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Archive for the ‘Ovulation Induction’ tag

Is Your Biological Clock Running Out?

By David Kreiner, MD

January 10th, 2014 at 10:35 pm


image courtesy of photo stock/freedigital

Tears start to course down the cheeks of my patient, her immediate response to the message I just conveyed to her. Minutes before, with great angst anticipating the depressing effect my words will have on her, I proceeded to explain how her FSH was slightly elevated and her antral follicle count was a disappointing 3-6 follicles. I was careful to say that though this is a screen that correlates with a woman’s fertility, sometimes a woman may be more fertile than suspected based on the hormone tests and ovarian ultrasound. I also said that even when the tests accurately show diminishing ovarian reserve (follicle number), we are often successful in achieving a pregnancy and obtaining a baby through in vitro fertilization especially when age is not a significant factor.

These encounters I have with patients are more frequent than they should be. Unfortunately, many women delay seeking help in their efforts to conceive until their age has become significant both because they have fewer healthy genetically normal eggs and because their ability to respond to fertility drugs with numerous mature eggs is depressed. Women often do not realize that fertility drops as they age starting in their 20s but at an increasing rate in their 30s and to a point that may often be barely treatable in their 40s.

A common reason women delay seeking help is the trend in society to have children at an older age. In the 1960’s it was much less common that women would go to college and seek a career as is typical of women today. The delayed childbearing increases the exposure of women to more sexual partners and a consequent increased risk of developing pelvic inflammatory disease with resulting fallopian tube adhesions.

When patients have endometriosis, delaying pregnancy allows the endometriosis to develop further and cause damage to a woman’s ovaries and fallopian tubes. They are more likely to develop diminished ovarian reserve at a younger age due to the destruction of normal ovarian tissue by the endometriosis.

Even more important is that aging results in natural depletion of the number of follicles and eggs with an increase in the percentage of these residual eggs that are unhealthy and/or genetically abnormal.

Diminished ovarian reserve is associated with decreased inhibin levels which decreases the negative feedback on the pituitary gland. FSH produced by the pituitary is elevated in response to the diminished ovarian reserve and inhibin levels unless a woman has a cyst producing high estradiol levels which also lowers FSH. This is why we assess estradiol levels at the same time as FSH. Anti-Mullerian Hormone (AMH) can be tested throughout a woman’s menstrual cycle and levels correlate with ovarian reserve. Early follicular ultrasound can be performed to evaluate a woman’s antral follicle count. The antral follicle count also correlates with ovarian reserve.

By screening women annually with hormone tests and ultrasounds a physician may assess whether a woman is at high risk of developing diminished ovarian reserve in the subsequent year. Alerting a woman to her individual fertility status would allow women to adjust their family planning to fit their individual needs.

Aggressive fertility therapy may be the best option when it appears that one is running out of time. Ovulation induction with intrauterine insemination, MicroIVF and IVF are all considerations that speed up the process and allow a patient to take advantage of her residual fertility.

With fertility screening of day 3 estradiol and FSH, AMH and early follicular ultrasound antral follicle counts, the biological clock may still be ticking but at least one may keep an eye on it and know what time it is and act accordingly.

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Did you realize that aging is not the only factor in the biological clock race? Did you know that certain conditions, like endometriosis, can play a part, too?


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Infertility Podcast Series: Journey to the Crib: Chapter 27: A Dozen Embryos, Who Will Stop This Madness?

By David Kreiner MD

August 12th, 2013 at 9:44 pm


Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Twenty-Seven: A Dozen Embryos, Who Will Stop This Madness? You, the listener, are invited to ask questions and make comments.  You can access the podcast here:

A Dozen Embryos, Who Will Stop This Madness?

When I wrote this chapter, the news of the day was that an IVF clinic had transferred 12 embryos.  In fact, it was learned weeks later that this was a hoax.  However, in the wake of Octomom, where 8 embryos were transferred, I felt there was still an important lesson to be learned especially since insurance companies often insist that a patient try multiple cycles of intrauterine insemination (IUI) before covering IVF… if they cover it at all. 


In fact, gonadotropin hormones in conjunction with IUI offers a 35% risk of multiple pregnancy including a 5% risk of triplets or more.  After obtaining six fetuses after one such cycle, I became very wary of offering gonadotropin IUI cycles to my patients.


Yet, this is what our insurance companies are covering rather than the safer IVF where only 1 or 2 embryos can be transferred at a time.


When we do an IUI, as many eggs that ovulate can implant resulting in a high risk multiple pregnancy.  I believe that it is not until we discourage the use of gonadotropins without IVF by offering a regulated covered alternative will we eliminate these risky multiples.


Until then, all of us including society, the government, insurance companies and employers are to blame for letting these dangerous multiple pregnancies occur.


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Was this helpful in answering your questions about multiple pregnancy risks in IUIs and IVF?

Please share your thoughts about this podcast here. And ask any questions and Dr. Kreiner will answer them.

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Infertility Podcast Series: Journey to the Crib: Chapter 15 Intrauterine Insemination

By David Kreiner MD

June 3rd, 2013 at 8:52 pm


Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Fifteen: Intrauterine Insemination. You, the listener, are invited to ask questions and make comments and Dr. Kreiner will respond.  You can access the podcast here:

 Intrauterine Insemination

Intrauterine Insemination, or IUI, involves preparing the sperm usually by a washing procedure removing prostaglandins and debris that would otherwise cause severe cramping when the sperm is introduced into the uterine cavity.  Since clomid, an anti-estrogen, can thicken the cervical mucus and create a cervical barrier to the sperm, IUI is a valuable adjuvant to clomid therapy.

The disadvantage of IUI is that as many eggs as you ovulate can fertilize and implant.  In cases where multiple eggs are developed in ovarian hyperstimulation therapy like clomid and FSH (bravelle, menopur, gonal F, Follistim) the risk of multiple pregnancy occurring is enhanced.  The increase in pregnancy rate from this therapy as well as the increased risks associated with IUIs needs to be compared with the relatively superior success rate from In Vitro Fertilization where a single embryo transfer may be performed and excess embryos cryopreserved for a subsequent cycle.  If costs of the treatments are a consideration, such reduced-cost procedures like Minimal Stimulation IVF or Micro-IVF may prove to be a cost effective alternative to IUI when insurance does not cover the IUIs.

Interestingly, not all insurance companies have caught on to this issue of a higher risk of multiple pregnancy with IUI associated with clomid or FSH.  Some require patients to go through a minimum number of IUIs prior to covering the more effective and safer IVF.

Ironically, a multiple pregnancy will cost the insurance company far more than if they had covered IVF.

Worth repeating from the last podcast on clomid therapy: For those patients without insurance coverage, Micro-IVF, minimal stimulation IVF (utilizing Clomid), costs approximately the same as three Clomid/IUI cycles but offers women under 35 years of age a better than 40% pregnancy rate and as such may be a more cost effective alternative.

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Was this helpful in answering your questions about Intrauterine Insemination?

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Infertility Podcast Series: Journey to the Crib: Chapter 6 Have You Had A Fertility Workup?

By David Kreiner MD

March 18th, 2013 at 7:33 pm

Welcome to the Journey to the Crib Podcast.  We will have a blog discussion each week with each chapter.  This podcast covers Chapter Six: Have You Had a Fertility Workup? You, the listener, are invited to ask questions and make comments.  You can access the podcast here:

Have You Had A Fertility Workup?

A fertility specialist called a Reproductive Endocrinologist, who has performed a three year fellowship training in IVF and infertility after an Obstetrics and Gynecology residency, will initiate the fertility workup by conducting a history and physical examination.  The exam includes a pelvic ultrasound of a woman’s uterus and ovaries to determine if there are any abnormalities that may affect implantation or pregnancy, as well as assess ovarian activity and the presence of endometriosis.

Different causes of infertility will be tested.  The most common factor, that affecting the male, is easily tested with a semen analysis.  Tubal obstruction preventing a woman’s eggs from reaching the sperm can be ascertained by a hysterosalpingogram, a radiograph of the uterus and fallopian tubes performed after injecting radio-opaque contrast through the cervix.

Other tests to better delineate problems in the uterine cavity may be performed such as a hydrosonogram, where water is injected through the cervix and the cavity inspected by vaginal sonography or with hysteroscopy, where a scope is placed through the cervix to directly inspect the uterine cavity.

Blood tests may be performed to assess ovarian activity, in particular day 3 FSH and estradiol levels and AntiMullerian Hormone.  Prolactin and TSH levels are checked to rule out other hormonal disorders that may affect ovulation and fertility.

Treatment can be directed at the cause of infertility, such as ovulation induction for women with ovulatory disorders or surgery to remove uterine polyps or it may be independent of the cause such as with ovarian stimulation and intrauterine insemination or IVF which will improve success rates regardless of the cause of infertility with some exceptions.  IUI will have limited success for tubal factor, male factor infertility and endometriosis.  IVF will have limited success in women who have diminished ovarian reserve or abnormal eggs unless they use eggs donated by young fertile women.  Today, there is a highly successful treatment available for all.

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Was this helpful in answering your questions about what to expect from a fertility workup?

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Don’t Jostle Your Ovaries

By Tracey Minella

February 10th, 2013 at 12:58 pm

It takes a strong woman to go through infertility treatment. And sometimes, in our headstrong, full-speed-ahead-with-blinders-on mode, we feel we’re unstoppable. Invincible, even. But we are not.

With some areas of Long Island blanketed in over two feet of snow, there is a potential danger to infertile women in treatment… snow shoveling. You are not invincible. Do not shovel snow if you are currently in a treatment cycle, have just completed a cycle, are in the two-week waiting period for results, or are pregnant. You must be gentle to and mindful of your ovaries.

When you take injectable medications for IVF (or ovulation induction) to stimulate your ovaries to produce multiple follicles… instead of the single monthly follicle you may otherwise have produced… one of the reasons the doctors monitor you so closely with blood work and sonograms is to reduce the risk of ovarian hyper-stimulation syndrome, or “OHSS”.

When you stimulate the ovaries, they temporarily swell a bit in response, which is expected. OHSS in its mild form can be uncomfortable, but usually resolves on its own. Fortunately, severe OHSS cases are incredibly rare. But in the 1-2% of those cases, patients may experience symptoms including rapid weight gain, abdominal pain, vomiting, and shortness of breath. Pregnancy hormones can worsen OHSS. So, it is important to report any of the above symptoms to your RE as soon as possible, before or after your retrieval or transfer (or IUI). For more info on OHSS, see

Most women know not to do anything that could be harmful to a developing baby, but they don’t often realize the potential risk certain activities can pose to their stimulated, or recently retrieved, ovaries. Play it safe. Don’t jostle your ovaries.

So put the snow shovel down, ladies. And, leave the vacuum alone while you’re at it, too.

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Have you ever done anything strenuous while stimulating? Have you ever experienced OHSS?


Photo credit: Peter Griffin @


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BFN! Negative Pregnancy Test Again! Now What?

By David Kreiner MD

February 5th, 2013 at 6:30 pm

image courtesy of david castillo dominici/freedigital

Women confronted with a negative result from a pregnancy test are always disappointed, sometimes devastated. Many admit to becoming depressed and finding it hard to associate with people and go places where there are pregnant women or babies, making social situations extremely uncomfortable. A negative test is a reminder of all those feelings of emptiness, sadness and grief over the void infertility creates.

We don’t have control over these feelings and emotions. They affect our whole being and, unchecked, will continue until they have caused a complete state of depression. This article can arm you with a strategy to fight the potentially damaging effects that infertility threatens to do to you and your life.

First, upon seeing or hearing that gut-wrenching news, breathe.
Meditation — by controlling and focusing on your breathing — can help you gain control of your emotions and calm your body, slow down your heart rate and let you focus rationally on the issues. It’s best to have your partner or a special someone by your side that can help you to calm down and regain control.

Second, put this trauma into perspective.
It doesn’t always help to hear that someone else is suffering worse — whether it’s earthquake or cancer victims — but knowledge that fertile couples only conceive 20% of the time every month means that you are in good company with plenty of future moms and dads.

Third, seek help from a specialist, a reproductive endocrinologist (RE).
An RE has seven years of post-graduate training with much of it spent helping patients with the same problem you have. An RE will seek to establish a diagnosis and offer you an option of treatments. He will work with you to develop a plan to support your therapy based on your diagnosis, age, years of infertility, motivation, as well your financial and emotional means. If you are already under an RE’s care, the third step becomes developing a plan with your RE or evaluating your current plan.

Understand your odds of success per cycle are important for your treatment regimen. You want to establish why a past cycle may not have worked. It is the RE’s job to offer recommendations either for continuing the present course of therapy — explaining the odds of success, cost and risks — or for alternative more aggressive and successful treatments (again offering his opinion regarding the success, costs and risks of the other therapies).

Therapies may be surgical, such as laparoscopy or hysteroscopy to remove endometriosis, scar tissue, repair fallopian tubes or remove fibroids. They may be medical, such as using ovulation inducing agents like clomid or gonadotropin injections. They may include intrauterine insemination (IUI) with or without medications. They also may include minimal stimulation IVF or full-stimulated IVF. Age, duration of infertility, your diagnosis, ovarian condition, and financial and emotional means play a large role in determining this plan that the RE must make with your input.

There may be further diagnostic tests that may prove value in ascertaining your diagnosis and facilitate your treatment. These include a hysteroscopy or hydrosonogram to evaluate the uterine cavity, as well as the HSG (hysterosalpingogram) to evaluate the patency of the fallopian tubes as well as the uterine cavity.

Complementary therapies offer additional success potential by improving the health and wellness of an individual and, therefore, her fertility as well. These therapies — acupuncture, massage, nutrition, psychological mind and body programs, hypnotherapy –
have been associated with improved pregnancy rates seen when used as an adjunct to assisted reproductive technologies.

A negative pregnancy test can throw you off balance, out of your routine and depress you. Use my plan here to take control and not just improve your mood and life but increase the likelihood that your next test will be a positive one.

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What have you done…or what tips can you add… to get through the disappointment?


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ASRM 2011 and IVF’s “Magic Bullet”

By David Kreiner, MD

November 10th, 2011 at 1:52 am

This past October, reproductive endocrinologists from around the globe gathered for the annual scientific meeting of the American Society for Reproductive Medicine (“ASRM”).  It is an opportunity for us to share experiences and learn from each other.  

I had lunch with a colleague practicing IVF in Mumbai, India and was fascinated with how similar our practices felt despite the huge geographic and cultural differences.  The human interactions and emotional and social issues of infertility afflict our apparently disparate populations of patients in very similar ways.

There were a few presentations during the five day conference worth noting.  

Regarding ovulation induction for patients unable to ovulate on their own: Metformin, in combination with clomid appears to be slightly more effective than clomid alone or letrizole which may have a lower risk of multiples.  Ovarian drilling (a surgical procedure involving cauterizing small craters in the ovaries) is equally effective and was suggested for clomid/letrizole failures.

The best presentation according to many attendees was on surgery to enhance IVF success.  Data was presented documenting the huge benefit of eliminating hydrosalpinges (fluid filled fallopian tubes) prior to embryo transfer.  It is thought that the inflammatory fluid in these tubes bathes the uterine cavity… creating a hostile environment for the embryos.  It appears that salpingectomy (removal of the tubes), or tubal ligation laparoscopically or by one of the less invasive hysteroscopic procedures (such as Essure) appear to be equally effective.

Cysts of endometriosis do not affect the number or quality of a patient’s embryos. Because of the risk of removing normal ovarian tissue (and thereby reducing the ovarian reserve), it is not generally recommended that patients undergo endometriosis surgery to improve IVF outcome.

Routine hysteroscopy (visualization of interior of uterus through a scope) on asymptomatic patients found abnormalities in 11-12% of cases.  Removing polyps significantly improved pregnancy rates.  It was recommended that patients undergo a hysteroscopy after one failed IVF, if not done sooner.

Fibroids that were partially in the uterine cavity affected pregnancy rates and should be removed.  Likewise, fibroids that are intramural (in the muscle of the uterus) and distort or increase the size of the uterine cavity should be removed to increase the IVF pregnancy rate.  

It was also suggested that resection of the uterine septum increases the IVF pregnancy rate.

There were several interesting presentations about IVF over the course of the five day conference. But the one that stimulated the most conversation on the trip home was a study from Egypt.  

This program injected (through a catheter placed vaginally through the cervix) 500 units of HCG into the uterine cavity just before performing the embryo transfer.  They found higher pregnancy rates in women who were injected with this "magic bullet".  It inspired enough interest that I expect a year from now, we will learn if the intrauterine HCG is in fact the IVF magic bullet.

Certainly, we will endeavor to utilize the worthwhile studies presented at this year’s ASRM to continue to improve the outcomes for our patients.

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Did you learn anything new from this post? What is the most interesting thing? If the “magic bullet” was available to you, do you think you’d be interested in it? How important is it to you that your RE attends the annual ASRM conference?

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What You Need To Know About a Fertility Work Up

By Dr. David Kreiner

December 19th, 2010 at 6:27 pm

I have received an enormous amount of email from patients over the years asking for information about how they should get started with their infertility workup.  Apparently, they are women, men and couples who have experienced difficulty conceiving and now want some direction about how they should proceed.  Building a family was something they had imagined their entire lives to be a natural progression–from student to career, getting married then having a family–and they’re frustrated that their difficulty conceiving has affected their lives.  For many—some of whom have never experienced a health problem– it prevents them from appreciating or even doing anything else.

See an RE for a Fertility Workup

My response to these emails has been to tell the patients to seek assistance from a reproductive endocrinologist, whose specialty and experience is in helping infertility patients conceive.  A reproductive endocrinologist, who has two to three years of additional specialty fellowship training in infertility after completing an OB/GYN residency.

The RE will conduct a history and physical examination during your initial consultation.  This exam typically includes a pelvic ultrasound of a woman’s ovaries and uterus.  He/she can tell if there are any uterine abnormalities that may affect implantation or pregnancy as well as assess ovarian activity and rule out cases of moderate or severe endometriosis.

Pelvic Inflammatory Disease

If he elicits a history of previous abdominal or pelvic surgery, a physician may suspect that scarring may have developed that typically interferes with fallopian tube transport of the egg to the sperm and the conceptus to the uterus.  An infection that develops after a pregnancy may lead to pelvic adhesions affecting the tubes as well as scarring within the uterine cavity itself which can prevent implantation.  Pelvic inflammatory disease, PID, can lead to tubal disease and may be associated with other sexually transmitted diseases including HPV, Herpes and especially Chlamydia.

Semen Analysis

The semen analysis is the simplest test to perform and will reveal a male factor in 50% of cases.  A post coital test performed midcycle around the time of ovulation when the cervical mucus should be optimal can detect a male factor or cervical factor when few motile sperm are detected within hours of intercourse.


A hysterosalpingogram, HSG, is a radiograph x-ray of the uterus and fallopian tubes after radio opaque contrast is injected vaginally through the cervix directly into the uterus.  It can detect uterine abnormalities that can affect implantation and pregnancy as well as tubal patency.  Unfortunately, this exam may be painful and in some patients with PID can result in serious infection.  Some physicians will administer antibiotics prophylactically for this reason.


A hydrosonogram is an ultrasound of the uterine cavity performed after injecting water vaginally through the cervix directly into the uterus.  It can also detect uterine abnormalities and shares some of the risks seen with HSG but to a lesser extent and usually with less associated discomfort.


A hysteroscopy is a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus.  The physician can visually inspect the cavity to detect uterine abnormalities.  The risks of pain and infection are also seen with hysteroscopy.

Blood Tests

Blood tests may be run to identify if a patient is ovulating with adequate progesterone stimulation of the uterine lining.  Day 3 E2, FSH and LH levels can give information regarding ovarian activity and ovulatory dysfunction.  AntiMullerian Hormone (AMH) levels correlate with ovarian reserve.   That is the number of eggs remaining in the ovaries.  Hormones that can affect fertility such as thyroid and prolactin are also assessed to ensure that extraneous endocrine problems are not the cause of the infertility.


Laparoscopy is a surgical procedure in which a telescope is placed abdominally through the navel thereby allowing a physician to inspect the pelvic organs.  He/she can identify endometriosis, cysts, adhesions, infection, fibroids etc. that may be causing the infertility.  Unfortunately, only about 25% of cases in women who have a laparoscopy performed will conceive because of treatment performed at the time of the laparoscopy.

Workup Results and Treatment

Treatment can be directed at the cause such as surgery to correct adhesions or remove endometriosis, uterine polyps or fibroids.  Treatment can also be independent of the cause but improve fertility nonetheless.   Ovulation induction increases the number of eggs and therefore the likelihood that an egg will fertilize.  Gonadotropin injections stimulate many more eggs to develop in a cycle than clomid fertility pills.  IVF with minimal or full stimulation is the most successful treatment for any cause of infertility.  The decision as to what treatment to undertake will depend on numerous factors including your age, duration of infertility, cause of infertility, cost of treatment and success of treatment as well as your insurance coverage for the treatment and your motivation to conceive and willingness to accept the risks associated with the treatment.   Today, there is a highly successful treatment available for nearly all women.

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