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  • Making Treatment Choices

    One of the most difficult choices facing patients is whether and when to move from one step of the fertility process to another. Agreeing to see a fertility specialist and choosing to pursue a treatment plan is often a decision that is reached by couples after much discussion and struggle. If one particular intervention does not result in a successful pregnancy, how do you decide what to do next?

    First of all, I encourage my patients to acknowledge the disappointment they experience when a specific course of action has not worked. Elisabeth Kubler-Ross in her book On Death and Dying describes a process by which people deal with grief and tragedy. She originally applied this process to those suffering from terminal illness. Later she applied the same concepts to any form of catastrophic personal loss. It is appropriate to view an infertility diagnosis in this context. The stages of grief described by Kubler-Ross include denial, anger, bargaining, depression, and acceptance. These steps do not necessarily come in the order noted above, nor are all steps experienced by all patients, though Kubler-Ross believes that a person will always experience at least two. Couples should be aware that they may experience grief differently from one another and that they may be at different stages in the process. Keeping an open line of communication is extremely important to minimize feelings of isolation, blame, guilt, and depression.

    At Texas Fertility Center, we encourage the couples we work with to schedule a time when both partners are available to come to the office to discuss their previous treatment, what we can learn from testing and treatment they have already undergone, and how this information influences the recommendations for the next steps. Sometimes, especially when the male partner has not been present at several of the office visits, this approach provides an opportunity to reinforce some of the fundamental aspects of their particular situation which may have been forgotten or may still be unclear.

    Reviewing success rates,costs, risks, and the time commitments involved in the various treatment options usually provides clarity about the pros and cons of pursuing a particular path. I often find that partners are not necessarily on the same page when it comes to their readiness and willingness to move forward. This is common; most of us do not arrive at decisions and conclusions in the same way or at the same time. However, when this happens, I usually recommend that the couple consider meeting with a mental health professional who specializes in treating people dealing with infertility. This person has access to tools that facilitate conflict resolution, compromise, and ultimately consensus decision-making.

    In my practice, I think the most difficult decision for couples is the one concerning the use of an egg or sperm donor. The typical first response is “No, we don’t want to do that.” If, in their personal situation, the data is compelling that utilizing a donor offers the best – or even only – chance for a successful pregnancy, my approach to the couple is different. I ask them to visualize their lives five years down the road. What do they see? Is it possible to be in a happy place with just the two of them? Does the vision of a childless family cause pain? The most critical part of this decision is being honest about priorities. Sometimes, couples only want a child if the baby shares both of the parents’ genetics. If that is not possible, then their preference would be to remain childless. However, if the most important thing is to parent a child together, then it becomes an issue of choices.

    What do I mean by that? I ask the couple to think back to situations in their lives where they did not get their first choice. This could mean in a relationship, job offer, etc. How did that ultimately turn out? I use this example because I can personally think of several situations where I thought I would die if I did not get my first choice (and then I didn’t), and what happened next was better than I ever imagined my first choice would be. The children that result from treatments using donor eggs or sperm are the children that couple was meant to have; maybe not what they would have chosen in the beginning, but what they can now not ever imagine living without. My best advice to couples in the transition of treatment decision-making is to visualize their possibilities and look at the most effective way to make that happen.

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  • Cysters Unite!

    Let’s face it – women with polycystic ovarian syndrome (PCOS) have a lot of uphill battles to climb. First of all, there are the nonexistent periods…that when they do come, do so with a vengeance! Then there’s the issue of acne (aren’t pimples supposed to go away after you hit 20??). Also, the extra hair growth – or loss — may make you crazy. To top it off, all the hormonal imbalances can lead to difficulty maintaining a healthy weight – even with vigilant diet and exercise. It’s enough to make you question your sanity!

    Fortunately, we are steadily learning more about this disorder which affects 5-10% of all women in the United States. PCOS patients – whether newly diagnosed or already undergoing fertility or other treatment – can take solace in the fact that there are an increasing number of resources to help them navigate the challenges. There is a website called www.soulcysters.com which provides a wealth of information for PCOS patients. There are also message boards/forums where women with PCOS can share information and gain power over this treatable condition. Another website with a lot of resources is www.pcossupport.org, which is the website for the Polycystic Ovarian Syndrome Association. A new organization can be found at www.cysterworld.com. What’s great about these resources is the ability to connect with a number of other women who are going through the same PCO-related challenges. You are not alone!

    Last week I posted about celebrities who have been public with their infertility challenges. There are also celebrities who have been vocal about their battle with PCOS: Jillian Michaels (of the Biggest Loser), Emma Thompson, and Victoria Beckman (a.k.a ‘Posh Spice). Not everyone with PCOS fits the classic description; PCOS patients can be thin or overweight and may or may not have the typical symptoms of acne or hirsutism.

    If you think you may have PCOS (i.e. you have irregular or absent periods – and perhaps excess hair growth or acne), it’s important to find a doctor that can work with you to manage your symptoms and optimize your health. It isn’t all about just bringing on regular periods. Patients with PCOS are at greater risk for other health issues (i.e. diabetes), and it’s important not to overlook this on the quest for cycle regularity or fertility. Knowledge is power; increasing your understanding of PCOS can help you to take control over your condition.

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  • Famous and Infertile: Celebrities Who Have Dealt with Infertility

    Up until recently, infertility was an intensely private matter. Women would go to great lengths to hide their challenges…which unfortunately led many to believe that infertility was a rare phenomenon. A refreshing thing has happened in the last 5 to 10 years. We have become more open about the issue of infertility – and many women are coming forth with their own stories. Among them are some notable women in the media – who have been generous enough to share their experiences and reveal how infertility affects everyone:

    Brooke Shields:

    “When you’re having trouble conceiving, it’s often tough to know where to turn for answers, and when you’re undergoing fertility treatment, it’s not always easy to find the support that you need. As natural as we’d all like it to seem, it’s important for women to be aware of potential problems and to take control.”

    Marcia Cross:

    “We decided to skip our honeymoon and try in vitro after the wedding. I had already been through infertility treatments. It’s very, very difficult to get pregnant in your 40s. It’s costly and tough on your body and your relationship.”

    “I don’t like the average woman being misled into thinking that fertility is something that goes on forever. When a woman gets older, they get a donor egg, which doesn’t make the baby any less beautiful or perfect. One’s own eggs only last so long, and sometimes at 43 or 44 you can have your own baby, but statistically it’s very difficult and expensive. You don’t want to wait that long.”

    Celine Dion:

    “I never gave up. But I can tell you that it was physically and emotionally exhausting.”

    Courtney Cox:

    “I get pregnant pretty easily, but I have a hard time keeping them.”

    Jamie Lee Curtis:

    Jamie wrote a children’s book, called “Tell Me Again About the Night I was Born” to “let children who joined their families through adoption know that their own birth stories were exciting too.

    Sisters Martie Maguire and Emily Robison of the Dixie Chicks:

    “The more people talk about it, the less stigma there is. I never want anyone to feel that it’s not as beautiful a way to have a child as any other.”

    And a few men have been open as well:

    Hugh Jackman:

    “We still wanted to adopt. That was our plan: we’ll have two and we’ll adopt one. Anyway we didn’t have children. We tried and that was tough. But the moment Oscar arrived, it just felt like he was always meant to come that way. I forget he’s adopted; he’s just my son.”

    Penn Jillette:

    “Naturally is cheaper and way more fun than in-vitro fertilization. But with IVF we did get to sing old Velvet Underground tunes together while I used a real hypodermic needle to give Emily her hormone shots.”

    Other notables who have been forthcoming with their struggles: Sarah Jessica Parker, Angela Bassett, Emma Thompson, Nicole Kidman, Kirstie Alley, Joan Lunden.

    In the end, whether you choose to be open with your infertility – or feel more comfortable keeping it private — recognize that it is a very common issue that affects many many women today. And remember that your friends and family who have gone through treatment may not necessarily reveal all the details. In fact, many will say that ‘donor egg IVF’ has replaced plastic surgery as the best-kept secret in Hollywood (& elsewhere). Everyone – including a fertility patient – is entitled to reveal only what they feel comfortable doing so. The point is to not assume that no one around you is dealing with the same issues…even if you are not hearing it out loud.

    We are lucky in this day and age to have so many more fertility options than even 5 or 10 years ago. With treatments like intrauterine insemination, surgery, IVF, donor egg IVF, and the use of fertility medications and gestational carriers, we can create families now in cases which would not have been possible just a short time ago. Some couples may ultimately decide that fostering a child or adoption makes the most sense for them. There is not one ‘right’ way to have a child. However your children come to you is the way it was meant to be.

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  • The Cyperskeptic’s Guide to Fertility Websites

    Have you heard? Herbal supplements can increase your fertility 330 percent. You can get pregnant in 60 days, guaranteed. Feng shui tactics, including displaying pomegranates or pictures of elephants with their noses down, will result in a baby.

    These claims pop up in a Google search for infertility cures. In fact, more than 2.5 million sites offer information to couples anxious for answers. Problem is, anyone can put together a website and we want to protect our TFC fertility patients from misleading or even dangerous advice.

    The National Institutes of Health’s Medline Plus offers an online tutorial to “Healthy Web Surfing” that reinforces what you already know, and provides clues to help distinguish between legitimate sites and those that blend information with advertising (called “advertorial”) to subtly plug a product or service, or sell your name to someone who does. Ask yourself these questions to determine if a site offers what Medline Plus refers to as “current, unbiased information based on research, not opinion.”

    • What’s your first impression of the site?
    • Is there a clearly stated purpose?
    • If there is a product or service, is it clearly marked as advertising?

    The first door you should open off the home page is About Us. One fertility website offers a wealth of information on the homepage, but only after several click-throughs do you learn that the site owner sells a fertility supplement on his “one-stop fertility resource center.” Cyberskeptics avoid sites where the main purpose is to sell, not educate. And they never give out personal information without first checking out a site’s privacy policy. A good example of a pharmaceutical company website committed to patient education and privacy is www.fertilitylifelines.com.

    Beware of sites with unclear ownership that leave you guessing as to who sponsors or directs the content. Ideally, you’ll enhance your knowledge of infertility with the assistance of a medical practice like TFC, non-profit like Resolve, government agency like Medline Plus, hospital or health organization.

    Finally, a Contact Us page should allow you to easily contact the organization. Next, verify the information’s accuracy and relevance. Two words should quickly confirm the site’s commitment to providing timely, scientific data: Editorial Board. That’s a list of qualified professionals’ names, usually followed by Ph.D or M.D. These contributors regularly review and update content. You can also check the site map for Editorial Policy, Editorial Review Policy and Credentials pages. Refer to WebMd for a sample Editorial Policy. This site provides a detailed explanation of who provides its news, and how they separate advertising and editorial.

    If it sounds too good to be true… You know the rest. There exists no “guaranteed cure” for infertility. As scientists, we can show you the statistics, and for many patients, these are encouraging. But no doctor will tell you that conception will occur, no matter what.

    As part of its commitment to helping couples and individuals overcome infertility, TFC regularly offers timely, concise articles addressing common questions and concerns. Check out our seminar schedule, past newsletters and blogs, with topics ranging from What Your IVF Nurse Wants You to Know to Men and Testosterone. Of course, we always welcome your questions in person and invite you to call us to schedule a consultation.

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  • Your Doctor is Recommending IVF…Now What?

    The IVF process can seem very overwhelming — especially if you have recently started an infertility evaluation or if you are not very familiar with the IVF process. At TFC, we make every effort to make this process as stress-free as possible. For optimal success, we want you to feel comfortable and confident proceeding with this treatment. We have a wide variety of resources available to all of our current patients (and potential patients!) to help them better understand the IVF process.

    TFC offers a monthly IVF orientation for anyone interested in learning more about IVF. The IVF orientation is a great overview of the IVF process and is presented by both a physician and an embryologist. It gives attendees the opportunity to see TFC’s most recent statistics, get a behind-the-scenes look at the embryology/andrology lab, and have your questions answered by the experts. This presentation will give you a good idea of what to expect during your IVF cycle. In addition, the orientation also helps people feel as though they are not alone as infertility can often be very isolating.

    When you start an IVF cycle with TFC, you will be assigned an IVF nurse who will be your direct point of contact at our office. It is very important to call your IVF nurse with cycle day one of your full flow. Your flow is what triggers your IVF cycle to start. Once you call us with your flow, your nurse will work with your doctor to form a customized IVF plan. Once we have your plan established, you will come in and meet one-on-one with your IVF nurse to explore all of the details of your IVF cycle. She will walk you through the process step by step – and she will also teach you how to do your injections. If you are nervous about the injections, don’t worry! We have lots of tips to help make them as easy as possible for you.

    You can call and reach your IVF nurse with any questions or concerns you have throughout your cycle. Should a situation arise after hours or on the weekend, we have an on-call nurse that is available to answer your questions. The on-call nurse can also get in touch with your physician as well. It is very important to ask your nurse or physician all the questions that you have. Please call and ask us rather than looking to the internet – “Dr. Google” often has misinformation!

    Our team of embryologists will also work with you and your physician to make sure you understand everything that is occurring at the lab. An embryologist will talk with you on both the day of retrieval and the day of transfer. Our goal is to make sure that we keep you involved every step of the way.

    At TFC, our dedicated team of physicians, nurses, embryologists, and staff are committed to making your IVF cycle the best experience it can be. We strive to make sure that you are well informed throughout your treatment cycle so that we can optimize success and help you to create the family you have always dreamed of.

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  • Causes of Infertility: Ovulatory Disorders

    Approximately 15 % of infertility is secondary to ovulatory dysfunction. It is very important to figure out what the dysfunction is, as different causes have different treatments.

    First and foremost comes obtaining adequate information from a patient’s history. If a woman is having irregular periods or lack of periods or bleeding all the time, she is likely not ovulating in a normal manner. Some of the things that can impact ovulation are abnormalities in thyroid function (hypothyroidism or hyperthyroidism), high levels of the hormone prolactin hyperprolactinemia), polycystic ovary syndrome (PCOS), lack of appropriate hormone production from the brain (hypothalamic amenorrhea), obesity, premature ovarian failure and also things like eating disorders and extreme stress. It is very important for us as physicians treating infertility to differentiate between the various etiologies so that we may appropriately select the form of treatment.

    Things such as thyroid disorder are easily treatable via synthetic thyroid hormone replacement if low or other modalities if high. Often normalizing thyroid function will cause normalization of the ovulatory function. For women with PCOS, often medications to induce ovulation such as Clomid, letrozole (Femara) or gonadotropins are of benefit. The oral medications such as Clomid and Femara are first line since they are easy to use, have low side effects, they are inexpensive, and risk of multiples is also low. Many women with PCOS are obese and have glucose intolerance. Such women would benefit from weight loss and use of a medication called Metformin which improves the sensitivity to the actions of insulin in the body. In general if someone is going to get pregnant with oral medication, 85% of the pregnancies will happen within the first 4 cycles, after which it would be of benefit to consider other options.

    For women with hypothalamic causes of ovulatory dysfunction, they are most likely to have success with the gonadotropin injections. Those women who have premature ovarian failure (i.e. premature menopause), unfortunately there are not any good options other than IVF with donor egg. For those women with hyperprolactinemia, an MRI of the brain is necessary to see if they have a benign tumor of the pituitary gland called prolactinoma. If the tumor is small, it can be treated with oral medications which will normalize the hormone levels and often result in return of normal ovulation. Of course healthy lifestyle, good eating habits, maintaining a normal weight and minimizing stress as much as possible may also be of benefit with respect to fertility.

    As you can see, there is no “one size fits all” when it comes to fertility and ovulatory dysfunction, at TFC we try very hard to determine the root of the problem and tailor treatment to have the best outcome for each individual patient.

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  • Expectations

    As little girls growing up, we often dreamed about the children that we were going to have. Later, we were cautioned not to have sex or to at least use protection by our parents who didn’t want us to get pregnant at a young age. Thus, it is frustrating and challenging to discover that you are actually having difficulty getting pregnant and having the family of your dreams. Many people don’t realize just how difficult it can be to get pregnant, especially if they have never had to undergo fertility treatments to achieve their dreams of having a child.

    When you go to the doctor’s office, you are often learning things about yourself; sometimes, you may hear something that you don’t want to believe to be true or don’t want to hear. We all know that, as we get older, ovarian reserve decreases. Thus, the quantity and quality of our eggs begins to decline. This can be hard information to swallow.

    At Texas Fertility Center, our physicians are honest about what they believe to be the best course of treatment for your specific case. Each patient’s treatment plan is individualized based upon their specific medical history and needs.

    It is very important to the physicians and the staff that we arm you with the information to make an educated decision on what we believe will be best for your case. Unlike other fertility offices, we will allow you to proceed with whichever treatment cycle you choose as long as you understand the chances of success for that specific treatment. For example, if donor eggs are the best recommendation for you, but you want to try IVF with your own eggs, we will allow you to proceed with IVF using your own eggs. Some programs do not give patients the flexibility to do this.

    Our goal is to help you have the family that you have always dreamed of by making sure your treatment is the most successful (and cost effective) that it can be.

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  • Success Rates: Truth or Fiction?

    One of the most daunting challenges that I face in my everyday practice is giving reliable and realistic expectations for success of various treatments, especially in older women, or women with diminished ovarian reserve. Most of the large published reports involving treatments such as surgical correction of infertility or ovarian stimulation with intrauterine insemination studied women younger than 40 years old with normal ovarian function. It is a very dangerous practice to try and extrapolate those results to a different patient population. My opinion is that the only way a couple can make the decision for treatment is based on the honest facts as we know them. Recently, a review appeared on a popular website criticizing the approach that one of my partners had taken in counseling a woman. She said she was told at TFC that the treatment she needed was donor egg IVF, and she was expounding the virtue of a clinic in California that would allow her to try another cycle with her own eggs. What that says to me is that that clinic was very happy to take her money, regardless of her chances for success. On closer inspection, this couple had already done several IVF cycles with low egg numbers, poor embryo quality, and no pregnancy. She was also in the “poor prognosis” category based on age, so what my partner told her was actually the best (or only) way to achieve a successful pregnancy.

    So why do the docs at TFC take a beating for being honest? There really is very little recourse when a negative review is posted, and it makes me really sad and frustrated to think that other readers may be misled by comments such as these. BTW, the cycle in California was also unsuccessful for this particular couple as well. Same thing goes for all those celebrity births in women in their 40’s we read about in People and Us Weekly. There never is a mention that those twins born to the 45 year old were conceived with donor egg IVF. I can tell you only one thing for sure: at TFC you will always be told the truth as we know it about your chances for success; only then can you make the right decision for treatment, based on truth not fiction!

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  • Just Relax!

    How many times have couples who are struggling to become pregnant been told to go home and relax, or, go home and don’t think about it? And, everyone has heard about couples who have “forgotten” about their fertility problem and have conceived. The implication is that self-induced stress is the reason for not conceiving. Therefore, one would assume that if a couple forgot about their fertility problems and lowered their stress, then their chance of conceiving would increase. The scientific data does not support “just relaxing” as a the cure for infertility.

    However, minimizing stress is very important for couples going through fertility treatments. To decrease stress, it is helpful for a couple to consume less caffeine and develop the correct balance between diet and exercise. Telling a couple to go home and relax will only add to their stress.

    Remember that men and women deal with stress differently. Women complain that men do not want to talk about this problem as much as they do. It is very beneficial for women to be able to talk to someone about the difficulty in becoming pregnant. After all, women process by talking. The problem with men is that they are “fix it “people. When they cannot fix a problem, it becomes very stressful, so they may not want to talk about it. It is important for men to realize that their women partners are not asking the men to fix it, but to just listen. Therefore, it is important for men to “turn off the sports on television” and spend time listening to their partners. On the other hand, it is important for women to realize that they need to give their relationship a break from talking about fertility. A good compromise is for the couple to spend time talking about the problem during the week, but avoid the subject on the weekend and enjoy a date with their partner.

    One of the most important recommendations for increasing the chance of conceiving is to develop a plan of action. Unless a couple has completely obstructed fallopian tubes, ovarian failure, or an exceptionally low sperm count, there is a chance that pregnancy might occur without medical intervention. However, the chance of conceiving may be as low as 10% over the couple’s reproductive lifetime. Therefore, it is always advisable to seek assistance from a board certified reproductive endocrinologist to increase the chance of conceiving. Having a structured plan will help lower stress.

    It is very common for couples to be given advice from a family member and/or a friend. Family and friends feel the need to give advice. In the process of giving you advice, they feel that they have to tell you a story about how someone else became pregnant. They are hoping that they have given you some insight on how to improve your chances of conceiving or, at least, told you a story that gives you hope. It is rare that the advice is of any benefit. Even though that have good intentions, the best thing for a friend or family member to do is to simply be a good listener, and not offer advice.

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  • Funding Infertility: An Investment in Your Future

    You’ve always heard that kids aren’t cheap. To raise a child, birth through adulthood, estimates range from $200,000 to $400,000 when you include a college education. No one expects to heap the cost of getting pregnant to that pile of cash. But here you stand, poised to make an investment that will lead you to parenthood, and a lifetime of providing for a child’s needs and dreams.

    Getting started

    Once our highly trained fertility doctors map out the treatment plan most likely to result in a pregnancy, the Texas Fertility Center financial team will help estimate the costs, and what your insurance will cover. Before the initial appointment, plan to ask your employer for a full copy of your health insurance contract (different than a benefits summary) and fill out an online insurance benefit questionnaire. This will enable the staff Texas Fertility Center to accurately consult with you with regards to an estimate of out-of-pocket expenses. Fortunately, Texas is a fertility-friendly state. Texas law mandates at least partial coverage for infertile couples and individuals; although some plans pay to diagnose infertility, but not to treat it. Unfortunately, no two cycles look the same, and our approximation of cost considering an average amount of medication, lab work and office visits, may in fact fall short of, or extend beyond, the estimate.

    Exploring your options

    Some couples turn to savings, a home equity or 401(k) loan or even take a part-time job to pay for out-of-pocket expenses, while others choose to finance fertility treatment costs with a low interest loan. At Texas Fertility Center, we do not directly offer financing, but instead refer patients to outside vendors, such as Advanced Reproductive Care (ARC), the nation’s largest network of fertility specialists. This program offers patients shared-risk financing, with ARC guaranteeing at least a partial refund if you don’t become pregnant. Multi-cycle programs like those offered by ARC give you a better chance of conceiving because, statistically, couples do not get pregnant after one round of advanced treatment such as IVF. Contact ARC to inquire about the IVF refund program that minimizes financial risk and relieves the pressure to get pregnant with one cycle. Among other finance companies specializing in healthcare, Med Loan Finance offers 12 month, 0 percent financing and serves Texas Fertility Center patients. If you have access to a flexible spending account (FSA) at work, create one now to help save your pre-tax dollars to fund the cost of treatment.

    Here’s how it works: You’ll first estimate your spending. Remember it’s “use it or lose it” for a calendar year. Then request that your employer deduct that amount from your monthly paycheck. When you turn in a reimbursable expense, the plan sends you a check from your pre-tax, banked funds.

    Making a plan

    Start a file with copies of all prescriptions, procedure orders and contact information for your insurance company’s representatives. Written documentation will serve you best if there is ever a question about your patient history and medical claims, so try to communicate with letters. The Texas Fertility Center website provides copies of sample letters of predetermination. After phone conversations, document the day, time and name of the insurance representative. We recommend deciding in advance how far you are willing to go to pursue treatment. At some point, the financial burden may become too great. Your relationship as a couple has to come first, so plan to have a frank conversation about when to say when, and how much you can afford in fertility treatments. Contact us to reserve a time with a Texas Fertility patient account representative and we’ll provide one-on-one advice and consultation. If you want to go one step further, advocacy groups such as RESOLVE work toward insurance reform to give infertile couples a voice.

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