Does my thyroid matter? - By Dr. Jessica Scotchie

There are many causes of infertility and recurrent pregnancy loss. Often the tests performed by Tennessee Reprodictive Medicine are screening tests to guide further investigation or treatment. Thyroid dysfunction is one condition that may affect our patients.

The thyroid gland is a small gland located in the neck, responsible for making thyroid hormones which help regulate metabolism. Thyroid dysfunction is very common, affecting up to 10% of the population at any given time. In general there are two forms of dysfunction: decreased thyroid hormone production (hypothyroidism) and increased thyroid hormone production (hyperthyroidism). Underactive disease, or hypothyroidism, affects 2-10% of individuals, and occurs 5-8 times as often in women than men. Overactive disease, or hyperthyroidism, is less common, affecting 1-5% of individuals. With both forms of thyroid disease, women are affected far more commonly than men (5-8x more often).

The symptoms of thyroid disease are easily recognized, but are also commonly seen in other disease presentations and among healthy individuals. Hypothyroidism presents with weight gain, fatigue, cold intolerance, hair loss, constipation, muscle aches, and difficulty concentrating. Hyperthyroidism often presents with weight loss, tremors, hair loss, anxiety, irregular heart beat (palpitations), and sweating. Both underactive and overactive disease can result in menstrual irregularities in women.

Most thyroid diseases are caused by autoantibodies against components of the thyroid gland. Antibodies are molecules made by our immune system to fight infection; in the case of auto-antibodies, our immune systems mistakenly make molecules to fight a part of our body that the immune system should recognize as a normal part of the body. The end result is organ damage, which either causes decreased thyroid hormone production (hypothyroidism) or increased hormone production (hyperthyroidism).

How do we screen for thyroid disease? Physicians will generally start with a thyroid stimulating hormone level (TSH). The TSH hormone is made in the pituitary gland (in the brain) and is sent to the thyroid gland to tell it to make thyroid hormone (think of the accelerator in your car). The thyroid then makes thyroid hormones (T4 and T3) which circulate back to the pituitary gland; the pituitary gland then recognizes that there is sufficient circulating T4 and T3 and keeps the TSH in a normal range (think of a feedback loop). When there is too little thyroid hormone, the pituitary should respond by increasing the TSH level (as if stepping on the accelerator harder to make the car go faster), therefore underactive thyroid disease typically presents with an elevated TSH level. In contrast, if there is too much thyroid hormone, the TSH is usually suppressed, because the high levels of T4 and/or T3 have signaled back to the pituitary that there is no need for TSH to keep signaling for more T4 and T3 to be made (think of the accelerator being pushed as hard as possible, there would be no need for you to push harder to go faster). There are other conditions in which this relationship is not as straightforward as just described, and for this reason it is important to rely on your physician to correctly interpret hormone results.

How do we treat thyroid disease? For the two abnormalities described previously, the goal is to restore the thyroid hormone levels back to normal. For hypothyroid disease, we replete the patient with thyroid hormone. Usually after about 4 weeks of treatment the TSH level is rechecked and the dose adjusted until the TSH is in a normal range. For hyperthyroid disease, treatment options include medications to suppress thyroid production (propylthiouracil and methimazole), radioiodine ablation, and surgical removal of the thyroid. The optimal treatment can be decided with your physician. There are other causes of thyroid diseases (tumors, cancer, nodular goiter) that are treated differently and beyond the scope of this blog.

You may be asking yourself, why does a fertility specialist care about the thyroid? The answer is normal thyroid function is critical for normal menstrual function and for optimal pregnancy outcomes. Hypothyroidism has been associated with increased risks of miscarriage, pre-eclampsia (blood pressure disease in pregnancy), and low birth weight babies. Untreated hypothyroidism can also result in mental deficiencies in children, which in the most severe form is known as cretinism. Some women do not have overt hypothyroidism, but have mild lab abnormalities that we would call subclinical hypothyroidism (high TSH but normal thyroid hormone levels). Subclinical hypothyroidism has also been associated with higher rates of miscarriage.

Hyperthyroidism is also associated with adverse outcomes, including pre-term delivery, pre-eclampsia, maternal heart failure, low birth weight babies, and miscarriage. Fetal hyperthyroidism can also occur as a result of maternal autoantibodies passing through the placenta, and causing fetal goiter (enlarged thyroid) which in severe cases can affect the mode of delivery.

Clearly, avoiding these complications is critical and generally easy to do by closely monitoring a woman’s TSH level and adjusting thyroid medications to keep the TSH level in a low-normal range (ideally < 2.5 mIU/ml in pregnancy). Women with hypothyroidism typically require increased doses of levothyroxine in pregnancy due to the expanding plasma volume that occurs in pregnancy. Women with hyperthyroidism are usually treated with oral medications, as radioiodine cannot be used during pregnancy.

The big central controversy with thyroid disesae at the present time is whether or not to screen all women who are trying to conceive or newly pregnant. We clearly know that overt over- and underactive thyroid disease is bad. We don’t have solid evidence that subclinical disease poses the same risk, or that treating women with subclinical disease improves these possible risks. There are two main professional societies that regularly review available medical evidence and make recommendations on practice guidelines for physicians. The American College of OBGYN currently does not recommend universal screening, on the basis that there is insufficient data to suggest that treating subclinical hypothyroidism improves obstetric outcomes. The Endocrine Society tends to lean more towards liberal screening, however they also do not recommend universal screening. They instead recommend screening any women with the following characteristics:

1. Infertility.
2. History of miscarriage or preterm delivery.
3. History of any thyroid dysfunction, or a family history of thyroid dysfunction
4. Presence of a goiter (enlarged thyroid).
5. Known thyroid antibodies.
6. Symptoms suggestive of disease as outlined above.
7. Type I diabetes.
8. Presence of other autoimmune diseases.
9. Prior head or neck radiation.

Most of the patients we see are infertility and recurrent pregnancy loss patients. In our professional opinion, due to the fact that treatment for thyroid disease (especially hypothyroidism) is generally well tolerated and has few risks, we feel that the benefits of treatment outweight the risks of treatment, and therefore screen most of our patients trying to conceive with a TSH level.

There Is Always Something To Worry About - Part 3

How to Get Pregnant and Have a Healthy Pregnancy

Step 3 – Getting Pregnant

When I meet an infertility couple, the first things I want to know are the age of the woman, her past reproductive history and how long this couple has been having intercourse without contraception. I’m generally not as interested in how long they’ve been “trying” to get pregnant. The reason I say this is because if couple has been “trying” to get pregnant for 6 months but have not used any form of birth control in six years, then they have 6.5 years of infertility. Their prognosis is frequently much worse than another couple who quit birth control 12 months ago and is not pregnant.

If you have not used birth control in 1-2 years and are not pregnant, call and make an appointment today to be seen by your provider or by us at 423-876-2229. If you are still truly in the early stages of trying to get pregnant, please continue to read.

Areas of Concern
When we give talks about getting pregnant, we frequently discuss 6 areas of concern: duration of infertility, adequate intercourse, adequate ovulation, adequate sperm, anatomy and ovarian reserve.

Of the six areas of concern, three are essential to conception and these are: a woman must produce an egg (ovulation), the man must have sperm, and the sperm and the egg must be able to meet (adequate anatomy.

Adequate Intercourse
Many couples who are trying to conceive fixate on exact timing of intercourse, when in truth exact timing is not particularly important. What is essential is that a couple has intercourse on, or prior to, the day of ovulation. Sex on a single day of the month has virtually the same chance of pregnancy if the sex occurs on the day of ovulation, the day before ovulation or even the day before that. Sperm can live up to 5 or 6 days and still fertilize. This means, for most couples, intercourse every 2-3 days is adequate.

Intercourse 24 hours after ovulation has a very low chance of pregnancy. After ovulation, the egg lives only about 12-24 hours. So make sure you have sex prior to ovulation if you want to conceive.

Ideally, adequate intercourse would mean satisfactory intercourse for both partners. Unfortunately, for the purpose of getting pregnant, it really only has to be satisfactory for the male – as he must deposit sperm into his partner. Female orgasm has no significant role in fertility. I know, it’s not fair.


Adequate Ovulation
Ovulation (producing an egg) is essential to getting pregnant. Most women who have regular predictable menses are ovulating. Ovulation is even more likely in regularly cycling women who reliably predict their menses because of breast tenderness or bloating or mood changes that precede the menses by a few days. Ovulation can be confirmed various ways, with basal body temperatures, ovulation predictor kits, or even a blood test. Ovulation is generally deemed adequate when the luteal phase is 11 days or longer based on basal body temperature charts or 12 days or longer based on ovulation predictor kits. For more details, click Ovulation.

Normal menstrual cycles are between 24-35 days. Shorter cycles frequently mean a woman’s ovarian reserve is declining and should be evaluated. Longer cycles can mean a woman is not ovulating and also should be evaluated.

Adequate Sperm
If a man has any sperm, it is possible to get pregnant; however, once sperm counts go below 15 million per ml, the chances of pregnancy can plummet significantly. Of course, we don’t recommend home sperm testing, because there are many facets of sperm which may affect fertility. Because it is a painless test, this should be the first test sought by a couple.

If there is a history of frequent sauna or hot tubbing, significant testicular trauma, testicular surgery, undescended testicle, prior radiation or chemotherapy, low libido, erectile dysfunction or low volume ejaculations then a more immediate evaluation should be pursued.

Adequate Anatomy
The fallopian tubes serve as a transit system for sperm and eggs. When a woman ovulates, the tube picks up the egg and holds it there for sperm to fertilize. For their part, the sperm are deposited in the vagina and have to swim through the cervical mucus, up through the uterus and out to the tube. Only 1 in a million sperm will eventually make it to the egg with intercourse.

□ If the cervical opening is small or scarred due to prior surgery it may not produce the needed cervical mucus which assists in the transport of sperm.
□ If the tubes are blocked, the egg and the sperm cannot meet.
□ If sheets of adhesions (scar tissue) separate the ovary from the tubes, getting pregnant can be a real challenge.
□ If benign tumors such as fibroids are growing in the uterus, this may prevent a pregnancy from taking hold.

Women with infertility for more than 1 year should have an x-ray called a hysterosalpingogram performed. For more details, click on HSG.

Endometriosis, a condition in which uterine lining grows outside the uterus, can sometimes distort the anatomy. Even when it doesn’t distort the anatomy, endometriosis can make getting pregnant more difficult. If you are just starting to get pregnant and you have a history of endometriosis, ask your physician if yours is so severe that you should do something about it. We’ll talk more about endometriosis and fertility in a future post. For more information now, click Endometriosis.

Ovarian Reserve
This is the biologic clock. The best predictor of the biologic clock is a woman’s age. By age 35, nearly 30% of women will be sterile. By age 40, nearly 70% will be sterile. In a study of women who never used any birth control and stayed married their entire lives, the last average pregnancy occurred at age 42. Many of these pregnancies ended in miscarriage because the embryos have a higher rate of being abnormal the older women get.

The biologic clock, or ovarian reserve, is determined by several factors: how many eggs a woman had at birth, how much damage has occurred to her ovary or eggs throughout her life, and how quickly she has lost her eggs.

Smoking, ovarian surgery, radiation and chemotherapy can all lead to premature depletion of eggs. Genetics can also cause early loss of eggs. We find that many women with unexplained infertility and with endometriosis have findings consistent with diminished ovarian reserve.

A sign that ovarian reserve is decreasing is a shortening of the menstrual cycle. Women who were regularly menstruating every 28 days, may find themselves having cycles every 24 days. This can be evidence of diminished ovarian reserve. The same goes for women who had PCOS and who never or rarely ovulated on their own who suddenly find themselves having normal menses.

If you have any of the risk factors above, strongly consider having your physician, or us, evaluate your ovarian reserve.

For more information click on diminished ovarian reserve.

If you have questions on any of the topics listed above, call us and make an appointment, visit our website: http://www.trmbaby.com/.

Fertility Testing At Home: Home Sperm Testing

Over the past few years more and more fertility tests have become available for home use. This month one of the leading journals in the fertility world, Fertility and Sterility, published a very nice review of many of these home tests. Coincidentally, I just gave a talk about many of these tests and thought I would share my thoughts about them.

For the sake of time and space, I’ll tackle these one at a time. Today, we’ll talk about home sperm testing.

Before we get there, let me give some background.

The idea of home testing fits a definite need among consumers. It’s nice to be able to learn that you’re pregnant without making a doctor’s appointment. It’s also nice to identify problems early, if that leads to evaluation and effective treatment.

The problem with a lot of tests on the market is that they can be falsely reassuring and may cause some people to delay proper evaluation. There is no good evidence that performing such tests actually improve a couple’s chance of conception. A patient without a history of infertility is most likely wasting their money. On the other hand, if a couple has not conceived within 1-2 years of unprotected intercourse, I’m not sure that any home test is particularly reassuring. A falsely reassured patient may delay treatment and therefore is at risk for not meeting their reproductive dreams.

Several years ago after hearing a story about home fertility testing on NPR’s All Things Considered, http://www.npr.org/templates/story/story.php?storyId=10712488 I wrote a letter describing some of the pitfalls to such testing. http://www.npr.org/templates/story/story.php?storyId=10819112

The two tests described where a semen test and a test to measure a woman’s FSH, marketed under the name Fertell (Genosis Ltd).

The Fertell sperm test can determine if a man has 10 million total motile sperm and is sold for close to $100. The advantage of this test is that many men are embarrassed to have a formal semen analysis performed. Also, the test determines the motile concentration, which is fairly predictive of normal fertility. Recently, the World Health Organization (WHO) published findings showing that 95% of fertile men had a sperm concentration of 15 million sperm/ml and 32% were progressively motile and 5% or more had a normal shape. A reassuring Fertell tests should correlate well with 2 of those 3 parameters. If abnormal, the test should lead a man to have further testing performed.

The drawback to the Fertell sperm test is that it does not test morphology, which can be very important. The cost is also a drawback. For an additional $50, a patient can have a full semen analysis at our clinic and have it interpreted by a physician who can interpret the results in the context of the couple.

Other home semen tests are also available. Embryotech has marketed several tests FertilMARQ, Start Male Infertility Test and PreConceive: A Male Fertility Sperm Test, all of which purport to evaluate sperm concentration. Because it tests only a single parameter (concentration), it tells nothing about motility or morphology. A man with few or no moving sperm may be falsely reassured. (As with the Fertell test, an abnormal result should be followed up with a visit to a physician’s office.)

There are also small microscopes available: http://www.amazon.com/Micra-Sperm-Test-Count-Motility/dp/B000SLM504. The disadvantage of this test is that interpretation is left up to the patient. As with all home testing, the disadvantage to the home microscope is that there is no one with clinical experience to interpret the test in the context of the couple.

One of the tenants of good medical practice is to treat the patient, not just the test.

As I said above, a normal test does not mean that all is well. A person without infertility may find this test reassuring; however, this person probably doesn’t need the test in the first place. A full semen analysis gives significantly more information than any of these tests. A couple with infertility is probably better off having a medical evaluation by a knowledgeable physician. However, if the only way to get a man to get tested is with at an at home test, I would pick Fertell since it gives the most information with the easiest interpretation.

A Christmas Carol - The Other Ghost

It was just before Christmas about 9 years ago. I was at the Streets at Southpoint, an indoor-outdoor mall in Durham, NC. It was a pretty mall, with a pedestrian street that was lined with stores glittering like Rockefeller Center. The bounty of the season was everywhere. The aroma of hot cider from the kiosk and the carols swelling up from the speakers disguised as rocks along the path, enveloped the crowd, bundled like they were trekking on an expedition to the North Pole itself.

I was trying to figure out what to get my mother, my father, my brothers, my sister, and my wife for Christmas. I confess that I rarely find things at the mall which make suitable gifts; however, I’ve always taken comfort in browsing and confirming my suspicion that this was not where I wanted to make my purchases. I guess this sort of made me an outsider, in a way. While I was glad to be surrounded by the holiday cheer, I did feel a bit disconnected. If I was honest with myself, I was actually a little sad and I couldn’t put an exact finger on the reason.

Then, as I walked down the path past a Crate and Barrel, I saw The Children’s Store. Moms and dads were bustling into and out of the store. As I stood outside the store, peering in the display window at the reindeer jumpers, elf pajamas and angelic ball gowns for little girls, I could see my reflection in the glass. Looking through my own reflection at the warm holiday interior, I began felt like a ghost: empty, vacant, barely a whisper. I felt like the Ghost of the Christmas That Would Never Be.

For people who have lost a loved one, for those separated from their families, for those without a family, with financial woes, with illness … we all know this is a tough time of year for some people. Watching other people, happy families apparently living the life of which you’ve been deprived can seem particularly unfair, or make you feel like a failure if you’ve not achieved these things.

This time of year can be especially difficult for people suffering from infertility. All the hopeless feelings, all the lonely feelings of isolation that infertility brings are magnified by the merriment of the season, the energy and bustle, the long lines at toy stores, by the crowds of twittering kids waiting to sit on Santa’s knee. All the holiday cheer can seem to just mock the pain of childlessness.

To make matters worse, if you feel like you’re on the outside of all of this Holiday fun and you see someone who is apparently blessed in ways that you are not, and you hear them complain about what seem to you trivial issues of the season… it can just make you mad.

In the end, most of us really do want to be happy. The question is, how is a person to rescue themselves from the sadness the season besets upon them?

Few solutions are perfect, but here are some things I have tried. Here are my suggestions, and I’m open to new ideas:

Own your feelings. Acknowledge them for what they are and ask yourself if you want them. If so, embrace them. Sometimes we need to do this first, before we can move on. It may be a miserable December, but it may be the first step to healing.

1. If you do not want these feelings, you should recognize that you may not be able to completely shake them. You may go for hours or days without the negative feelings resurfacing; however, it doesn’t mean you’ve been defeated when they do.
2. Focus on what the season is really about, for you. In my family’s tradition, Christmas, the season is a reminder of the gifts we have received – even though we were not worthy to have received them. Because of the gift already received, the season is about giving to others. (I know we all have different backgrounds and beliefs, but I do think the spirit of the holidays, Joy and Peace, can be enjoyed by all. When I was at my lowest, and thought I’d never have a child I would pray. I did pray that we would be given a child, but more than that I prayed that I could find peace in the event that we never did.
3. If being around children is too much for you, some people say you should avoid areas that are likely to be filled with them. I find this to be an impractical solution for many people, but you should not feel guilty for protecting yourself.
4. Consider devoting your time to someone else in need. This can be healing for you can for them.
5. Get plenty of rest. (Fatigue makes nearly everything worse.)
6. Get plenty of exercise. (This makes you feel vibrant and boosts your metabolism.)
7. Surround yourself with supportive people.
8. Seek counseling. If needed. If you’ve wondered if you should get counseling, then you probably should. I know a lot of wonderful people in the Chattanooga area and can make recommendations.

For some people this year, the Christmas season is going to be something to be survived, not enjoyed.

If this is you, plan ahead. If you need to, give me a call…. do something to help reclaim your life.

Tubal Reversal verus in vitro fertilization (IVF)

The Burning Question

One of the most common questions I get asked both by physicians and by patients around the Southeast is about tubal reversal surgery compared to in vitro fertilization (IVF).


It's easy to understand why there is so much interest. Millions of women have had their tubes tied. Inevitably, if millions of women are opting for "permanent" sterilization, many of them will later regret it.

I could spend a lot of time talking about who is likely to regret this decision. There is good data on that. But I'm not writing this blog entry for women who are trying to decide among different contraceptive options. I'm writing this for the women who find themselves in the unfortunate situation of wanting another child, but their tubes have been surgically blocked, cut, burned, clipped, tied, fried (and/or all of the above).


The bottom line is there are many people who regret their decision and they always ask me the same question: which is better, tubal reversal surgery (reanastamosis) or IVF?


The Universal Answer
One of my mentors drove a lot of residents and fellows crazy when they approached him looking for a quick answer to what they thought was an easy question.


To almost every question, his answer was, "It depends."

Then he'd launch into a 5-10 minute lecture on the pro's and con's and nuances, caveats, hard and fast rules, exceptions to those rules and so on.


I'll try not to do that to you.


If you want the short answer to this question, I'll give it to you and I'll tell you why. Just scroll to the bottom of this blog and read: "The Short Answer." But be warned, you'll miss some good stuff in between.


Critical Questions I Must Know to Answer the Question for You...
For me to know to best advise a patient, there are some absolutely critical questions I need answered.


1) How were her tubes sterilized?
2) How old is she?
3) How many more children does she wish to have?
4) Does her partner have adequate sperm?
5) Does she or her partner have a history of previous infertility?
6) Does she or her partner have any religious barriers to IVF?


Tackling these questions one at a time:

1) How were her tubes sterilized?

In general, the less damage to the tube, the easier the repair. Some methods,
such as the Filshie Clip, or the Fallope Ring create very little damage and
reconnecting these is a lot easier than if the tubes were burned in multiple
locations, or if large segments of the tube were resected. It can be
important for a physician to see the operative report from the tubal
ligation. If a lot of damaged tube has to be removed and there is not much
to put back together, the chances of success are much lower. In general, a
minimum of 4 cm of tube is required at the conclusion of the reanastomosis
to have a legitimate shot at getting pregnant.

2) How old is she?

Older women, especially in their forties, have less time to conceive and
their monthly pregnancy rates are much lower than younger women. After age 37, monthly fertility rates begin to drop rapidly. There are women at age 37 who get their tubes reversed, but if they have not had a baby in one year, then their chances of conceiving at age 38 are significantly lower. Each 6 months to a year, fertility wanes. For good prognosis patients, a single cycle of IVF is generally as successful as trying to conceive for one year on your own. In other words, you can pack a year's worth of treatment into two months.

Even for young women, ovarian reserve testing should be considered. This testing can tell you if your eggs are behaving their age, or
like a much older woman.

3) How many more children does she wish to have?

A young woman who wants to have several more children spaced out over several years may be the best candidate for tubal ligation reversal. When she's not trying to get pregnant, she'll need to use some kind of birth control, but this can stop when she's ready to try again.

On the other hand, a woman who wants only one child, or the older woman who wants more than one child may be a better candidate for IVF. If she only want one child, we can limit the number of embryos we place in the uterus. In some cases, we only place one embryo in the uterus. Once she delivers her baby, she still has her sterilization in place.

Finally, the older woman who wants more than one child may do best with IVF. In her case, we can be a little more aggressive about the number of embryos we place in the uterus, assuming she is willing chance the pregnancy will be twins. Also, if she gets pregnant and
delivers a single child, she may have embryos that we were able to
freeze. Months later, after birth, after she finishes breast feeding and
gets through the sleep deprivation of having a newborn, she can return
to clinic and use the embryos that are in storage. She will have
virtually the same chance of conceiving as she did when she was a
younger age.

4) Does her partner have adequate sperm?

A lot of centers which specialize in tubal ligation reversals do not require a
semen analysis of the male partner. I will acknowledge that in most cases, the male partner will have adequate sperm, but on numerous occasions, shortly before tubal surgery, I have found that the male partner's sample was wholly inadequate. Surgery would have put those women at unnecessary risk, with little hope of achieving pregnancy. If a physician does not offer or recommend a semen analysis be performed, I would be suspicious that he or she was not acting in my best interest.

5) Does either partner have a prior history of infertility?

If so, I would carefully consider your choice. In these cases spontaneous
pregnancy is much less likely and IVF would be favored.

6) Does she have religious barriers to IVF?

If so, tubal ligation should be preferred.

So who should you seek for advice?

The best people to talk to are physicians who perform both procedures. They are less likely to sway you toward one over the other. They will also try to put the statistics into real clinical context to help you understand what you're getting for your time, effort and money.

From them, you should get truthful statistics about real results. If you looked at a graph of how many pregnancies occur after tubal ligation reversal compared to IVF, you would probably run straight to surgery and have your tubes reversed - because in every age group, far more pregnancies are achieved per reversal than per IVF cycle (according to nationwide IVF statistics).

But not so fast! If you look a little closer, you'll notice the live birth rate only barely favors tubal reversal over the average national IVF success rate.

First, what happened to all of those extra pregnancies? Many of these tubal reversal pregnancies are located in the tube.

Another reason live birth rates are similar between tubal reversal and IVF is this: the statistical deck is stacked in favor of tubal reversal. That's because many tubal reversal clinics compare their success rates to "average national IVF success rates."

This is NOT a fair comparison.

Tubal reversal patients are the best prognosis patients for conception. To compare these patients to ALL IVF patients is like comparing apples to Orangutans.

Most IVF patients do not have proven fertility and voluntary sterility like tubal reversal patients do; most have multiple other more-serious fertility problems.

If you randomised these best prognosis patients to tubal reversal versus IVF, you would almost certainly see significantly higher live birth rates from IVF, with a much lower risk of tubal pregnancy.

The Short Answer

Ok, I promised you a short answer. If you've read this far, you're probably going to think I'm just going to recommend IVF, but I'm not going to do that. See which category you are in, and this is generally what I would advise.

1) Money is scarce and you can find a cheap tubal reversal and you're willing to sacrifice some chance of success - go with tubal reversal.
2) If you have religious conflicts with IVF - go with tubal reversal.
3) If you are a young woman who wants several more children spread out over a number of years - go with tubal reversal.
4) If you want to get pregnant but don't want to have to use future contraception - go with IVF.
5) If you want just one child - go with IVF.
6) If you're older and want several more children - go with IVF.
7) If you want the highest chance of pregnancy, period - go with IVF.


Conclusion

I hope this was simple enough. There are some details, some pros and cons of each choice that I have left out of this blog post. For any individual patient, there may be additional testing I'd recommend. I didn't discuss all the risks associated with each procedure, either.

If you have questions regarding which treatment is right for you, come see us. Dr. Scotchie and I will try to help you find it.

How Does Anyone Have a Baby?

If you are having difficulty getting or staying pregnant, you are not alone. At some point, infertility affects 15% of all couples. Recurrent pregnancy loss affects another 3% of couples.

If you are one of these couples, you may feel isolated and depressed. You will get all sorts of helpful and unhelpful advice from people (including yourself) who really do care. Perhaps one of the worst things someone can tell you is to “relax” or “quit trying so hard.” This advice generally has two effects:

To make you even more tense.

To make you think it’s all your fault.

At Tennessee Reproductive Medicine, we understand the stress that infertility and pregnancy loss causes. While it is true that in extreme cases stress can cause a woman to stop ovulating, very rarely is stress a cause of infertility. If stress isn’t causing the infertility, as so many people commonly think, let’s consider what is normal and abnormal in the world of conception so you can take charge of your fertility. 

Normal Conception Rates
After one year of adequate unprotected intercourse, 85% of couples ages 20-40 will be pregnant. Of the 15% who aren’t pregnant, half of those will be pregnant within the second year. The monthly chance of conceiving among couples in which the woman is less than 32 years old is approximately 20-25%. This illustrates that human reproduction is very INEFFICIENT! It may take some couples many months to conceive and this is within the range of normal. After age 32, monthly conception rates start to decrease slightly, then more significantly after age 35 to about 10-15% chance per month.

When Should I Seek Help Conceiving?
Infertility is considered the lack of conception after 12 months of unprotected regular intercourse (timed adequately during the suspected time of ovulation). All couples who have not conceived after 12 months warrant a full evaluation. While some couples will spontaneously conceive after 12 months of attempts, most will need some form of fertility therapy and further attempts at natural conception may be wasting precious time.

Furthermore, many couples warrant a sooner evaluation if there is a history suggestive of:

-ovulation disorders
-tubal disorders
-male reproduction disorders
-female greater than 35 years old
-endometriosis
-female with prior radiation or chemotherapy treatments

Do I need a fertility specialist?
Sometimes this is an easy question to answer, sometimes it's difficult. Consider your situation and conditions by taking this TRM Quiz at http://www.trmbaby.com/welcome/do_I_need_fertility.shtml. If the total number of points equals or exceeds 15 points, and you wish to conceive, strong consideration should be given to seeing a fertility specialist, specifically a reproductive endocrinologist.

Interpret With Caution!

It’s been a while since I’ve written anything here. Quite frankly, I’ve been a bit busy, and no topic seemed particularly inspiring. Until yesterday.

I was asked to make a comment for a local television station, WRCB TV3 Eyewitness News, which was running a story on a New York fertility doctor (Dr. Sami David) who says that too many couple use IVF to get pregnant and that many of those couples should try alternate methods first. He notes that his favorite fertility drug is antibiotics.

What I am about to write may at first sound like a preamble to denouncing this doctor’s claims, or like a build up to a defense of IVF.

It really is neither.

The "Caution" Part...

I am saying there is a lot said about fertility and infertility treatments which should be interpreted with caution. In this post I’m going to elaborate on some of the ways any news story you might encounter can be misinterpreted.

This post is also an expansion of what I would have like to have said if the news station actually had the time to air it. My response to the news story was limited to about 8 seconds and the reporter was only able to highlight a couple of sentences of my response. Such is the nature of broadcast journalism. I am very grateful to Channel 3, the NBC affiliate, that they gave me what time they could spare to my point of view. I am also very happy that they put my entire response on their website.

It appears that the story was filmed by a New York affiliate station and sent to local NBC affiliates from the network. Local affiliates could interview local physicians as time permitted. In case the link above does not work, I’ll give you the skinny on the news story:

Dr. Sami David performed the first IVF procedure in New York and he has not done one since that time. He says that IVF has a high failure rate and that many people who resort to IVF could get pregnant without it. He said doctors need to pay more attention to treating the man and looking for not-so-obvious causes of infertility and treat those causes. The story illustrates the proof of this concept by interviewing a woman who went through three IVF cycles but miscarried all three times. She then saw Dr. David, conceived and now, happily, has a child. Dr. David has now written a book explaining much of this. It is called Making Babies.

Unavoidable Bias

There are several inherent and hard to avoid biases in stories like this. For example, simply by saying Dr. David is offering an alternative, this does not mean many people in our field aren’t also incorporating some of the same treatments. Much of what Dr. David promotes and what your typical fertility would promote will be similar. The implication is that most fertility doctors push a lot of people to IVF.

As a matter of fact, fewer than 10% of our patients ever require IVF. Dr. Scotchie and I try very hard to use IVF as a last resort.

Another unavoidable bias is that simply by reporting this story, makes the information seem like its new. Just because this story is in the news, this does not make it new. The reason Dr. David is in the news is not because of remarkable success rates. The reason he is in the news is because he has written a book. He is promoting the book and he seems to be doing a good job with that. By saying this, I’m not trying to imply that Dr. David wrote this only to promote his practice and to make money. I have not read the book, but until I see proof otherwise, I’ll assume that he wrote it to get the word out that for some people, there are alternatives to IVF. Quite frankly, if I were a reporter, I’d be inclined to write a story about it, because there people who would be interested in it.

My First Thought

My first thought upon hearing what Dr. Sami has to say is: I agree that some people get thrust into IVF too quickly. I think some doctors don’t do enough investigation to find out if there is a treatable cause. This is especially true of male factor infertility. I know this because I get to review a lot of medical records as a second opinion, and not just from Tennessee or the surrounding areas. Friends from all over the country refer their friends to me to give them my assessment.

Doctors are partly to blame, and there are various reasons for this. High tech treatments do generate more income for the practice than low tech treatments. Also, high tech treatments are generally far more likely to be successful than low tech treatments. A pregnant patient is usually a very satisfied patient. It makes the patient feel good. It makes the doctor feel good.

It can be difficult for patients to know if a doctor is pushing you too quickly into IVF. Second opinions can be valuable here. However… CAUTION must be exercised when getting a second opinion. (I promise to write about this VERY soon. But this is too big a topic to tackle here.)

Sometimes the doctors push for IVF too quickly and, truthfully, sometimes the patients push themselves into IVF before they’ve tried all other reasonable options.

My Biggest Fear

My biggest fear about this story is that there would be people who would interpret Dr. David’s message in a way that would cause them to delay seeking the advice of a fertility specialist.

I worry especially about women approaching their mid- to late-30s who spend several years trying on their own, or using herbal or homeopathic remedies. By the time they reach my office, they have significantly decreased chances of conceiving due to age, or due to the limited number of remaining reproductive years with which to attempt pregnancy.

Despite treatment, it can take some couples years to conceive. I should know. My wife and I were one of those couples.

Dangers of Interpreting Success

It is sometimes hard for doctors to know if it was treatment or time which cured a patient.

I am careful to counsel my patients that I may not know if it was our treatment which helped them conceive. In some cases, all we can say is that we increased the odds of conception in a given month.

It is a happy reality of my practice that some patients will conceive spontaneously before, between or after an infertility treatment.

In cases when patients get pregnant between treatments, patients usually understand that they did not conceive due to treatment. I will know it, too.

Some practitioners have a difficult time in knowing if a patient got pregnant because of treatment or simply because it was a patient’s time to conceive. For example: Suppose I am a doctor who gives everyone an antibiotic or an herbal remedy. A portion of my patients would have conceived anyway. But since all of my patients are “under treatment” at all times, I would be likely to think that the therapy was what made the difference. The patient would think so, too.

Under a lot of alternative regimens, patients are always technically in treatment. In these cases, it can be very difficult to know what actually caused the pregnancy. In my experience, the assumption of the practitioner and the patient is to give credit to the treatment.

In certain situations, I downplay my role to patients. Still, when they get pregnant, they give me the credit, even when it’s more likely that I was not the difference maker.

Example:

If I do surgery on 12 infertility patients and remove low-grade endometriosis and then do no other treatments, studies have shown that 3 of them will get pregnant within the next 12 months. All three who conceive say “the surgery worked” and that’s why they got pregnant. All three give me the credit.

The truth is, if I had not done surgery, 2 of the 12 would have conceived on their own.

This means, I must do 12 surgeries to get one additional pregnancy than doing nothing. This is called number needed to treat, NNT, to get 1 different outcome.

I tell patients this beforehand. Still, EVERY single patient who has gotten pregnant after surgery remarks something like, “The surgery worked!”

I usually say something like, “Maybe, there’s a 33% chance that it did.”

This example illustrates the point that doctors and patients can be very likely to give or accept credit more often than deserved.

Even when it is more probable that my intervention had something to do with the pregnancy, I am careful to counsel patients that the only thing we did was increase the chance.

For Example:

If I do an intrauterine insemination (IUI) on a patient and the patient gets pregnant, I cannot always say that the pregnancy was due to the procedure or due to intercourse that she and her partner had a few days earlier. All I know is that the IUI increased their chances of conception that month.

The news story used an example of a patient to represent Dr. David's success. In this example, the patient had failed to have a baby after three IVF attempts. She was then treated by Dr. David, and after an unspecified amount of time, she got pregnant. Did Dr. David's treatment get her pregnant? Or was it just her time to succeed? Clearly both the doctor and the patient have given him the credit. In all honesty, neither of them could possibly know.

I am wary when anecdotes are used as evidence that a treatment is successful. It does not mean I don’t try some of those same treatments myself, but both the patient and I must still be wary about interpreting the results.

My Final Thought

I’m sure there is a lot more I could write. But my wife is cleaning the house for family members of mine that are arriving from out of town, and it seems somehow wrong that she is doing all of the work, so I’ll leave it at this.

I have not read Dr. David’s book, yet. My suspicion is that I will agree much more than disagree with it. I do think it is very sensible to not turn your back on any practical ways to improve your ability to conceive.

There are many recommendations out there for stress reduction, optimal supplements, exercise, sexual positions. I’ll try to address some of these issues in future blogs.

I think I’ll write about the pitfalls of second opinions next.

But first, I have to mop.

What to expect when you're not expecting - or, the slow erosion.

Infertility can make you crazy.

In some previous posts, I discussed how the advice from others can contribute to a sense of anxiety. What we in the world of medicine must also acknowledge is that the infertility investigation and treatment can also be maddening.

Couples embarking down this path need to be prepared for the emotional landmines that can occur. While many couples have very different causes of infertility or may get different treatments, they do share many of the same frustrations.

How it begins:
The first maddening aspect of infertility is that getting pregnant should not be difficult. After all, some people get pregnant with a single act of intercourse. Teenagers get pregnant…. some more than once. Women on the pill get pregnant. We hear women say, “He’d just walk by me and I’d get pregnant.”

So it’s frustrating to have difficulty in an area that seems to be easy for most people. This frustration can turn into guilt, hopelessness, a sense of inadequacy, a sense of injustice, sorrow or anger… or all of them at once.

How it perpetuates:
To get control of the situation, many women start monitoring their menstrual cycles. She and her husband have sex when the calendar tells them to. (Fun at first…. but this can lead to a loss of intimacy.)

Other couples seek the advice of physicians. For many couples, the problem resolves here… problem is found and fixed… medicine is taken… pregnancy happens. But if you’re not one of those fortunate couples, the sense of inadequacy grows, as does a sense of anxiety.

I’ve been on both sides of the desk on this. When my wife and I started seeing doctors to try to get pregnant, it seems every time we had an appointment, we received more bad news.:

“You’re not ovulating…”
“You did not ovulate with the medicine”
“Your tubes are damaged.”
“We tried to fix your tubes, but they’re damaged beyond repair.”
“You need IVF.”
“We got 25 eggs. Half fertilized. Only 5 are still growing.”
“You’re not pregnant.”

Repeat.

Then there those times when the news it at first good, but then turns bad.

Early on, before each IVF cycle, we were told that we were excellent prognosis, but with each attempt, we had the same outcome - failure.

Then there was the time we finally got pregnant. My wife's hormone levels were rising wonderfully. I will never forget the serenity that took over me and my wife at this point. I remember going to the driving range and hitting golf balls while she read “What to Expect While You’re Expecting.” We had 2 weeks of unbridled bliss.

Then, my wife started to experience pain. A friend performed an ultrasound, and where we should have seen an embryo, there was just the smallest amount of fluid in the uterus. Over the next few days, the pain escalated and finally she saw her doctor. She was still in pain, but that didn’t matter. Her emotions soared as he performed her ultrasound. He saw the baby. He showed it to her. It looked normal. It had a robust heart beat and little arm buds. He was saying everything looked good when his assistant tapped him on the shoulder and whispered something. Suddenly the doctor stopped talking and looked closer at the screen. He scanned for a moment, and then looked at my wife.

The other shoe dropped.

It seemed that this perfectly formed baby, with a robust heart beat was not in the uterus, but in the fallopian tube.

Within 3 weeks, we had been taken from the heights of happiness to a breathless sorrow. It was so cruel to be given hope, only to have it taken away. In our hearts, we knew there was nothing wrong with that baby. It was a victim of geography.


The loss of that child has changed me forever. Whenever my wife and I talk of that time, we are crushed. And when I see someone else who is losing a pregnancy or a child, I am swept back in time and feel a rent in my soul.

This is how life was for us. We were given hope. Then hope was dashed.

Still, by some accounts, my wife and I had it easy. There are couples who don’t have infertility at all, but suffer repetitive pregnancy losses. There are couple’s who have identified problems, but lack the financial means to undertake treatment. Then there are those 10% of couples in whom we can find nothing wrong. This can be especially frustrating for them.

There are many roads to the madhouse. Many infertility patients will find themselves on that road. For some, it can ruin a marriage, or enjoyment in life. For some people, the trauma suffered from infertility is not completely healed by getting pregnant or even having a baby.

Infertility patients are likely to be more worried about things going wrong in pregnancy than someone who never had trouble conceiving. I see this in patients, and it was true for me and my wife. If you've gone through a lot to get pregnant, if you've suffered many disappointments, you just simply feel like the pregnancy is high risk. You keep waiting for the other shoe to drop. You've been trained to know that it will.

In my final year of Ob/Gyn residency, when my wife were at what we thought was the end of our IVF journey (we were going to try one last cycle), we got pregnant. At the time a woman misses her menses, the average hCG level is supposed to be around 90mIU/ml. My wife's was 53. We were told that this was okay in an IVF cycle, but we were still deeply concerned. In two days, the hormone did rise as it was supposed to. Two days later, it doubled again.

It was an agonising 2 weeks until our first ultrasound. We were trying to be cautiously optimistic (which, as an aside, never actually worked for us.) I'll never forget how scared both of us were, waiting for our physician to enter the room to perform the ultrasound. Finally, once the scan began, the doctor was quiet what seemed like an eternity. I was looking closely at the monitor, but couldn't see very well from my vantage point.

She withdrew the transducer and put it aside and told us: the embryo was only half the size it should be and it didn't have a heart beat. She recommended returning after the weekend to confirm that the pregnancy was not viable. She said it wasn't hopeless, that sometimes embryos play "catch up," but the truth was all over her face. She was clearly in pain when she said this to us.

I will say without shame that my wife and I broke down. I tried to go back to work, but seeing the condition I was in, my friends volunteered to cover my shift on labor and delivery. I went home. I was badly shaken and felt absolutely abandoned. There was so little hope. Every time I had grasped at hope, I had come up empty.

Fortunately, friends around us had not given up. It's almost like they willed our outcome to be different. When I returned home, Robert Strauss (a mentor and friend at UNC Hospitals) called me and said that he just didn't believe that we didn't have a heartbeat. He said that he would be on call tomorrow and that he wanted me and my wife to come back in and get an ultrasound on the high resolution machine then.

The next morning, we got the scan with Dr. Strauss. The embryo was normal size. There was a heartbeat. A Niagara of relief and thankfulness crashed upon us.

Within days, we once again had been taken on an emotional roller coaster, and now we were on the uphill again.

Of course none of this made me less nervous. It seemed that the very earth beneath our dreams was so fragile. After that, about 3 times per week, my wife came to the hospital where I would do an ultrasound on her. We were almost paralyzed with fear before each scan.

Despite now having a pregnancy on its way, my wife could not give up her progesterone shots and I could not let go of my sense of dread.

I could not give it up until the day I called Jenifer Behrins, a friend of mine who had 4 children but had suffered severely in each pregnancy from intractable nausea and vomiting and multiple hospital admissions. I confided my fears to her. I told her how worried I was, despite how well everything was going. She listened while I spoke, then paused. Then she gave me some of the best advice I've ever received. I share her advice with nearly all my newly pregnant patients who I imagine feel much like I did about our pregnancy.




Jenifer said, "You need to enjoy this. You never know what's going to happen. You need to enjoy every moment of your pregnancy. You need to enjoy every moment of that child's life. Don't worry if he's doing everything he should be, what stage he's at, if he's advanced, or if he's slow.... just enjoy it. Enjoy every stage for what it is, because you never know for sure that you'll get another stage. You never know what the future holds."

To someone else, her advice may have seemed someone dark and pessimistic. To me, it was liberating. She gave me permission to celebrate the here and now. I realized that if I didn't enjoy the small blessings, I might not ever enjoy the big ones. It was my first step out of the madhouse.

Epilogue:
I know not all patients enter this madhouse I allude to. Some people weather this much better than I did. I envy them. I don't know if this experience makes me a better doctor, but I'd like to think it does. I do know that it feels very personal to me when a patient does not get pregnant or has a loss. Those old emotions are like live wires, hidden just below the surface.

I know my experience affects some things that I do. When I do an ultrasound for a heartbeat, I look for the heartbeat and tell the patient as soon as I see it. With that out of the way, I go about my measurements.

I've also realized that infertility doctors can make you feel very high risk, especially if we bring you back for ultrasounds every week of the first trimester. It's a double edge sword. On the one hand, seeing an embryo grow everyweek is reassuring. On the other hand, if I bring patients back every week, it can make them feel like things are more in perile than they actually are.

The truth of the matter is this: as long as things are going well and there is no bleeding or history of recurrent pregnancy loss, once you see a normal heartbeat, the miscarriage rate drops dramatically. For most women under 35 years old, once you see a heartbeat, the miscarriage rate is about 4-7%.

The sad truth for me is that the sooner I get a patient back to her doctor, the more likely she is to feel like a normally pregnant woman. For sure, it can be hard for me to let go. It can be hard for her to let go, too. In the end, it's what we all must do, and we're all better off for it.

Infertility: From the Inside Out

On June 12, 1993, on a blistering hot Chattanooga day, I married Kristi Cheryl Poe. It was a big wedding. Lots of family. Even more friends.

There is a picture of my wife from our honeymoon in Bermuda. She is standing in the bedroom of an old house that has been turned into a museum. Her hands are cupped in front of her, her shoulders hunched and a guilty smile crosses her face as she looks back at the camera. She’s standing over a baby’s crib. The cradle at her feet and the guilty look speak volumes about the direction she wants our lives to go. It’s clear. She wants kids.

To be honest, I hadn’t given much thought to children at this point, but it was plain to see that this meant a lot to her. When we got back from Bermuda we placed that picture, among others, on the wall in our den. That picture reminded us of very happy times.

We thought our lives were fabulous. Like many young couples, we were not in a rush to start a family, but we also didn’t try to prevent it from happening.

So in the beginning, not getting pregnant in a given month was no big deal. We knew these things took time. So time passed.

More time passed. Months passed. Seasons passed, then years, and anniversaries and the births of friends’ children. Then birthdays of children.

Throughout all of this, month after month, the picture on the wall hung there, reminding us of what she, now we, wanted very badly. The picture on the wall had not changed. My wife still had the same smile on her face, but now instead of looking guilty, it started to look a little sad.

In fact, every time I looked at that picture of my wife, I secretly wondered if we were not meant to have a child. That made me sad. So much optimism, crushed.

I can’t say this didn’t wear on us a little. We began to lean on friends and confide in them. Most of them were absolutely wonderful. They just listened. But I have to confess, it was hard to hear advice from some people who had easily gotten pregnant.

“Relax,” they reassured.

or

“Oh, you’re just trying too hard.”

or

“I know someone who adopted, and then got pregnant!”

or

“I know someone who quit trying and then BAM, got pregnant!”

You get the gist.


If you’re reading this, you’ve probably heard these stories yourself. I was too early in my career to know anything about something called “recall bias” (more on this later in an upcoming post). I assumed that stress was a major cause of infertility. And I knew what these people were saying. It was apparent without reading too far between the lines.

They were essentially saying, “It’s all your fault. You’re causing this.”

If these people were trying to help us relax, I confess it had the opposite effect.

All of this occurred at the beginning of our nearly 10 year journey with infertility that would take us across more than 600 miles and to three fertility centers and more cycles of IVF than I can remember reliably. Over the coming months, I’d like to document that journey and use this as a touchstone to talk about infertility treatments and tests.

It is my hope that this blog will help two groups of people: those who are struggling with infertility, and those who are giving advice.

Every couple is different. Having been a patient and a doctor who treats these conditions, I’ve seen what infertility can do to people and to families. I’ve seen it from many angles and from the inside out. I’ll tell you what I’ve learned.

Our particular journey as a married couple started with a trip to Bermuda. That little picture on our wall is a reminder to us of who we were and what happened to us along the way. It is a reminder of the joy and the unspeakable sorrows, the hope and the disappointments we experienced along the way. For better or for worse, our experiences with infertility shaped us as a couple. These experiences shaped me as a doctor.

For me, that picture of my wife in Bermuda says so much. It’s a constant reminder of how cruel hope can be and of how fragile and how strong we all are. For these reasons, it is still one of my favorite pictures of my wife.