Jennifer Hirshfeld-Cytron, M.D./MSCI stopped by Reddit to answer any and all infertility questions.

Redditor:

Hi Dr. Hirshfeld-Cytron, thank you so much for taking the time to do this AMA. I want to know what your thoughts are on acupuncture and if you think that it has any positive effect on pregnancy outcomes. It’s a touchy subject around here and I’m curious as to what your take is on it. I was told by my clinic that “We don’t say it will help but some people swear by it” which is fairly inconclusive. I saw a fertility acupuncture clinic once a week for two months leading up to my FET and had a chemical pregnancy and my benefits for acupuncture have run out and I’m not sure if $70 a pop is worth it to do again for my next retrieval/fresh transfer cycle.

I’m very curious what you think as I am trying to decide if I’ll do this going forward or not. Thank you so much!

Dr. Hirshfeld-Cytron:

I think WITHOUT question acupuncture improves stress. Stress doesn’t cause infertility but infertility and it’s treatments do cause stress. Stress that can lead to drop out of treatment. For this reason I do recommend acupuncture or yoga (non-heated) or meditation. Does acupuncture improve FET success? That is not clear. It doesn’t appear to make it worse. The studies that showed a benefit require that 1) acupuncture close and convenient to you or your IVF center 2) done day of or after FET. I agree it’s expensive.. some take insurance or can use HSA dollars. I hope this helps

Redditor:

Thank you so much for taking the time to speak to us. I’m particularly happy to have your input here, as you deal with what we have all encountered.

“Stress” is a major buzzword for couples with infertility (particularly for women), and I’ll admit that I see red when I hear it. I would wager that every single member of this subreddit has been told to “just relax” or “stop stressing,” as the general population has a hard time accepting diagnoses like PCOS, DOR, azoospermia, blocked tubes, etc., (I believe it comes down to a desperate need to feel in control. Therefore, “your infertility must be caused by something you’re doing wrong [too stressed], and my fertility is because I do things right [just drank wine and had some fun!],” but that is a separate discussion for another time.)

Nevertheless, we do experience stress, great quantities of it, and it negatively affects our daily lives. How do you deal with the tension between these two worlds with your patients? And how do we correct the record in public? I saw that the Telegraph’s take on your yoga study was “Stress can harm chances of getting pregnant,” which is misleading given that you seemed to be suggesting a much specific “Stress can keep infertile couples from pursuing treatment.” (And please correct me if I’m misunderstanding you!) I think those headlines are leading to many of the “Just relaxes” we get.

And after all that, I truly am looking for an honest answer to this: How is my stress actually affecting my chances at conception?

Dr. Hirshfeld-Cytron:

I agree with everything you said. In times of famine and war couples are able to reproduce. We KNOW infertility stress is on par with a cancer diagnosis but the support is dramatically lower. I view stress as a component of infertility treatment that needs to be addressed to avoid patients dropping out of treatment. That is a real concern as 40% or so of patients drop out prior to success due to the stress.

Stress NEEDS to be treated— i do believe in non-heated yoga and we have done 2 studies showing a positive impact and decrease in stress. Acupuncture, therapy, meditation apps… finding what works for you and doing it. Some it is walking etc. Some IVF studies suggest stress during treatment can negatively impact sperm/ outcomes etc, but that isn’t to say it causes infertility.

Redditor:

My luteal phase has always been on the short side, usually between 9-11 days. I ovulate every month on my own, but usually only after a few positive OPKs in a row (so, I’ll get 2-3 days of a positive OPK and ovulation occurs, according to BBT and once confirmed by ultrasound, 48 hours after the last positive OPK). We were told by our first RE that we were unexplained. My current RE didn’t give me a diagnosis but since my cycle length varies and I have a short luteal phase, he did say that there could be “something going on with my ovulation”, but no definitive diagnosis like PCOS.

I know it doesn’t “matter” since we’ve moved to IVF after two failed IUIs, but I still want to know what’s wrong. Are there ovulatory disorders other than PCOS and hypothalamic amenorrhea? I’ve seen folks on the internet mention “weak ovulation” – is that a real thing and is that what could be going on? It would be great to have some sort of explanation, even if it’s not a real diagnosis (I understand you can’t diagnose someone over the internet!).

Dr. Hirshfeld-Cytron:

Luteal phase deficiency is a debated diagnosis that can explain what you have experienced. Our “unexplained” infertility is likely a subtle issue of sperm or egg not yet able to be tested. sometimes in IVF based on visual appearance of egg, embryo growth a diagnosis can be determined… that isn’t to say doing IVF for a diagnosis but it is a another potential benefit. Like most aspects of medicine, the focus has been on improving treatments in infertility.

Redditor:

My question is: my diagnosis is DOR, amh of 0.9, afc 6, and fsh of 8.7 we did ivf 6 months ago and I only got two eggs out of my six follicles (only one fertilized). I was on high doses of Gonal-f and menopur (I want to say 250-350). We triggered with ovidrel. We have no other issues other than me taking levothyroxine for my thyroid. I wan on a bunch of doctor recommended suplementos for six months before my ivf cycle. So I feel like I gave it best I had. We only had one 3-day embryo to transfer. We immediately changed to donor eggs because we wouldn’t be able to afford multiple cycles to have the family we wanted at that rate. Did we give up too soon? Is there another protocol that could have done to give us better results or at this point is it just have been a money and time gave of how much we could have investes to get the all the embryos we needed for the family we wanted?

Dr. Hirshfeld-Cytron:

This is so hard to say and taking the step to donor is just a big decision… take costs out of yet then yes I would potentially try another stimulation lower dose gonal-F/menopur ?microdose lupron? estrogen priming? but living in the real world and comparing success the donor is better and without question a better “bang” for the buck.

Redditor:

Thanks for doing this! My question is about research and practice guidelines for treating females in same-sex partnerships for infertility. I had to challenge my insurance about how they define infertility and medical necessity for the purposes of coverage (very generous infertility benefit with almost no restrictions or limits) and in looking into practice guidelines and such I found virtually nothing on people in my situation.

The standard of unprotected sex for a year is basically impossible for someone in my situation to accomplish. Yet, the alternatives I was presented with were not very satisfactory. Insurer wanted me to pay for 12 medicated IUIs performed by a doctor (cost of more than $24,000 including donor sperm) to qualify for coverage. From what I could find there is very little medical evidence to indicate that 12 IUIs would be a necessary or helpful standard of treatment. But according to my doctor there isn’t another standard that could be argued since I hadn’t had the year of unprotected sex with a man. I argued (successfully, but only after I started the process of suing my insurer for discrimination) that they should count our 16 home insemination attempts with a known donor as equivalent exposures to sperm, since he had a normal sperm analysis and we got good timing. Originally this was considered insufficient because we couldn’t prove we had done the inseminations (any more than a married different-sex couple could prove they had sex for a year, I suppose?) My provider acquiesced that 16 cycles of well-timed inseminations using temping and OPKs was sufficient and used that to diagnose unexplained infertility. But there are lots of legal complications and associated expenses and risk to using known donor sperm, and the equivalent exposures to donor bank sperm would be prohibitively expensive for many people, especially with no guarantee the insurer would accept that as adequate. It’s not like being gay automatically shields a person from having medical infertility, and even if your testing comes back in normal ranges unexplained infertility is so common – but how do you get that diagnosis for insurance purposes if you can’t get it by having sex with your partner for a year (for free)?

Why don’t there seem to be any practice standards that address this? For a field where it feels like many treatment recommendations are based on a balance of medical evidence and cost considerations it is puzzling that this doesn’t get much attention. Is this on your radar? Are professional associations addressing it? Is it just that insurance coverage for infertility is so few and far between and this population of patients is relatively small that this issue of needing the diagnosis to cover treatments doesn’t come up as much?

Dr. Hirshfeld-Cytron:

There are quite a few medical professional organizations, ASRM in particular, that focuses on this. The problem is insurance is not a medical organization. You are 100% right that discrimination is built into the insurance that you had; the ONLY way to change that is at the level of the insurance company. Let your HR know that the plan they choose discriminates again same sex female couples. You and your company are the “customer” for insurance companies. I practice in IL with a state-mandate and have been able in some cases for home insemination to “count”; but what “counts” is completely up to the insurance company and the plan your HR chose.

Redditor:

Here’s my story. I’m 30, my husband is 31. He has no issues. I have PCOS, hypothyroidism (taking 75mcg Synthroid) and I had a laparoscopic surgery in Nov 2017 where they found slight endometriosis and one blocked tube. We moved to IVF and in mid Feb 2018 we had an egg retrieval with 8 frozen embryos. April 6, 2018 we had our first embryo transfer. Protocol was bcp, lupron overlapping with the last few bcp, period and monitoring ultrasound on cd2 and started estrogen pills and patches and baby aspirin, stopped lupron a week later, started progesterone PIO and Crinone two weeks from starting estrogen and had a transfer on the sixth day. My cycle resulted in a negative. The only symptoms I had were knuckle and joint pain on 4dpt and 6dpt, which led me to researching about NK cell issues. So I requested to see the report for the NK Cell Assay that my doctor had done before my transfer. He had said everything looks normal in the report and I don’t need any treatment. But this is how my report looks (tests done at RFU, Chicago): Test Name Reading Reference Range 50:1 32.7 10-40 25:1 24.5 5-30 12.5:1 14.5 3-20 IVIG 50:1 8.1 IVIG 25:1 7.9 Intralipid 50:1 14 Intralipid 25:1 9.5 %CD3 70 60-85 %CD19 19.4 2-12 %CD56 8.8 2-12 %CD19+CD5+ 17.1 5-10

Anti-Phospholipid Antibody, IgG, IgM – All Negative

Could you please help me understand my NK Cell Assay Report and recommend what I need to do to successfully get pregnant with my next FET?

Dr. Hirshfeld-Cytron:

Hi, thank you for your question. I and others have studied NK cells and there is NOT a relationship between peripheral (in your blood) NK cells and IVF success. IVF works 50-60% and may simply need to put another embryo back. Nk cells is not scientifically sound in my opinion and leads to treatments that don’t improve success.

Redditor:

Hi Dr Jenny – Thank you for doing this! My question is about how to think about my odds of success at this point. When I started my IVF journey at age 35, I was diagnosed with pretty extreme DOR (AMH = .2 & FSH = 10-14) and was given odds of 5-10% of ever getting to live birth. Fast forward two REs and 4 rounds of freeze-all IVF, and I now have 3 PGS normal embryos (2 are day-7 [yikes?] and 1 is day-6. All are 2AAs). I’m doing one more round to hopefully bank a few more normals. What I’m struggling to understand is across let’s say 4-5 PGS normal blasts, doing eSets, I would think my odds of at least one live birth are getting to be above 70% (despite the day-7s) but I’m never quite sure whether statistics align with rounds of IVF or transfers (eg, my round #3 could in theory result in 3 transfers going one by one). For context, I have no other issues, just DOR. Thanks again!

Dr. Hirshfeld-Cytron:

Once the embryos are PGT (PGS) tested success should be 60-70%; but this does vary by clinic. In general should only require placing one embryo. I would ask your doctor if when the embryo is day 7 BUT PGT-A normal do they see the same success? Do they see improved when placing two?

In general, PGS tested embryos success of 60-70% and just need one! DOR makes it harder to get the embryos but once normal then equals the playing field. Success, especially day 7, varies by clinic. Asl your doctor in their stats do they see the same success when PGT normal embryos are day 7 compared to day 5? Do they see same success with eSET as DET in day 7

Redditor:

We have had two failed transfers (beta = zero) of non pgs tested, single embryos. Both cycles were medicated with oral estrace and crinone, lining was aprox 6.5 each time. We are trying to determine our next steps and in the process of seeking second opinions have heard suggestions including, ERA, retrieval with PGS, just trying another eset without changing protocol, trying another eset with changing protocol (thicker lining and PIO) double transfer, fresh transfer. It is so overwhelming and the doctors we’ve spoken with seem to think we have unlimited energy and money to keep trying things until something works. Our diagnosis was tubal only and we’re in our early 30s. What would you advise as a good course of action for a couple with a supposedly “simple” diagnosis who have had two failed frozen transfers?

Dr. Hirshfeld-Cytron:

I would recommend ERA only if both transfers were FET. If one was fresh would consider changing protocols to thicken lining and transfer 2

 


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