Treatment

Once the decision has been made to proceed with fertility treatment, many patients wonder if it is going to work for them. For an overwhelming majority of patients, the answer is yes, but overcoming infertility may involve a course of treatment, meaning it might take a couple of tries to achieve pregnancy. In cases where the first cycle isn’t successful, the key when looking to start another cycle is optimizing fertility treatment to increase the chance of success.

How can your fertility treatment protocol change to increase the likelihood of pregnancy?

When a treatment cycle does not result in a pregnancy, some patients see the attempt as a failure. This couldn’t be further from the truth. Changes in medication, treatment type, and introducing genetic testing can all lead to an increased likelihood of pregnancy next time around.

“The reality for patients is that fertility treatment is a great diagnostic tool,” explains Dr. Shruti Malik of Shady Grove Fertility’s Fair Oaks, VA and Arlington, VA offices. “Treatment allows us to gain valuable insights into your fertility that no diagnostic test can give us. Each attempt gives us an opportunity to make changes until we get the formula just right so that conception can happen.”

The key is to tailor each subsequent treatment to address what we learn about the patient in the previous cycle. “These minor tweaks and changes often lead to the outcome each patient is looking for,” says Dr. Malik.

Optimizing Fertility Treatment: Look at the Medication

No matter the treatment type, one of the most commonly made changes after an unsuccessful cycle is to the medication protocol. These adjustments may help increase or decrease the number of follicles, affect uterine lining thickness, and impact other key parts of your cycle.

Intrauterine Insemination (IUI) Medication
For most women, whether under the care of an OB/GYN or a fertility specialist, clomiphene citrate (Clomid) will be the first medication they use to help them conceive. Clomid is a common oral medication that helps treat irregular or absent ovulation. While it can work really well for some patients, others may experience a thinning of the endometrial lining that may impact the ability for an embryo to implant in the uterus.

For patients under the care of a fertility specialist, your physician will monitor both the growth of the follicles and the thickness in the lining throughout the cycle. If the lining does not become as thick as desired or the cycle does not result in a pregnancy then an alternate dose of Clomid or another medication such as Letrozole may be an option in a subsequent cycle.

Letrozole works in a very similar way as Clomid without the side effect of a thin lining. If a follicle does not develop, or the first cycle with one to two follicles is not successful, then your physician may add an additional medication, gonadotrophins, to the medication protocol. Gonadotrophins stimulate the ovaries to produce between two to four follicles, which gives the sperm more targets to hit, thus increasing the chances of pregnancy.

In Vitro Fertilization (IVF)
The most common change to medication in an IVF cycle comes when planning the stimulation medication dosing. If a cycle does not result in the number of eggs expected, then either the type of medications may be changed and/or the dosing will be increased in the next cycle. This will allow the patient to recruit and develop more follicles from the beginning instead of having to try to catch up mid cycle.

Optimizing Fertility Treatment: Transitioning to a New Treatment Type

More than half of all the treatment cycles preformed at Shady Grove Fertility are low-tech options such as IUI. “We believe in a stepped-care approach to treatment, starting with the simplest, most affordable treatment option first and moving up to more advanced treatments when medically indicated,” explains Dr. Malik.

“For many patients, it makes sense to start with a more basic treatment, but if that treatment doesn’t prove to be successful, it becomes a question of when to consider transitioning to another treatment to increase the chances of conception,” Malik adds.

In women under the age of 35, the success rate with IUI is between 16 to 20 percent. “The goal here is to bring the patient to the chances of pregnancy per month seen in the fertile population, which is around 20 percent.” As patients move to more advanced treatment options, such as IVF, the chance of pregnancy in that same age group more than doubles to 50 percent.

“IVF treatment can be very insightful as to why previous attempts did not work,” explains Dr. Malik. IVF treatment answers many of these questions we have about the patient and the factors that can impact her ability to conceive.

• Is there a viable egg available and is that egg mature?
  Eggs that are being prepped for ovulation, grow and develop within the follicles found in the ovaries. However, not every follicle will contain an egg. During IVF treatment each egg is aspirated from the follicles during the egg retrieval. This allows us to confirm that, yes, there was in fact an egg in the follicle. After the eggs have been removed from the ovaries, physicians have a unique opportunity to determine if the eggs are mature. An immature egg cannot be fertilized making this a key piece of information in understanding the patient’s specific fertility.
• Is the sperm able to fertilize the eggs?
  During IVF, fertilization is done in an embryology laboratory, which allows embryologists to confirm that fertilization occurred. “There can be instances where the semen analysis looks great but the sperm is unable to fertilize the egg,” explains Dr. Malik. “This is a factor that can only be discovered when you are able to monitor the fertilization process as is the case with IVF,” adds Dr. Malik. When fertilization does not occur, your physician might recommend intracytoplasmic sperm injection (ICSI), which allows us to inject a single sperm into the egg increasing the rate of fertilization.
• How do the embryos develop?
  Another factor that greatly impacts the outcomes of treatment is the quality of the embryos. Embryos undergo a rating system to determine the high from low-quality embryos. Higher quality embryos are more likely to implant and become a viable pregnancy. Similar to the case with fertilization, this can only be evaluated outside of the body. The quality of a patient’s embryos can help inform the physician’s recommendations for a subsequent cycle. For patients who have low quantity or low quality embryos, the physician may suggest other treatment options such as donor egg treatment.

When egg or embryo quantity or quality becomes a barrier to conception, as commonly seen in women over the age of 40, then moving to donor egg treatment will significantly improve the outcome of treatment. For women over 40, chances of pregnancy via donor egg treatment is approximately 56 percent per cycle, double what the same age group would experience with IVF treatment using their own eggs.

Optimizing Fertility Treatment: Genetic Testing

Genetically abnormal embryos can implant and start a pregnancy but will often result in a miscarriage during the first trimester. “There are many patients that can easily get pregnant either on their own or with the use of fertility treatment but they’re unable to maintain the pregnancy,” says Dr. Malik.

The most common cause of first trimester miscarriage is a chromosomal abnormality within the embryo. As a woman gets older, her likelihood of having a genetically abnormal embryo increases. If you’re experiencing recurrent pregnancy loss (two or more consecutive miscarriages), your physician will discuss the option to genetically test each embryo with preimplantation genetic screening for aneuploidies (PGT-A), previously known as preimplantation genetic screening- PGS, to find those that are genetically normal.

During PGT-A, an embryologist biopsies each embryo to look for any chromosomal abnormalities that would likely result in implantation failure or miscarriage.

When a cycle does not result in a pregnancy or ends in a miscarriage it’s important to understand all of the care options available to you. Be sure to talk with your physician about the best path for you. Most patients will not need all of these options, but it is important to be aware that they exist and to let them guide you in your decisions about treatment.

Medical Contribution by: Shruti Malik, M.D., of Shady Grove Fertility’s Fair Oaks, VA and Arlington, VA offices.

Editors Note: This blog was originally published in December 2018.
 

Haven’t started your infertility treatment plan? Take the first step and learn more about fertility treatment. Click to schedule an appointment with one of our physicians or call our New Patient Center at 888-971-7755.

While infertility is often regarded as a female problem, the partner’s role is equally as important, as 40 to 50 percent of all infertility cases are due to male factor infertility. Dr. Paul Shin, Reproductive Urologist at Shady Grove Fertility, answered common questions about male factor infertility. Watch the full interview:

Q: How common is male factor infertility?
Dr. Shin: Male factor infertility accounts for upwards of half of couples trying to conceive who can’t. About 40 percent of the time you’ve got a female-related factor, about 40 percent of the time you’re dealing with a male factor, and another 20 percent or so is a combination of the two.

Q: What causes male factor infertility?
Dr. Shin: The causes of male factor infertility can really run the gamut from things that people are born with, so congenital abnormalities to different chromosomal issues, to things that can be acquired and can worsen over the course of a man’s lifetime, like testicular tumors, varicose veins, hormone deficiencies, lifestyle-related problems. These are all things that can factor into what a man’s effective sperm count is.

Q: Are there lifestyle changes men can make to improve sperm count?
Dr. Shin: The lifestyle changes are always a little bit of a tricky thing to advise people on and the tack that I usually take with many of my men is to ask them to observe more or less common-sense health measures. In general, when you’re talking about issues of general health and fertility, the two concepts are going to really dovetail pretty nicely together. The things that you know you should do for a healthy lifestyle are all things that are going to promote better fertility. No smoking, get some exercise, try to manage the stress in your life, but things like alcohol use, even tobacco and marijuana consumption, are all dose dependent. If you’re a heavy user almost to the point of abuse or addiction, that’s going to be such an assault on your overall health, that your fertility is going to suffer. However, if you have a glass of wine with your dinner at night, it’s not going to make that big of a difference. I think it’s more of a common-sense lifestyle that I try to propose to people.

Q: Are there certain supplements that men should be taking?
Dr. Shin: In general, I tend to be a bit of a purist in that you really ought to shore up your diet first before you lean a lot on supplements. Eating not as much processed food, more whole food, cooking more at home as opposed to eating out at restaurants. All of these things I think add up to a healthier lifestyle, which in turn is just going to benefit your fertility.

Q: Why do you test the man and woman at the same time during the fertility work-up?
Dr. Shin: For a lot of reasons. The first reason is that it’s super easy to test men. All you need is a masturbated semen sample, which most men aren’t going to have too much difficulty providing you. We also have the luxury of having so many different labs that men can produce in the privacy of their own home, which is a big deal for them. To walk into a strange place in a laboratory, get shut in a room that there are all these people around and they know what’s going on, so there’s a lot of apprehension amongst men because they have this preconceived notion of what it’s like to go in and give a semen analysis. When you can demystify that and make it available for them to do at home, it’s easy to do.

The biggest reason to get men evaluated early is that when you identify male factor problems, there’s oftentimes things that we can do or intervene to impact a change, but they take months to affect the change. The time that you want to identify a male factor problem is earlier on, so you have more options later on down the line as opposed to getting painted in the corner of having to do something more aggressive.

Q: What does a semen analysis help you identify?
Dr. Shin: At baseline and at its most fundamental, the thing that we’re trying to identify with the semen analysis is simply what is a man’s capacity to achieve a natural pregnancy with his female partner. At baseline, that’s the way we’d prefer everybody to do it, right? It’s certainly more fun, it’s more cost effective, it’s more convenient than doing it with the help of medications and injections and shots. Some couples don’t have a choice but what you’re really trying to draw a beat on with that first or second diagnostic semen analysis is – can the guy simply deliver enough or a reasonable amount of motile sperm into the female reproductive tract?

The analogy that I oftentimes would give to people is the female reproductive tract is like this big obstacle course or obstacle race. Just like any other obstacle course, the number of sperm that you start with isn’t always the number that you finish with and so it’s to your benefit to optimize that. The things that we focus on are the ejaculated volume of semen, the overall number of sperm, the percent of sperm that are moving and swimming, how those sperm are shaped or how they look, and then probably the most powerful number in the whole analysis is simply what is the raw number of moving sperm that you have to start with because that’s really going to be your best estimate as to what your potential to move forward is. There’s a lot of variability amongst semen analyses too so oftentimes we’ll want to check one or two just to get an idea of what neighborhood the patient lives in so that we can make our best guess as to how much help the couple is going to need.

Q: Does a man’s age affect his fertility?
Dr. Shin: Yes and no. It is definitely true that the reproductive decline that men go through as they get older happens over decades as opposed to a handful of years. In general, if you look at a man’s sperm-making capacity as he ages, the count and the number may be affected by things like an enlarged prostate or a diminished semen volume, but a man’s capacity to make sperm should continue throughout most of his adult life. The decline in that function, just like it is for women, can vary. The steepness of that decline can vary, but for the most part, we expect that it’s more of a gradual issue.

As to the question, can a man father pregnancies as he gets older, the answer is absolutely yes. You see examples of that in popular culture everywhere you look, but the subtext is that we are aware of more and more research where the sperm of older men don’t perform as well. The sperm of older men can take longer to get their female partners pregnant and you can have higher rates of miscarriage. When that sperm is put through an ultimate functional test, like in vitro fertilization (IVF), you can sometimes see that that sperm doesn’t function as well, you don’t get as many blastocysts or embryos. There are different clues that as a man reproduces or as a man gets older, his capacity to reproduce does take a little bit of a hit but it’s more of a qualitative look.

The strongest link with the effects of older men really have more to do with things along the neurocognitive end of the spectrum for the offspring. We’re talking about things like Asperger syndrome and autism and even to the point of things like schizophrenia, all have higher incidences in the offspring of older men. Again, we’re talking about more common occurrences of things that are still relatively rare, so I’ve never had it be a major obstacle for men, but it is something that we always talk to men about in terms of counseling because for a lot of those things, early intervention and recognition is really the key. If you can clue them into that ahead of time, it can really help with the development of the child.

Age and male infertility is also a relatively new phenomenon because we’re actually having a generation of fathers at ages that people in the past really didn’t concern themselves with fathering kids. We’re in a stage of really figuring out what those age effects are as well.

Q: What are the treatment options for male factor infertility?
Dr. Shin: The treatment options for male factor infertility span really the range of doing things to improve native sperm counts to help men’s ejaculated counts get better, which will improve natural pregnancy rates or even through IUIs.

There’s also sperm retrieval procedures for men who either don’t produce sperm or who are blocked or obstructed. On the production aspect of things, we treat things like testicular tumors and cancer, varicose veins. These are all surgical things that we do to help to augment men’s sperm counts.

There’s different hormonal treatments that you can offer. One of the big things that we’re seeing more of is men who come in on some form of testosterone replacement therapy that without even knowing it has really impacted their sperm counts. We can work from an endocrine perspective and help those men maintain hormone levels that are reasonable, so they have energy and libido and sex drive while preserving their sperm counts.

Then on the obstructive side of the spectrum, we do reconstructive surgery and microsurgery so that you can reestablish the flow of sperm into the semen. Example being vasectomy reversals but also just sperm retrievals from either the testicle or the epididymis, and freezing that sperm in an IVF cycle. The treatment options that we offer really run the full range from medical intervention all the way to different aspects of surgery.

Q: Is there a difference between a urologist and a reproductive urologist?
Dr. Shin: The interesting thing in reproductive urology is that if you look at the world of medicine, urology is this little black box that most people just don’t want to deal with and they’re happy to send patients into. Then in the world of urology, reproductive urology is this small box within the realm of urologists, so there’s maybe a hundred people in the U.S. that do what I do. We actually have two of them here at Shady Grove Fertility.

One of the main differences is going to be that male factor reproductive problems are exceedingly complex. They run the gamut from things people are born with to correctable lesions to sometimes things that you can’t do anything about. You have to have a wide and varied skill set with regard to how to take care of these couples, but more than anything else, one of the big differences with going to see a reproductive urologist is that we’ll devote the time it takes to really figure these problems out. This is not just a simple five to ten-minute office visit where you adopt one treatment plan and that’s your only option. Oftentimes, couples come in having multiple different pathways that they can follow and there’s so many different factors that need to go into that decision-making, not the least of which is the medical and surgical impact on a guy, what the medical burden is for his female partner, and you also have to factor in cost. Many of the fertility treatments that we can offer sometimes can be very expensive but there’s also a time factor to consider.

As reproductive urologists, we’re trained to think at the end of the line of – how do we help this couple achieve a pregnancy in a manner that makes sense for them, that’s ethically sound for them, and that makes cost-effective sense. I think that’s the difference that sets us apart. Not that we know any more or less urology. It’s like anything else. There’s a certain familiarity that comes with the subject matter with being specialized in it but it’s really having the breadth of knowledge and the time to really put into helping couples solve these problems, which can sometimes be pretty significant.

Q: What else would you like to tell patients about going through fertility treatment?
Dr. Shin: There are a couple of things that male patients will specifically bring up. The first is that there’s a hefty amount of sexual dysfunction that goes along with infertility and it’s something that no one really likes to talk about. Think about what’s happening. You’re taking something that is fun and elective, and you do it to your choosing and turning it into work. You’re making it a chore; you’re making it number eight on your to-do list of things that you can’t get through number six on. As a result, I make it a real point to talk to a lot of couples, and the guys especially, about things like difficulty maintaining erection and problems with ejaculating or premature ejaculation or just not being in the mood. These are all things that I feel are important to remind patients that it’s part and parcel for going through the infertility process. That intercourse becomes less frequent, it becomes more workman like and that it’s important to address those issues up front because once you have a kid those problems can continue to fester.

I always remind couples that we also have really robust counseling services here at SGF to talk about just the psychological and emotional burden of infertility. We live in an age where we’re instantly connected to a billion people on Instagram who are having babies, we’re subject to our parent’s questions to say where are my grandchildren, what’s wrong with you guys, what’s going on, what’s the holdup? We have a lot of couples come in where that’s a big deal for them psychologically and emotionally and they don’t have any outlet to talk about that. I do try to talk to people about the emotional and psychological toll that infertility has not only on your personal self-esteem, but also for your relationship at large.

One of the other things that really gets to couples about infertility is the lack of control that they have over it. Sometimes, you don’t have a choice in the matter. This isn’t anything that you opted into or out of and when couples find themselves in there, it can really feel like drowning in this sea of information. All these websites and chat rooms that you can go into and get advice and you get this unfiltered advice from everywhere, so it really pays off to talk to reproductive specialists for that reason. To help give you some clarity on what the treatment options are, what is likely to work, what is likely to not, and put it all into some perspective.

SGF’s Center for Male Fertility, led by Dr. Paul Shin, and Dr. Cori Tanrikut, offers a range of male services including basic evaluation and testing to state-of-the-art microsurgical techniques including varicocele repair, vasectomy reversal, and vasectomy, as well as sperm injection and extraction techniques that have nearly eliminated infertility among couples with a severe male factor.

When a couple goes through an infertility struggle, so much of the process revolves around mental strength, which is why SGF offers a variety of resources to provide support. Both in-person and online events, along with support groups, are posted monthly and encouraged for all patients to attend.

WATCH: Maria and Areen’s Patient Story: Overcoming Male Factor Infertility

When Maria and Areen Movsessian of Rockville, MD, tied the knot, they had no idea they would face years of infertility and heartache when they were ready to start building their family. They also had no idea that their struggle to conceive would lead them to uncovering a diagnosis of azoospermia, a rare condition characterized by the absence of sperm in the semen. After trying for years, the couple was blindsided to learn of Areen’s unexpected male factor infertility and wondered, “Is it ever going to be us?”

For more information about overcoming male factor infertility, watch SGF’s Male Fertility Webinar On-Demand.

To schedule an appointment with reproductive urologists, Dr. Shin, Dr. Tanrikut, or any of SGF’s reproductive endocrinologists, please call our New Patient Center at 1-888-761-1967 or submit this brief form.

SGF is home to the largest fresh-cycle egg donor program in the country. Each year, we work with thousands of women who are interested in helping people become parents through egg donation. This year marks an especially significant practice milestone, with 85,000 babies born since the center first opened its doors in 1991, and our egg donors have played a significant role in this remarkable achievement.

The mission of Shady Grove Fertility, as co-founder Michael J. Levy, M.D., describes it, has been to always do what’s in the best interest of the patients. It’s the Golden Rule of the practice.

“It is a wonderful challenge to reflect on the reality that in the 29 years of practice at Shady Grove Fertility we have helped bring over 85,000 babies into the world. I do not think that this is best understood by the staggering reality that every baby, child, and young adult would fill a large sports stadium, 170 elementary schools, 42 high schools, or a large university. It is best understood by thinking about one recent patient. When we first saw her she was feeling overwhelmed and depressed by 5 years of infertility. When she returned to proudly show us her baby her demeanor was transformed to one of pure joy. Her mother wrote to thank us for both her grandchild and for helping ‘get her daughter back.’ If we reflect on that baby, her parents, and grandparents we begin to realize what doing this 85,000 times really means,” shares Dr. Levy.

Our egg donors have helped make these moments of joy possible for patients who need an egg donor to become parents and we are so grateful for them. Without the generosity of the women in our Egg Donor Program, we would not have reached this incredible milestone. Patients from all over the world turn to SGF when they are seeking an egg donor. One of our Ireland patients shared her message of gratitude for her egg donor:

“Thank you a million, million, million times for giving him, and us, life. Thank you for the better life we have being his parents. Thank you for allowing for us to be Santa, have birthday parties, and be called ‘mom and dad.’ Thank you for the opportunity to see life through the eyes of our child; the hugs, the love, the chaos, the crisis over a missing toy and the messy car… we love it all. Honestly, we couldn’t love and cherish him any more than we do. We are proud to be his parents.”

SGF’s physicians and patients are so grateful for our past, present, and future egg donors. We continue to grow each day and make parenthood possible through egg donation.

Editor’s Note: This article was originally published in November 2017, but was reviewed and updated for accuracy in November 2019. 

Folklore, mommy forums, and even the medical community have long touted the notion that women suffering with endometriosis do not have the same success using fertility treatments, such as in vitro fertilization (IVF), as other women or couples. However, new research from Shady Grove Fertility, conducted in partnership with the National Institutes of Health’s (NIH) National Institute of Child Health and Human Development (NICHD), has shown that, in fact, endometriosis may not negatively impact chances of delivering a baby with IVF treatment.

Presented this week at the 75th Annual American Society for Reproductive Medicine Scientific Congress and Expo in Philadelphia, this new study gives hope to women diagnosed with endometriosis. According to the American College of Obstetricians and Gynecologists, 10 percent of women have endometriosis and almost 40 percent of women with infertility have endometriosis.

SGF’s Director of Research, board certified reproductive endocrinologist, Kate Devine, M.D., who sees patients in SGF’s Washington, D.C., K Street location explains the concept behind the study, “We wanted to understand whether endometriosis, which may decrease a couple’s chances of conceiving naturally, also decreases their chances of having a baby from IVF, as many believe. Furthermore, we wanted to understand ‘why’. Was it that these women didn’t have the same rate of genetically normal embryos? Or that they have impaired endometrial receptivity preventing them from achieving or keeping a pregnancy?”

This retrospective study looked at 472 frozen embryo transfers in SGF patients using chromosomally normal blastocysts (as shown by preimplantation genetic testing for aneuploidy [PGT-A]). Three subsets of patients were included: women with surgically proven endometriosis, patients with isolated male factor infertility, and non-infertile patients electing genetic testing for a single gene disorder. The male factor infertility and single gene groups of patients were selected for comparison, as they typically yield strong pregnancy and delivery rates using IVF and because neither egg nor uterine infertility factors were likely to be present.

The results from the study showed that women with endometriosis had statistically similar rates of pregnancy and live birth compared to the other groups. Further, when patients with endometriosis were compared to each control group, there was no difference in the number and frequency of chromosomally normal blastocysts with PGT-A.

“We are excited to see that even though women with endometriosis may have impaired fertility, their diagnosis is not limiting them in their success with IVF treatment,” shared Dr. Devine. “Patients can be reassured that their chances of a live birth are good when a euploid blastocyst is available.”

“I’m encouraged for women and what this means for how we treat endometriosis. Along with advancements that we continue to make across the board, this study should encourage women with endometriosis that it’s very possible to build their family with the right treatment and timely care,” adds Devine.

Looking for More Information on Getting Pregnant with Endometriosis?

Watch our Endometriosis On-Demand Webinar

During our on-demand event, hosted by Dr. Naveed Khan, viewers will learn about the causes and symptoms of endometriosis, and the treatments that are now available to help women conceive. With proper counseling and care, the chances of getting pregnant with endometriosis are high for most women.

Register today to participate in this informative, free on-demand webinar and watch now or at your own convenience.

To learn more about this study, or to schedule an appointment with one of our physicians, please call our New Patient Center at 888-971-7755 or complete this brief online form.