Edward L. Marut, M.D. joined Reddit for a Q&A session. We’ve compiled some of the best questions…

Redditor:

You’ve been practicing in infertility for quite some time now. What do you think have been the greatest changes you’ve seen in the field since you first started practicing, either in treatments themselves or the culture around them, and how are you optimistic or pessimistic about the future for infertility patients?

And, while you are lifetime board certified, what do you do to stay fresh on the latest advances?

Dr. Marut:

I started aspirating eggs in monkeys before I ever did my first egg retrieval on a patient. The changes leading to the high success rate in IVF including ICSI, assisted hatching, blastocyst cultures, and Preimplantation genetic testing have all made huge strides. Efforts to identify the ideal embryo are being made which should improve outcomes even more.

I do medical student and resident teaching despite being in a private practice. I regularly attend medical conferences dealing with REI subjects and read multiple journals with fertility content as well as medical endocrine, genetics, general OBGYN and other specialty subjects.

Redditor:

I am interesting in gathering different perspectives—I been trying IVF over the past year (three cycles, all unsuccessful) and previously two cycles(one of which was successful). Each time I make a decent amount of eggs, have high fertilization rate, and plenty of embryos by day 3. None survive to day 5 though. Only once was one able to make it to day 5 to be biopsied for PGS. Is there any explanation for this?

I finally got pregnant my last cycle from a day 3 transfer but miscarried & the POC were tested and showed chromosomal abnormalities, maternal origin. I am 40. So, now I’m wondering if it is too risky to proceed with future day 3 transfers, but I never make it to day 5.

Also I am curious if there is evidence to support use of human growth hormone or açaí supplementation in older women (now 40) or just anecdotal support?

Dr. Maurt:

Most good IVF labs have high conversion of d3 embryos to blastocysts, and the trend is to allow all embryos to go to d5 (or later for freezing.) One which does not make it is likely abnormal either developmentally or genetically. Some labs do d3 transfers because they do not have an efficient culture system.

Growth hormone has had mixed results in a number of studies, and since it is now illegal for physicians to prescribe it for anything but a documented GH deficiency, it’s a moot point. There are absolutely no data to show that any supplements improve either ovarian reserve or egg quality (sadly.)

Redditor:

I’ve had a similar experience. I’ve read that there is some indication that drop off after day 3 is more likely a sperm issue than egg. Do you think there is any truth to that?

Dr. Marut:

Yes, but less likely since it’s obstructive. Some men have poor testicular sperm no matter the reason for the TESE

Redditor:

Can a high level of exercise interfere with normal ovulatory function?

Dr. Marut:

Everyone has a point at which the energy drain of exercise will cause disruption in normal hormonal production from the pituitary, and have a negative effect on ovulation. The classic marathon runner has no periods due to lean body and physical stress. Some women only have low progesterone. Reduction in the intensity may correct the problem.

Redditor:

What are your thoughts on Mini-IVF for DOR patients?

Dr. Marut:

Patients who have shown poor response to high dose stimulation may do as well or better on low dose stimulation, say with clomiphene and gonadotropins. I would always try the aggressive approach first.

Redditor:

I’ve heard PCOS patients tend to have lower quality eggs. Is that the case? If so, anything you would advise PCOS patients to do in the lead-up to IVF?

Dr. Marut:

There is great variation in egg quality in PCO patients. Where clinically appropriate, a metabolic workup, specifically looking at insulin resistance is indicated. Treatment that condition can help.

Redditor:

Do you recommend and/or have you seen improvement in egg quality/quantity from taking supplements like CoQ10 and DHEA?

Dr. Marut:

I had seen some female animal studies on CoQ10, so offered it, but now have seen more recent discussion that it doesn’t help. However, it definitely has a beneficial effect in men. DHEA is a poorly regulated hormone that has never been shown to be helpful except anecdotally. I don’t like giving my female patient a male hormone!

Redditor:

Have you noticed any major trends with lifestyle factors and IVF success? Obesity and smoking are the “obvious” ones, but I’m curious if you have anything else (whether lit supported or just a pattern you’ve noticed) like shift work, caffeine use, alcohol consumption, etc?

Dr. Marut:

There is a lot of bad information about the need to abstain from all caffeine and alcohol. Certainly, tobacco and marijuana have no place in attempting pregnancy. Up to 2 cups of caffeinated coffee is safe even into pregnancy, and 1-2 drinks a week before ovulation is ok. Once pregnancy is possible, better to back off the chardonnay. Shift work can throw off a woman’s menstrual cycle for sure. Men who work outdoors in the summer have decreased semen quality because of the heat.

Redditor:

Have you ever had a patient with incongruent results re: AMH and antral follicle count? What do you typically think in these cases, and do your IVF protocols for these cases typically become protocols for a poor responder or strong responder? For example, how would you approach a first IVF for someone who at the age of 28 presented with an AMH of 1.6 but an antral follicle count of 25+? (FSH around a 7 cd3, E2 sometimes up to 200 cd3) Has the way you’ve approached such cases changed as multiple egg retrievals are performed?

Dr. Marut:

I see a lot of discrepancy between AMH and AFC. I consider the AFC the “functional reserve” and form my protocol on that number. That high E2 is a pain and may require a down regulation protocol which I am not fond of because of hyperstimulation risk.

Redditor:

Do you think it is better to induce a withdrawal period artificially before starting femara for an IUI? Was reading a paper that had higher success rates without inducing a period.

Also, after a successful pregnancy, what can one do to get back to having normal periods?

Dr. Marut:

Great question; for years we have always been inducing a period before ovulation inducing meds. Now there is evidence that if the lining of the uterus is not excessive it may be better not to.

Redditor:

My question is: Do you often see low quality embryos or low numbers making it to blast with TESE sperm? I’m curious if this was just our case or if it’s generally just not as great to use. We’re trying to decide if we should try again or go with donor. We had 13/14 mature and 8 fertilized with all 8 going strong and 6 top rated embryos on Day 3. Then only 2 made it to mid quality early blasts and resulted in a negative and CP.

Our clinic has downplayed any negatives about TESE sperm but we were really hoping for better results and are unsure if we should try this way again.

Dr. Marut:

Over the years I have seen some reduction in quality embryos using TESE sperm, even to the point of failure to reach blastocyst. It seems worse with non-obstructive azoospermia compared to post vasectomy. If the clinics results with ejaculated sperm are better, the testicular sperm may be the issue.


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