialist is that you will be monitored with ultrasound and bloodwork throughout the stimulation phase of whichever treatment you do. That way, you and your physician will know if the medications are having the desired effect. 

If a treatment cycle does not result in a pregnancy, the patient will meet with their physician to review how the cycle went and how to proceed.   

In addition to one-to-one conversations with physicians, patients are also provided opportunities to speak with their nurse, professional counseling staff, and make use of SGF’s resource library and free, fertility events.  

When to move forward to IVF  

“Ultimately patients will make the decision on what to do moving forward with their treatment. I always provide the patient information on their cycle, the success rates, and data that we have which helps them to make the most informed decision,” offers Dr. Crochet. “If a pregnancy is not achieved within a few cycles of oral medication or IUI, we can review those cycles together and decide when to move on to IVF.”  

IVF is the most successful treatment a couple can do using their own eggs and sperm. IVF is also one of the few treatment options where success rates have gone up over time due to technological advances. Women under the age of 35 have a 50% chance of getting pregnant on their first cycle. However, about 59% of women undergoing IVF will have remaining high-quality embryo(s) to freeze for a subsequent frozen embryo transfer (FET). 

SGF also offers innovative financial plans to help make fertility treatment more affordable, including the Shared Risk 100% Refund Program.  

When to move forward to donor egg treatment 

Some patients, especially those who are over 40 or have other medical conditions that reduce the quality of their eggs, go straight to donor egg treatment. For most patients, however, the move is a result of not having success with IVF. 

For these patients, it can be a hard transition, especially if they are younger,” says Dr. Crochet, “but the upside is that their chances of success can jump to over 50% when they move to donor eggs.” 

For women unable to conceive using their own eggs, donor eggs allow for a woman to carry a child that is genetically linked to the male partner. Donor egg treatment also offers the highest pregnancy and delivery rates of any fertility treatment because the donated eggs come from women between the ages of 21 and 32 which coincides with these women’s peak fertility. Patients using donor eggs at Shady Grove Fertility have a 51% live birth rate with each transfer. 

Extensive personal and medical histories are provided on every donor. Once a donor is chosen, the cycle is quite simple for the donor egg recipient. You will take medications that prepare your uterine lining for pregnancy. The male partner will provide a semen sample that will be used to fertilize the donor eggs. Once the embryos are ready, an embryo transfer will take place. 

Bringing home a baby 

When mapping out a treatment plan, it helps to focus on the end goal — bringing home a baby.  

Along the way, your physician will guide you with evidence-based recommendations for the needs of your family, and the SGF community will be there to support you in whatever decisions you make.  

“For people struggling to conceive, we encourage you to reach out to a fertility specialist at SGF so we can help build the family of your dreams,” shares Dr. Crochet. “We’ll take our patient-centered approach of stepped-care treatment to optimize your chances of success.”   

Medical contribution by John R. Crochet, Jr., M.D.  

John R. Crochet, Jr., M.D., is board certified in obstetrics and gynecology (OB/GYN) as well as reproductive endocrinology and infertility (REI). Dr. Crochet received his medical degree from the University of Texas Medical Branch in Galveston. He then completed his residency in OB/GYN at the University of Texas Southwestern Medical Center in Dallas where he received commendations for his teaching and was recognized for excellence in laparoscopic and endoscopic surgery and ultrasonography.

For many patients who pursue fertility treatments, especially for intrauterine insemination (IUI) or in vitro fertilization (IVF), a common ritual becomes visits for morning monitoring during your treatment cycle. The goals of these sometimes-frequent appointments are to make necessary mid-course adjustments to your treatment protocol and to determine the best timing for ovulation or egg retrieval by monitoring estrogen levels and follicle size. This helps us achieve the best possible outcome for you while avoiding potential complications. 

What is involved leading up to monitoring?  

There are common initial steps in your fertility journey with Shady Grove Fertility – initial consultation with a physician, meeting with the nurse clinician nurse, initial Day 3 blood work, ultrasound, HSG, and semen analysis. Some of these tests may have been done prior to coming to see an SGF physician and can be incorporated without repeating. 

Once a treatment plan has then been decided upon by your physician, the new protocol begins. This visit is very important because it provides your physician with baseline readings of hormone levels as well as an opportunity to view the uterus and ovaries via ultrasound. 

“The ultrasound provides us with a view of the shape and musculature of the uterus, ability to see if there are any cysts present, and a visualization of the uterine lining,” explains Alex Polotsky, M.D., medical director of SGF Colorado, who sees patients at our Denver office. “Additionally, egg cells should be ‘immature’ and the follicles at a ‘resting state’.” 

Typical baseline blood hormone levels prior to the start of medication for IUI & IVF should be:

• Estrogen – < 50pg/ml
• Human chorionic gonadotropin (hCG) – < 1 mIu/ml 
• Progesterone – < 1ng/ml

Once your physician has reviewed the results of your blood work and ultrasound, you will receive a phone call from your nurse to confirm your medication protocol and to make an appointment for your next monitoring appointment. 

How many monitoring appointments do I need? 

The amount of monitoring necessary is tailored to each patient. A patient who is using oral ovulation stimulation medication such as clomiphene citrate (Clomid)  or letrozole (Femara) with an IUI or timed intercourse cycle may require only 2 to 3 monitoring sessions, whereas patients using injectable medications in conjunction with either an IUI or IVF may need to be seen up to 7 times in a 2 week period. 

“The number of times we bring a patient in for monitoring is usually related by the strength of the medication in their treatment protocol,” shares Dr. Polotsky. “Patients who are on lower strength stimulation drugs such as Clomid or Femara may need to be monitored less frequently. In contrast, patients on stronger, injectable medications need to be watched much closer to adjust the dose of medication being given for safety and effectiveness.  Safety is paramount as we want to make sure patients have appropriate response. The so-called “Goldilocks Rule” is a good way to describe – we want just the RIGHT response, not too much and not too little.

What is the ideal follicle size and uterine lining to begin treatment?

At each visit, our physicians look for a balance between hormone levels and ovarian response. Since the hormone estrogen is the prime factor in both increasing follicle size and building up the uterine lining, making sure that levels continue to rise throughout the cycle is a key factor. 

We look for the follicles and uterine lining to grow at an appropriate rate. So, if we see a patient with too high a response to the medication, then we will adjust it to slow them down some, while we will increase the medication for a patient who may be responding at a slower rate. 

At that first monitoring appointment, the patient’s ovaries should be non-active or “resting” meaning that none of the follicles have begun maturing. As medication is introduced, the follicles will begin to grow, roughly an average of 2 mm per day during the later stages of stimulation. The increase of estrogen levels within the blood provides hormonal evidence that the follicles within the ovaries are maturing. 

“The rate of follicular growth is dependent on the phase of the stimulation cycle,” explained Dr. Polotsky. “Early on, follicular growth may be minimal, but once the follicle(s) have committed to ‘active’ growth, then they may grow 1-3 mm per day.” 

How many follicles should my ovaries be producing? 

The number of follicles produced is dependent on the treatment option. For women who are utilizing an IUI cycle, physicians will look to keep the number of follicles lower to avoid the risks of multiple pregnancy, while in a more controlled IVF cycle a woman may produce a greater number of follicles because we can limit the number of embryos transferred later on. 

“The expected number of follicles is dependent on many factors, primarily age and overall ovarian reserve,” said Dr. Polotsky. “The definition of a ‘good’ number of follicles varies from patient to patient and is based on their individual treatment protocol and type of stimulation they are undergoing.”

What is the ideal follicle size to trigger ovulation? 

“The maturity of an egg in the follicle is in part reflected by the follicular size; on average, the ideal follicular size is 18 to 20 millimeters or larger, depending on the type of medications used,” explains Dr. Polotsky. 

The increasing estrogen level is also responsible for building the uterine lining. An optimal measurement of thickness for the implantation of a fertilized egg is greater than 7 mm and preferably greater than 8 mm, regardless of the type of treatment one undergoes. 

When the lead follicle(s) reach about 20mm in size, the estrogen is rising and the uterine lining is a thickened ‘feather pattern’ in a medicated cycle, it is time to administer HCG, or, for some patients undergoing IVF, Lupron. The HCG (or Lupron) brings about the final important phases of maturation of the egg in the follicle, as well as ovulation for an IUI cycle or to plan the proper timing for the egg retrieval in an IVF cycle. It is at this time that the follicle, the estrogen it is producing, and the responding uterine lining should all be working together to create the best environment for the introduction of a fertilized egg. 

Monitoring at Shady Grove Fertility

By frequently checking the important variables in a fertility treatment cycle through these monitoring visits, we can provide the patient with the best chances of achieving their goals of successfully conceiving a healthy pregnancy and ultimately delivering a healthy baby, whether through IUI or IVF. 

Medical contribution by Alex Polotsky, M.D.

Alex Polotsky, M.D., M.Sc., FACOG, is board certified in obstetrics and gynecology and reproductive endocrinology and infertility. He is the Medical Director for SGF Colorado. Dr. Polotsky sees patients at SGF Colorado’s Denver office.