Category: IF 101

The What, How, and Why of Recurrent Pregnancy Loss (RPL)

The What, How, and Why of Recurrent Pregnancy Loss (RPL)

Many of us, who have been in the journey of TTC for a while, might have unfortunately experienced one or several pregnancy losses. From biochemical pregnancy, early 1st trimester miscarriages, to a stillborn, each loss is emotionally tolling and frustrating. Many doctors would tell you that one loss is just an unfortunate fluke, very unlikely to happen again. But did you know that as many as 15% of all women under 35 years of age will experience an early loss (Bashiri, Harlev & Agarwal, 2016)? No woman likes hearing these statements or being a data entry in these statistics. So, like a good medical detective and curious “yenta” that I am, (and once my mourning and healing process allowed me to do so), I decided to investigate more about pregnancy loss. I hope that this information might help someone out there achieve closure, accept that you did nothing wrong to cause this, and believe that it is not your fault this happened.

But did you know that as many as 15% of all women under 35 years of age will experience an early loss (Bashiri, Harlev & Agarwal, 2016)? No woman likes hearing these statements or being a data entry in these statistics. So, like a good medical detective and curious “yenta” that I am, (and once my mourning and healing process allowed me to do so), I decided to investigate more about pregnancy loss. I hope that this information might help someone out there achieve closure, accept that you did nothing wrong to cause this and understand more about some of the causes and treatments.

What is RPL?

Recurrent pregnancy loss (RPL) is defined by ASRM as “two or more clinical pregnancies losses documented by either ultrasonography or proved in a histopathologic examination” before 20 weeks gestation. However, the “Royal College of Obstetricians and Gynaecologists (RCOG) and the European Society of Human Reproduction and Embryology (ESHRE) [defines it] as three or more consecutive losses before 24 weeks gestation”. This is a significant discrepancy, which might cause certain physicians to delay diagnosis and treatment in women with only two losses. (This is why is extremely important to understand and accept that you are your best advocate and to seek advice/treatment from an RE who is open minded and would proactively look for the patients’ input). As well, many physicians and medical societies do not count chemical pregnancies as part of the diagnosis of RPL, but after much controversy, it has been included in many studies as part of the RPL diagnosis (as implantation rate could be diminished due to poor uterine lining receptivity, uterine anomalies or blood clots).

Common causes of RPL:

RPL_Causes

  • Autoimmune disorders and other immunological anomalies
  • Parental chromosomal aberrations (genetic problems
  • Uterine anomalies
  • Endocrine/hormonal abnormalities
  • Thrombophilias/Blood clotting disorders.
  • Infections
  • Obesity/Undernutrition
  • RPL: The effects of Age and Aneuploidy

Over the next few articles, I will attempt to further examine each one of these causes and discuss potential treatments (if available).

References:

  • Bashiri, A., Harlev, A., & Agarwal, A. (2016). Recurrent Pregnancy Loss. Cham: Springer International Publishing.
  • Chromosomal Abnormalities: Aneuploidies | Learn Science at Scitable. (2017). Nature.com. Retrieved 11 August 2017, from https://www.nature.com/scitable/topicpage/chromosomal-abnormalities-aneuploidies-290
  • Schattman, G., Esteves, S., & Agarwal, A. (2015). Unexplained infertility. Pathophysiology, Evaluation and Treatment.. New York, NY: Springer.
So what’s IUI?

So what’s IUI?

For many of you navigating the infertility treatment avenues, IUI might be one of the options your RE (reproductive endocrinologist) recommends. For many, is the #1 line of treatment, while for others, is a stop before reaching the (dreaded) world of IVF.
IUI stands for intra-uterine insemination, and it is usually recommended for couples dealing with mild male infertility factor, cervical mucus issues, endometriosis or unexplained infertility. It’s a relatively non-invasive procedure, which aims at giving the sperm a head start in the race toward the egg(s) by bypassing vaginal acidity and cervical mucus hostility.

As with any other IF treatments, the cycle starts on day 3 of a woman’s period. If the woman is not naturally getting a period, this can be induced by taking OCP’s (Desogen, Micronor) or an injectable such as ProveraTM. On day 3, a woman will go into the RE office to get bloodwork (usually to check hormone levels of estrogen, FSH, LH) and an internal ultrasound (to ensure ovaries are quiet and uterine lining is good). Depending on the diagnosis, the IUI cycle could be “natural” (no meds) or stimulated. A stimulated cycle could use standalone or a combination of medications. In a standalone oral medication cycle, a pill such as Clomid or Femara is taken from day 5-9 of the cycle. While an injectable cycle can include gonadotropins (Follistim, Gonal-F) with or without GnRH agonist/antagonist for ten days.  clomid iui

Depending on the diagnosis, the IUI cycle could be “natural” (no meds) or stimulated. A stimulated cycle could use standalone or a combination of medications. In a standalone oral medication cycle, a pill such as Clomid or Femara is taken from day 5-9 of the cycle.

antagon oiOn the other side, an injectable cycle can include gonadotropins, such as Follistim and Gonal-F, taken for 7-10 days. Some cycles might include GnRH antagonist like Ganirelix, either given in a fixed fashion, starting at day 6 or staring when lead follicle reaches 14mm of diameter.

iui combined cc inj.jpg
In between cycle days 10-12, you will go back for ultrasound and bloodwork. If one of the follicle measures between 18-20mm of diameter, you will be instructed to give yourself a trigger shot, such as ovidrel, Novarel or Pregnyl, to induce ovulation. The next day, the IUI procedure will be done.

iui
Intrauterine insemination

 

The day of the IUI, the male partner will give a semen sample. The sample will then be processed, counted and washed to concentrate the amount of sperm and clean debris. After which it will be inserted into the woman’s uterus via a catheter. Once the catheter is removed, she will stay in a supine position (laying on the back) for 5-10 minutes before being allowed to leave. About a week later, on cycle day 20, another blood test (progesterone) is done to determine if ovulation occurred. Two weeks after the IUI, the woman will go for the beta hCG “pregnancy” blood test. Hopefully, you will get a BFP, and you will start pregnancy monitoring.

 

Our infertility story and choosing a medical school

Our infertility story and choosing a medical school

The most amazing thing about applying to medical school is knowing that you gave your best in each of the 100’s of essays you wrote and the interviews you attended. Of course, it was an exhausting and money draining journey, so when I heard of my first acceptance, I was on top of the world. However, when I tell people that I was going to a DO school and not an MD school, I could see the confusion and disappointment on their faces. I don’t get me wrong; I do get that many people out there are not familiar with DO’s. Thus I take that into consideration as part of their “facial gesture assessment.”

When DH and I embarked on the journey of applying to medical school, we simultaneously started navigating the infertility road. At the time, however, we had no idea of the toll of IF treatments. A year and four months later, I was rejected from more than a dozen medical schools, put on a couple of waitlists (or what I called “death lists”) and got a couple of acceptances. On top of that, we underwent four cycles of fertility treatments, had one very early pregnancy loss (about a month or so) and an 8-week loss of our twin peanut boys, which included a D&C and three months of non-stop bleeding. The roller-coaster of hormones made me gain an awful 25 lbs, gave me mood swings, hot flashes, headaches, and what not. I went through good, bad and really tough days, plus all of the stages of grieving, while still finishing my last two semesters of school and interviewing at med schools in three different states.
After my hCG finally went down to zero, I decided that I needed a break from the fertility clinic, and doctors in general. I think at that point I was still in denial and too much pain, but it was one of the best decision I’ve ever taken. During the next six months, I took control of my health, went from a morbidly obese BMI of 32 to a healthy BMI of 25 (lost 40 lbs and still counting), graduated, and chose a great DO school instead of a great MD school.
It was not an easy decision. We weighted the cons and pros of everything, from moving to another state, the holistic vs. the conventional approach to medicines, Step 1 scores, job security for DH, and most importantly health insurance coverage.

Why was health insurance so important? Well, that’s a given, in an era where Obamacare, the insurance Marketplace, and the Trump administration are constantly scaring everyone in America about the future of healthcare coverage. However, more than that, going to the MD school meant losing our current super fantastic PPO health insurance policy ($100 deductible, 90% coverage in network and no referrals needed at all). Furthermore, the state where the MD school is located doesn’t have a state fertility mandate, which basically means that state laws specifically exclude coverage for fertility diagnosis and treatment.
This wasn’t fair! (But who said life was fair?). Once again, a curve ball is coming my way, and I have no idea how to spin it off to a home run. I certainly loved both schools and could have been happy at either, from an educational standpoint. But, what about having babies? Should we postpone having them for another four years because of lack of fertility insurance coverage? We definitely could not afford to pay for it out of pocket. So, in the end, it all came down to the possibility of having children ASAP (with the help of G-d and science). I am glad about our choice. I am a happy camper at DO medical school so far, and we are embarking in Season #2 of IF treatments, hoping for a baby (or babies) to stick with us next time around.

Infertility Support Organizations

Infertility Support Organizations

A TIME : USA

A TIME is the premier, internationally acclaimed organization that offers advocacy, education, guidance, research, and support through our many programs to Jewish men, women, and couples struggling with reproductive health and infertility.

A TIME is strongly endorsed by leading Rabbonim and physicians and is widely recognized as an organization that is sensitive to the privacy of each couple while providing a wide array of essential services in a caring and professional manner.

Services:

  • Medical referrals
  • Support groups
  • Hashgacha/Supervision
  • Insurance advocacy
  • Therapy
  • Adoption services
  • Rabbonim referrals

http://www.atime.org/

US Phone: (718)-686-8912

Puah Institute: USA & Israel

PUAH Institute, established in 1990, has helped thousands of couples suffering from infertility through the process of building a family. Staff members have an extensive breadth of knowledge enabling PUAH Institute to handle everything from complicated medical inquiries to relevant halachic questions. Couples receive the benefit of PUAH Institute’s expertise in a private and compassionate environment conducive to their needs. Professional expertise is also available to the general public through a wide variety of lectures, seminars and training courses. Participants at these sessions include rabbis, physicians, healthcare providers, and couples, all of whom share the common goal of raising awareness about reproductive health issues at both the social and medical levels.

Services:

  • Medical referrals
  • Hashgacha/ Supervison
  • Counseling
  • Events
  • Rabbonim

https://www.puahonline.org/

Bonei Olam: USA & Israel

Bonei Olam today is recognized in the worldwide medical arena for its leadership role at the forefront of reproductive medicine, research, and technology. Our myriad programs cover every step up the process including financial assistance, work up, medication, high-risk pregnancy, preimplantation, genetic diagnosis, pre-and-post cancer fertility, education, awareness, and adoption assistance.

Services:

  • Financial assistance
  • Insurance advocacy
  • Fertility preservation
  • Free loan program
  • Advanced genetic testing & research
  • Adoption services
  • High-risk pregnancy care

http://www.boneiolam.org//

Brooklyn NY Phone: (718)-252-1212

Lakewood NJ Phone: (732) 942-7773

Monroe NY Phone: (845) 751-1212

Spring Valley, NY Phone: (845) 388-1212

West Coast CA Phone: (323) 673-1212

Canada Phone: (514) 312-2977

Israel Phone: 1-800-300-307

Chana: UK

For 22 years, Chana has been giving emotional and practical support to Jewish couples who are experiencing primary or secondary infertility. Many couples in the Jewish community are affected, often dealing with their situation in silence and alone. Chana is here to help.

Services:

  • A strictly confidential helpline
  • Specialist medical support and information
  • Confidential counseling for individuals and couples
  • An expert Medical Advisory Panel
  • Information events

http://www.chana.org.uk/

Helpline: 020 8201 5774

Office London Phone: 020 8203 8455

Infertility Treatment Grants and Scholarships

Infertility Treatment Grants and Scholarships

Hope does exist for patients whose primary barrier to infertility treatment is the cost. Below is information about nonprofit organizations that provide financial assistance to select infertility patients.

For details, including application deadlines, please visit their websites. The listing of these organizations does not mean or imply an endorsement by RESOLVE.

Baby Quest Foundation

Grants are awarded two times yearly.
Provides a dollar range of $2,000-$16,000 (combination of money and medications).
Open to all, genders, singles, same sex couples, all who are permanent residents of the U.S., etc. (Click here to see more requirements on the Baby Quest website).
Baby Quest funds a range of procedures including egg and sperm donation, egg freezing, artificial insemination, in vitro fertilization, embryo donation, and gestational surrogacy.
Applications fees apply – $50 Application fee.
Contact Information:
Website: Visit http://www.babyquestfoundation.org for more information about Baby Quest’s grant
Email: bqfoundation@gmail.com
APPLY FOR A BABY QUEST GRANT – NEXT GRANT DEADLINE: November 15, 2017

The Tinina Q. Cade Foundation – Family Building Grant

This grant is offered twice per year – Once in the spring and once in the fall.
Provides up to $10,000 per funded family to help with costs medical infertility treatments and domestic adoption.
Open to all; applicants must have a diagnosis of infertility from their doctor and must be legal, permanent U.S. residents.
Applications fees apply- $50 Application fee.
Dates of Interest:

Grant is available online 7/5/16.
Grant submission deadline for SPRING consideration 2/1/17.
Grant decisions announced for SPRING funding 6/1/17.
Money available for SPRING grant applicants 8/1/17 available (grant MUST be redeemed by 8/1/18).
Grant submission deadline for FALL consideration 7/1/17.
Grant decisions announced for FALL funding 10/15/17.
2017 Cade Foundation Family Building Gala (required for all grant recipients) November 2017.
Money available for FALL grant recipients 1/1/18 (grant MUST be redeemed by 12/31/18).
Savannah Grant – Exclusively for Shady Grove Fertility Patients
All Shady Grove Fertility patients are eligible to receive the Savannah Grant, which will provide up to $10,000 in support for fertility treatment.
To apply for these grants, please submit an application for the Cade Foundation Family Building Grant. Shady Grove Patients will automatically be considered for a traditional Family Building Grant as well as the Savannah Grant.
Contact Information:
Website: Visit http://www.cadefoundation.org for more information about the Family Building Grant
Email: info@cadefoundation.org
Phone: (443) 896-6504
Fax: (410) 741-3701
APPLY FOR THE FAMILY BUILDING GRANT

The International Council on Infertility Information Dissemination- Scholarship:

The INCIID program is not a grant. INCIID does not pay a recipient’s expenses. Couples that meet certain criteria (financial and medical need) may be eligible for participation.
Provides a basic IVF cycle which is donated by a facility. This includes the treatment and physician services and monitoring at the designated clinic.
INCIID depends on donations to operate programs. Community members who pledge to an annual donation as a Bronze ($55 annually) member are eligible to receive a scholarship. The cost for a bronze annual level donation is a minimum of $55.00. Donate Here.
If you are NOT already a registered member, you can register in the community FIRST.
The selection committee selects couples based on cost-of-living, submitted paystubs, tax returns and a letter from their doctor recommending IVF as medically necessary.
Visit INCIID’s Frequently Asked Questions for more information about the program and eligibility requirements.
Dates vary in this program.
Contact Information:
Website: Visit http://www.inciid.org for more information about the, From INCIID the Heart IVF Scholarship Program.
Email: INCIIDinfo@inciid.org
Phone: (703)379-9178
Fax: (703)379-1593
APPLY FOR THE INCIID SCHOLARSHIP

The JFCS Fertility Fund: A Gift From the Heart

The JFCS Fertility Fund is a fund to help individuals and families who are confronted with infertility and the financial burden of IVF treatments that are not covered by insurance.

Applicants must be Jewish and reside in the Greater Philadelphia Region.
Application Process: Grants are provided as they are received.
Other resources through JFCS: The Hebrew Free Loan Society of Greater Philadelphia provides interest-free loans to Jews in our community for fertility treatments. For more information, visit http://www.hflphilly.org
Contact Information:
Website: http://www.jfcsphilly.org/fertilityfund
Phone: 1.866.532.7669
APPLY FOR THE JFCS FERTILITY FUND

Kevin J. Lederer Life Foundation – Life Grant

Must reside in Illinois, Indiana or Wisconsin.
Must have a diagnosis of infertility certified by a medical provider, with the exception of applicants who are single, or part of a same sex couple.
Grant requests may not exceed $10,000.
Past procedures are not eligible for Life Grants.
Visit Kevin J. Lederer Life Foundation’s Frequently Asked Questions for more information about the grant and eligibility requirements.
Contact Information:
Website: Visit http://www.lifefindsaway.org for more information on how to apply.
Email: grants@lifefindsaway.org
APPLY FOR A LIFE GRANT – Grant recipients will be announced July 2017

The Parental Hope Grant

The Parental Hope Family Grant Applicant (or Co-Applicant) must have one of the following:

A medical diagnosis of infertility by a Reproductive Endocrinologist according to the American Society for Reproductive Medicine’s definition of Infertility; or
Be a carrier of a genetic disease or chromosomal disorder that requires the use of Assisted Reproductive Technology (“ART”) services for healthy offspring; or
A Reproductive Endocrinologist has recommended ART services due to recurrent pregnancy loss.
$50 non-refundable application fee.
Contact information:
Website: http://www.parentalhope.org
Email: info@parentalhope.org
APPLY FOR THE PARENTAL HOPE FAMILY GRANTS – Parental Hope Family Grants are awarded annually. The next Application deadline is August 1, 2017.

Pay it Forward Fertility Foundation – Fertility Grant

The grant applies only to in vitro fertilization treatment (IVF), IVF with donor eggs and embryo adoption.
Grant amounts vary among the grant recipients, and partial and full grants can be awarded.
The age limit for the female partner is under 40 years old unless using donor eggs or doing embryo adoption. The application states that the female patient must be under the age of 40 when starting an IVF cycle.
Applicants must be United States (U.S.) citizens or permanent U.S. residents.
Visit Pay it Forward Fertility’s Frequently Asked Questions for more information about the grant and eligibility requirements.
$50 donation fee for processing application.
Contact Information:
Website: Visit http://www.payitforwardfertility.org for more information on how to apply.
Email: info@payitforwardfertility.org
Phone: (855) 888-PIFFF (7433)
APPLY FOR THE PAY IT FORWARD FERTILITY GRANT

In-State Assistance Only

New York State Infertility Demonstration Program
A grant from New York State for IVF treatment that is given to select IVF clinics.
On-Site Infertility Facilities Selected to Participate.
Funds are allocated to select centers meeting high standards of IVF success rates and patient volume.
To determine if you are eligible for the New York State Infertility Demonstration Program, please contact one of the providers on this list.
Contact Information:
Website: Visit Infertility Demonstration Program for more information
Email: bwh@health.state.ny.us
Phone: 1-800-522-5006 or through TTY access at 1-800-655-1789
Fax: (518) 474-6041

Cleveland Clinic – Ohio Hospital Care Assurance Program (HCAP)
You must be a resident of Ohio, Florida or Nevada and meet the geographic requirements identified in the policy.
They offer emergency and other medically necessary hospital-level services free of charge.
Eligibility:

(1) You are currently an eligible recipient of the General Assistance or the Disability Assistance Programs

(2) Your income is at or below 100% of the Federal Poverty Guidelines (the FPG).

For information regarding Cleveland Clinic Financial Assistance Policy and Financial Assistance Application Form, please refer to the contact information below for Cleveland Clinic financial counselors.

Contact Information:
Website: http://my.clevelandclinic.org – Financial Assistance
Phone: (866) 621-6385

Halachic Infertility

Halachic Infertility

Halachic Infertility refers to a case where a woman ovulates prior to immersion in the mikva. Since studies have shown that relations must occur before ovulation in order to result in conception, this “early ovulation” results in infertility.

A woman who suspects that she ovulates before she can immerse in the mikvah should first determine her date of ovulation. There are several ways to do this:

1) She can measure her temperature upon arising every morning (the “basal body temperature”). There is generally a rise of about 0.3 degrees Centigrade (0.5 degrees Fahrenheit) just prior to ovulation. This method can be cumbersome for women who wake at irregular times, and body temperature can be affected by other factors, such as illness. Therefore, other methods are more popular today.

2) She can use an “ovulation prediction test,” which measures the surge in lutenizing hormone (LH) that precedes ovulation by 12-24 hours. These kits are readily available in pharmacies or Amazon without a prescription, and may be used in the privacy of one’s home.

(Here you can find many types of ovulation test) https://www.amazon.com/s/ref=nb_sb_noss?url=search-alias%3Daps&field-keywords=ovulation+test

3) A physician may order blood tests to determine hormone levels on particular days of her cycle.

4) Under direction of a physician, she may undergo a series of ultrasounds which follow the development of the ovarian follicle and record ovulation directly.

A woman who discovers that she is ovulating before immersion should next verify that her menses really last as long as she thinks. Any color other than bright red on a hefsek taharah or other internal examination should be brought to a rabbi to check whether it is, in fact, problematic. The rabbi should be aware that she cannot conceive due to early ovulation, as certain leniencies may apply in this situation. Many cases of halachic infertility can be solved by avoiding unnecessary delay of mikveh immersion.

What are the causes of “early ovulation” and what can be done within halacha to treat this issue?

There are two scenarios that result in early ovulation:

  • Short Cycle
  • Long Bleeding

Normal or Average Menstrual Cycle

On average, a regular menstrual cycle occurs every 28 days and lasts from 2 to 7 days. In most cases, women ovulate 14 days prior to their upcoming menstruation, or on the 14th day of her monthly cycle.

According to halachot of niddah, women cannot immerse in the mikvah until at least 12 days (11 days according to Sephardic opinions)  from the onset of menstruation.

On average, a woman will therefore immerse (depending on the duration of bleeding) anywhere from the 12th day of her cycle to the 14th day of her cycle. Most women will ovulate after immersion, an optimum time for fertility. Women who have an average 14 day cycle and bleed for a full 7 days will ovulate on the day of immersion, a situation which is considered to be borderline and may result in infertility.

Short Cycle

Short cycle infertility is defined as a case where even a woman with the shortest duration of bleeding cannot immerse in the mikveh prior to ovulation. Women whose cycles are 25 days or less will not immerse until at least the 12th day after the onset of monthly bleeding. Since ovulation generally occurs 14 days before the onset of monthly bleeding, we can calculate that ovulation in such cycles will occur on or prior to the 11th day of the monthly cycle. Such women cannot immerse prior to ovulation, which results in infertility.

Women whose cycles are 26 days are considered to be borderline cases; some may ovulate prior to immersion while others may ovulate after immersion, depending on the duration of her bleeding period.

Long Bleeding

Long bleeding is defined as a case in which either the duration of menstrual bleeding or occurrences of irregular bleeding lead to an inability to immerse in the mikveh prior to ovulation.

Any instance where the duration of bleeding combined with the mandatory minimum 7 day waiting period after the cessation of period leads to immersion after ovulation. For instance, a woman with a 27 day cycle will ovulate on day 13 of her cycle. If her period lasts for 7 days, she will immerse no earlier than day 14.

Please note that a monthly period lasting for longer than 7 days may require medical attention. A physician should be consulted.

Solutions

The above calculations are explanatory in nature and should not be relied upon to calculate the date of ovulation. There are methods to determine the exact date of ovulation which should be used to determine if religious infertility is indeed the case. If it is determined that a woman is indeed suffering from religious infertility there are methods within halacha to address the situation.

The following solutions are not general in nature. Each case must be evaluated and treated on an individual basis in consultation with a Rabbi or Puah Rabbinic Counselor.

  • Short Cycle Solutions: Short cycles can be caused by excess stress or dietary issues. In such cases, dietary changes (eating 3 healthy well balanced meals each day), relaxation techniques and/or moderate exercise may result in the extension of the cycle to normal levels. If these solutions are not effective, there are natural remedies as well as pharmacological remedies that may be prescribed. This should only be done in consultation with a fertility professional and/or Puah Rabbinical Counselor.
  • Long Bleeding Solutions: Many cases of long bleeding are the result of unnecessary stringency in the observance of the laws of niddah. The responsibility in this area is placed on the woman herself and the natural inclination when in doubt is to err on the side of caution. As such, there are women who postpone their immersion date in error and can actually halachically immerse earlier than they think. If there is any question as to the determination of a stain or spot halachically, a Rabbi should be consulted for a definitive halachic ruling.

    Not every case, however, can be solved through halachic leniency. In particular, the seven blood-free days cannot begin before bleeding has stopped, as confirmed by a hefsek taharah. Therefore, a woman with early ovulation whose menses last at least five days may require medical intervention in order to conceive.

    There are a number of medical treatments that can delay ovulation. One common treatment is clomiphene citrate (Clomid, Serephene, or Ikaclomin). This drug is normally used in fertility treatment to induce ovulation, but it is helpful in this case, because it has the side effect of delaying ovulation. Another approach is to use estrogen at the beginning of the cycle to delay ovulation by a few days. Other hormonal manipulation can delay ovulation as well. All these medications require a prescription, and must be used under the supervision of a physician.

    If the standard medical treatments fail or are unsuitable, there are other possible ways to intervene, but these should be developed by a medical team working together with a rabbi experienced in fertility.

    There are also natural remedies that may be employed to shorten the duration of a menstrual cycle. For example, in some cases, drinking the juice of one lemon each day of menstruation has been shown to be effective in shortening the duration of a period.

Reference:

http://www.jewishfertility.org/halachic-infertility.php

http://www.yoatzot.org/womens-health-and-halacha/?id=584

 

Hormone levels & fertility blood work

When TTC, it is important to closely track your cycle, ideally through the use of urine-based ovulation testing (ovulation tracking), basal temperature tracking, or blood work. As a Frum woman, if you believe that hormonal imbalance or halachic infertility may be contributing to your difficulty in achieving pregnancy, it is crucial to determine whether or not ovulation is occurring within 24-36 hours of going to the mikvah (more on this topic in a later post).

Please note that all labs have their own normal values, and those presented in these charts are just an average. These charts are provided as a tool to help Frum patients have a better dialog with their doctors, not for self-diagnosis or as a substitute for good medical care.

Female Hormone Levels
Hormone to Test
Time
to Test
Normal
Values
What Value Means
Follicle Stimulating Hormone (FSH) Day 3 3-20 mIU/ml FSH is often used as a gauge of ovarian reserve. In general, under 6 is excellent, 6-9 is good, 9-10 fair, 10-13 diminished reserve, 13+ very hard to stimulate. In PCOS testing, the LH:FSH ratio may be used in the diagnosis. The ratio is usually close to 1:1, but if the LH is higher, it is one possible indication of PCOS.
Estradiol (E2) Day 3 25-75 pg/ml Levels on the lower end tend to be better for stimulating. Abnormally high levels on day 3 may indicate existence of a functional cyst or diminished ovarian reserve.
Estradiol (E2) Day 4-5 of meds 100+ pg/ml or 2x Day 3 There are no charts showing E2 levels during stimulation since there is a wide variation depending on how many follicles are being produced and their size. Most doctors will consider any increase in E2 a positive sign, but others use a formula of either 100 pg/ml after 4 days of stims, or a doubling in E2 from the level taken on cycle day 3.
Estradiol (E2) Surge/hCG day 200 + pg/ml The levels should be 200-600 per mature (18 mm) follicle. These levels are sometimes lower in overweight women.
Luteinizing Hormone (LH) Day 3 < 7 mIU/ml A normal LH level is similar to FSH. An LH that is higher than FSH is one indication of PCOS.
Luteinizing Hormone (LH) Surge Day > 20 mIU/ml The LH surge leads to ovulation within 48 hours.
Prolactin Day 3 < 24 ng/ml Increased prolactin levels can interfere with ovulation. They may also indicate further testing (MRI) should be done to check for a pituitary tumor. Some women with PCOS also have hyperprolactinemia.
Progesterone (P4) Day 3 < 1.5 ng/ml Often called the follicular phase level. An elevated level may indicate a lower pregnancy rate. If low progesterone levels are an issue for you, consider taking a natural fertility supplement like FertilAid for Women.
Progesterone (P4) 7 dpo > 15 ng/ml A progesterone test is done to confirm ovulation. When a follicle releases its egg, it becomes what is called a corpus luteum and produces progesterone. A level over 5 probably indicates some form of ovulation, but most doctors want to see a level over 10 on a natural cycle, and a level over 15 on a medicated cycle. There is no mid-luteal level that predicts pregnancy. Some say the test may be more accurate if done first thing in the morning after fasting.
Thyroid Stimulating Hormone (TSH) Day 3 .4-4 uIU/ml Mid-range normal in most labs is about 1.7. A high level of TSH combined with a low or normal T4 level generally indicates hypothyroidism, which can have an effect on fertility.
Free Triiodothyronine (T3) Day 3 1.4-4.4 pg/ml Sometimes the diseased thyroid gland will start producing very high levels of T3 but still produce normal levels of T4. Therefore measurement of both hormones provides an even more accurate evaluation of thyroid function.
Free Thyroxine (T4) Day 3 .8-2 ng/dl A low level may indicate a diseased thyroid gland or may indicate a non- functioning pituitary gland which is not stimulating the thyroid to produce T4. If the T4 is low and the TSH is normal, that is more likely to indicate a problem with the pituitary.
Total Testosterone Day 3 6-86 ng/dl Testosterone is secreted from the adrenal gland and the ovaries. Most would consider a level above 50 to be somewhat elevated.
Free Testosterone Day 3 .7-3.6 pg/ml
Dehydroepiandrosterone Sulfate (DHEAS) Day 3 35-430 ug/dl An elevated DHEAS level may be improved through use of dexamethasone, prednisone, or insulin-sensiting medications.
Androstenedione Day 3 .7-3.1 ng/ml
Sex Hormone Binding Globulin (SHBG) Day 3 18-114 nmol/l Increased androgen production often leads to lower SHBG
17 Hydroxyprogesterone Day 3 20-100 ng/dl Mid-cycle peak would be 100-250 ng/dl, luteal phase 100-500 ng/dl
Fasting Insulin 8-16 hours fasting < 30 mIU/ml The normal range here doesn’t give all the information. A fasting insulin of 10-13 generally indicates some insulin resistance, and levels above 13 indicate greater insulin resistance.

 

Blood Glucose Levels
Type of Test Time to
Test
Normal
Values
What value means
Fasting Glucose 8-16 hours fasting 70-110 mg/dl A healthy fasting glucose level is between 70-90, but up to 110 is within normal limits. A level of 111-125 indicates impaired glucose tolerance/insulin resistance. A fasting level of 126+ indicates type II diabetes.
Glycohemoglobin / Glycosylated Hemoglobin (HbA1c) anytime < 6 % An HbA1c measures glucose levels over the past 3 months. It should be under 6% to show good diabetic control (postprandial glucose levels rarely going above 120). Good control reduces the risk of miscarriage and birth defects.

 

Glucose Tolerance Test with Insulin (GTT / IGTT)
Time Normal Glucose Values Normal Insulin Values What the Results Mean
Fasting < 126 mg/dl < 10 mIU/ml Normal glucose results are 70-90, 111 or over is impaired, 126 or over is diabetic. Insulin levels above 10 show insulin resistance.
? hour < 200 mg/dl 40-70 mIU/ml A truly normal glucose response will not exceed 150.
1 hour < 200 mg/dl 50-90 mIU/ml Some want to lower the threshold on glucose to < 180 to identify early stages of diabetes. Insulin > 80 shows insulin resistance, or a level 5 times that of the fasting level (i.e., a fasting of 11 followed by a 1 hour > 55)
2 hours < 140 mg/dl 6-50 mIU/ml A truly normal glucose response is 110 or lower.
Insulin > 60 is IR.
3 hours < 120 mg/dl
4 hours < 120 mg/dl

 

Cholesterol, Triglycerides and C-Peptide
What to Test Time to Test Normal
Values
What value means
Triglycerides (TG) 8-16 hours fasting < 200 mg/dl Borderline high is 200-400, high is 400-1000, and very high is >1000. Elevated levels are a risk factor for coronary artery disease.
Cholesterol Total 8-16 hours fasting < 200 mg/dl A level of 200-239 is borderline high, and a level 240+ is high. Increased levels are associated with increased risk of heart disease.
low-density lipoprotein cholesterol (LDL) 8-16 hours fasting < 160 mg/dl This is the “bad” cholesterol. In someone with one risk factor for heart disease, < 160 is recommended, with 2 risk factors < 130, and those with documented coronary heart disease the target is < 100
high-density lipoprotein cholesterol (HDL) 8-16 hours fasting > 34 mg/dl This is the “good” cholesterol which may be increased through a healthy diet and exercise. The HDL level is usually estimated by taking total cholesterol and subtracting LDL, rather than by direct measure.
C-peptide 8-16 hours fasting 0.5 to 4.0 ng/ml Levels increase with insulin production.
Creatinine < 1.4 mg/dl Levels 1.4 mg/dl and higher may indicate renal (kidney) disease or renal dysfunction.

 

Male Hormone Levels
Hormone to Test Normal Values What value means
Testosterone 270-1100 ng/dl Testosterone production is stimulated by Leydig cells in the testicles. Low levels of testosterone combined with low FSH and LH are diagnostic of hypogonadotropic hypogonadism.
Free Testosterone .95-4.3 ng/dl  
% Free Testosterone .3% – 5% A normal male has about 2% free, unbound testosterone
Follicle Stimulating Hormone (FSH) 1-18 mIU/ml Basic hormone testing for males often only includes FSH and testosterone.
Prolactin < 20 ng/ml A level two or three times that of normal may indicate a pituitary tumor, such as a prolactinoma, which may lead to decreased sperm production. Elevations can be treated with bromocriptine.
Luteinizing Hormone (LH) 2-18 mIU/ml LH stimulates Leydig cells and production of testosterone. A problem with LH levels alone is rarely seen, so testing is only needed if testosterone level is abnormal.
Estradiol (E2) 10-60 pg/ml  
Progesterone (P4) .3-1.2 ng/ml  

 

Progesterone in Pregnancy
When Normal Values What Level Means
Mid-Luteal Phase 5+ ng/ml As mentioned above, a level of 5 indicates some kind of ovulatory activity, though most doctors want to see a level over 10 on unmedicated cycles, and over 15 with medications. There is no mid-luteal level that predicts pregnancy.
First Trimester 10-90 ng/ml Average is about 20 at 4 weeks LMP, and 40 at 14 weeks LMP. It is important to note that while a higher progesterone level corresponds with higher pregnancy success rates, one cannot fully predict outcome based on progesterone levels. Progesterone supplementation is unlikely to help if started after a positive pregnancy test.
Second Trimester 25-90 ng/ml Average is 40 at beginning, 90 at end.
Third Trimester 49-423 ng/ml Usually peaks at about 175.

 

hCG Levels in Early Pregnancy
Days Post Ovulation/Retrieval Weeks/Days LMP Average Singleton Level Average Twin Level
10 3w3d 25  
12 3w5d 50  
14 4w0d 100  
16 4w2d 200  
Early-detection pregnancy tests (detecting 20 miu/ml hcg) can assist you in detecting pregnancy before your missed period.

 

Oral Glucose Tolerance Test for Gestational Diabetes
Time Normal Values Gestational diabetes is diagnosed if 2 or more levels are above the normal range. It is treated through diet, insulin injections, and sometimes with metformin. You may want to check All About Gestational Diabetes.
Fasting < 105 mg/dl
1 hour < 190 mg/dl
2 hours < 165 mg/dl
3 hours < 145 mg/dl

 

Reference: http://www.fertilityplus.com/faq/hormonelevels.html#female

 

Fertility Meds

Fertility Meds

Most people dread taking medications because they don’t understand how the medication works, or because they are expensive and time-consuming. Therefore, many will try to swing their doctor to avoid giving them meds or give them a “generic” to reduce costs. However, when it comes to the fertility meds, many are only available in the Brand name (meaning no generic exist) and are extremely expensive. If until now you have been TTC without fertility meds and have now been introduced to the overwhelming world of fertility drugs, don’t despair! In this article, I will try to demystify the many fertility drugs and will give you hints on how to save money on them.

Oral Fertility Meds  (aka the first line of treatment)

The fertility pills such as Clomid (Clomiphene) and Femara (Letrozole) help the pituitary gland improve the stimulation of developing follicles (eggs) in the ovaries. They work by blocking estrogen receptors in the hypothalamus, which in turns releases higher amounts of GnRH into the anterior pituitary, telling it to release higher levels of FSH and LH. Thus the ovaries are “forced” to increase follicle development and estrogen. The increasing levels of circulating estrogen as sensed by the hypothalamus, which then sends an LH surge producing ovulation. The side effects can range from headaches, mood swings, ovarian cysts to weight gain. They also increase your chances of twins. Clomid has been known for causing thinning of the uterine lining, which can potentially impact implantation rates or causes miscarriages.

Injectables

Injectable medications are the second line of fertility treatment, usually used after several cycles with CC failed. Injectable medications can be subdivided into several categories.

  • GnRH Agonist (Lupron, Buserelin, Nafarelin, Synarel):

This medication mimics the structure of GnRH molecule in the hypothalamus, thus is able to bind to the GnRH receptor and elicit the response of the anterior pituitary to release FSH and LH during the first 4-6 days. Thus, the blood levels of LH and FSH which are initially raised with the initiation of GnRHa therapy are sustained well above normal for 4-6 days, producing a “flare effect” (a 10x increase in LH).  However, it sorts of gets stuck and ultimately blocks the receptor from further activity and inhibits the action of this hormone in the brain. This is referred to as “pituitary down-regulation”. At this point, the pituitary gland becomes depleted of FSH and LH. However, after taking it for 10-20 days, it produces a hypogonadal effect, thus drastically reducing FSH and LH. The administration of subcutaneous GnRHa is rarely associated with significant side effects. Some women experience temporary fluctuations in mood, hot flashes, nausea. It is given subcutaneously.

lupron

  • GnRH Antagonist (Ganirelix, Cetrotide, Cetrorelix, Orgalutron):

Also known as antagon, GnRH antagonists are competitive inhibitors of GnRH. They work by blocking GnRH from binding to its receptor in the hypothalamus and rapidly depleting FSH and LH, preventing premature luteinization (ovulation). Unlike the agonist long course of treatment (10-20 days), the antagonist is effective within 2-3 days of treatment. They are usually recommended in women with PCOS, as they reduced the risk of OHSS. As well, they reduced the possibility of having a cycle cancellationganirelix.

  • Gonadotropins (Menoupur, Follitism, Gonal-F):

There are two gonadotropins, FSH and LH. These gonadotropins are excreted in the urine. Two varieties are commercially available. The 1st is menotropins or urinary-derived Human Menopausal Gonadotropins (hMG). The 2nd is genetically-engineered Recombinant DNA-gonadotropins, (FSHr and LhR). If administered to women at a sufficient dosage beginning early enough in the menstrual cycle, commercially available gonadotropins will prompt the development of multiple follicles each of which houses one egg. LH (and hCG) directly stimulates the tissue surrounding the ovarian follicles ) which in response produces male hormones (predominantly testosterone). The testosterone is then carried to the surrounding follicles where FSH converts it to estrogen. Risks and Side Effects of Gonadotropin Therapy: some women taking gonadotropins report breast tenderness, backaches, headaches, insomnia, bloating, and increased vaginal discharge, which are directly due to increased mucus production by the cervix.

  •  Human Menopausal Gonadotropins (hMG)– Menopur, Merional 75IU: hMG contains both FSH and LH. Menopur also contains a small amount of added hCG.menopur
  • Urinary-Derived FSH (Bravelle) this is essentially hMG that has been processed further to extract most of the LH. It is less expensive than FSHr.Bravelle
  • Recombinant FSH FSHr (Folistim, Gonal-F and Puregon): derived by way of genetic engineering. FSHr appears to be more bioactive than urinary-derived FSH products such as Bravelle and hMG and response to FSHr, more consistent and predictable.

WhatsApp Image 2017-07-30 at 00.42.52 (1)

gonalf

Recombinat LH (Luveris): Since some LH is essential to provoke the ovarian stroma to produce some testosterone for delivery to the follicles for conversion into estrogen, a small amount must be given with FSHr to achieve egg development.

  • HCG (aka trigger shots Pregnyl, Novarel, Ovidrel):

The effect of the “trigger shot” is to send eggs into a reproductive division known as meiosis where the objective end point is a decrease in the number of chromosomes in the egg from 46 to 23 (half) prior to ovulation or egg retrieval. In the process, approximately half of the chromosomes are expelled from the egg nucleus in a membranous envelopment. This so called first polar body comes to lie immediately under the envelopment of the egg (the zona pellucida) in a region known as the perivitelline space. Ovulation will occur 36 after the HCG trigger is given. This trigger shot comprises one of three medications: a) urinary-derived hCG (hCGu), e.g., Novarel, Pregnyl and Profasi, b) Recombinant hCG (hCGr), e.g., Ovidrel, or c) an agonist such as Lupron, which upon being injected provokes a surge in the release of pituitary gland-derived, LH) is initiated.

 

Acronyms

Acronyms

Whenever I looked at a TTC/IF blog or article, I have a hard time trying to “get” all of the two and three letter acronyms and abbreviations. Thus, I hope that this list helps you “get” all of this jargon once and for all (or use it as a reference whenever you feel lost in translation).

2WW  2 Week Wait
 ACA  Anti-cardiolipin Antibody
 ACTH  Adrenal Corticotropic Hormone
 AF  Aunt Flo, After Flo, Period, or Menstrual Cycle
 AH  Assisted Hatching
 AI  Artificial/Assisted Insemination
 ANA  Anti-nuclear Antibodies
 APA  Anti-phospholipid Antibodies
 APTT  Activated Partial Thrombin Time
 ART  Assisted Reproductive Technology
 ASA  Anti-sperm Antibody
 ASRM  American Society of Reproductive Medicine
 BA  Baby Aspirin
 BBT  Basal Body Temperature
 BCP  Birth Control Pills
 BD  Baby Dance (sex)
 Beta  HCG pregnancy test
 BFN  Big Fat Negative
 BFP  Big Fat Positive
 B/W, b/w  Bloodwork
 CAH  Congenital Adrenal Hyperplasia
 CASA  Computer-assisted Semen Analysis
 CB  Cycle Buddy
 CBAVD  Congenital Bilateral Absence of Vas Deferens
CC Clomiphene Citrate
 CCCT, CCT  Clomiphene Citrate Challenge Test (Clomid Challenge Test)
 CD  Cycle Day
 CF  Cystic Fibrosis
 CM  Cervical Mucus
 CMV  Cytomegalovirus
 CNM  Certified Nurse Midwife
 COH  Controlled Ovarian Hyperstimulation
 CP  Cervical Position
 CPFM  ClearPlan Fertility Monitor (Brand Name)
 CVS  Chorionic Villi Sampling
 D&C  Dilation & Curettage
 D&E  Dilation & Evacuation
 DE  Donor Eggs
 DES  Diethylstillbestrol
 DH  Dear Husband
 DHEAS  Dihydroepiandrosterone
 DI  Donor Husband
 DIPI  Direct Intra-peritoneal Insemination
 DOR  Diminished Ovarian Reserve
 DPO  Days Post-Ovulation
 DPR  Days Post-Retrieval
 DPT  Days Post-Transfer
 DP3DT  Days Post 3-Day Transfer
 DP5DT  Days Post 5-Day Transfer
 DW  Dear Wife
 Dx  Diagnosis
 E2  Estradiol
 EB, EMB  Endometrial Biopsy
 ENDO  Endometriosis
 EPT  Early Pregnancy Test
 ER  Egg Retrieval
 ET  Egg Transfer
 ETA  Embryo Toxicity Assay
 ETF  Embryo Toxicity Factor
 FAQ  Frequently Asked Questions
 FBG  Fasting Blood Glucose
 FI  Fasting Insulin
 FF  Fertility Friend
 FHR  Fetal Heart Rate
 FP  Follicular Phase
 FM  Fertility Mucus or Fertility Monitor
 FRED  Fertility Response Early Detection (Brand Name)
 Frostie  Frozen Embryo
 FSH  Follicle-Stimulating Hormone
 FTTA  Fertile Thoughts to All
 GD  Gestational Diabetes
 GI  Gastrointestinal
 GIFT  Gamete Intrafallopian Transfer
 GnRH  Gonadotropin-Releasing Hormone
 GP  General Practitioner
 GTT  Glucose Tolerance Test
 hCG, HCG  Human Chorionic Gonadotropin
 hMG, HMG  Human Menopausal Gonadotropin
 HCP  Health Care Practitioner
 HEPA  Hampster Egg Penetration Assay
 HPT  Home Pregnancy Test
 HRT  Hormone Replacement Therapy
 HSC  Hysteroscopy
 HSG  Hysterosalpingogram
 HX  History
 IBT  Immunobead Binding Test
 ICI  Intra-cervical Insemination
 ICSI  Intra-cytoplamic Sperm Injection
 IF  Infertility
 IGTT  Insulin and Glucose Tolerance Test
 INCIID  International Council on Infertility Information Dissemination
 IM  Intramuscular injections
 IOR  Immature Oocyte Retrieval
 IR  Insulin Resistant
 ITI  Intra-tubal Insemination
 IUGR  Intra-uterine Growth Retardation
 IUI  Intra-uterine Insemination
 IVC  Intra-vaginal Culture
 IVF/ET  In Vitro Fertilization and Embryo Transfer
 IVF  In Vitro Fertilization
 IVIg  Intravenous Immunoglobulin
 LAD  Leukocyte Antibody Detection Assay
 LAP  Laparoscopy
 LH  Luteinizing Hormone
 LIT  Leukocyte Immunization Therapy
 LMP  Last Menstrual Period (start date)
 LOL  Laughing Out Loud
 LP  Luteal-Phase
 LPD  Luteal-Phase Defect
 LSP  Low Sperm Count
 LUF, LUFS  Luteinized Unruptured Follicle Syndrome
MAI  Miscarriage after Infertility
 MC, m/c, misc.  Miscarriage
 MENTS  Subject Matter May Be Difficult to Read
 MESA  Microsurgical Epidiymal Sperm Aspiration
 MF  Male Factor
 MMR  Measles-Mumps-Rubella Vaccine
 MRI  Magnetic Resonance Imaging
 NK  Natural Killer Cells
 NORIF  Non-stimulated Oocyte Retrieval In (office) Fertilization
 NP  Nurse Practitioner
 NSA  Non-Surgical Sperm Aspiration
 O, OV  Ovulation
 OB  Obstetrician
 OB/GYN  Obstetrician/Gynecologist
 OC  Oral Contraceptives
 OD  Ovum Donor, Ovulatory Dysfunction
 OHSS  Ovarian Hyperstimulation Syndrome
 OPK  Ovulation Predictor Kit
 OPT  Ovulation Predictor Test
 OTC  Over the Counter
 P4. Prog  Progesterone
 PA  Physician’s Assistant
 PAI-1  Plasminogen Activator Inhibitor-1
 PAF, PANFERT  Pregnancy After Infertility
 PCO  Polycistic Ovaries
 PCOD  Polycistic Ovarian Disease
 PCOS  Polycistic Ovarian Syndrome
 PCP  Primary Care Physician
 PCT  Post Coital Test
 PESA  Percutaneous Epididymal Sperm Aspiration
 PG  Pregnant
 PGD  Pre-implantation Genetic Diagnosis
 PI  Primary Infertility
 PID  Pelvic Inflammatory Disease
 PIO  Progesterone in Oil
 PLI  Paternal Leukocyte Immunization
 PMS  Pre-menstrual Syndrome
 PMN  Perinatal Mortality
 POAS  Pee on A Stick
 POC  Products of Conception
 POF  Premature Ovarian Failure
 PROM  Premature Rupture of Membranes
 PTSD  Post-Traumatic Stress Disorder
 PZD  Partial Zona Dissection
 RE  Reproductive Endocrinologist
 R-hFSH  Recombinant Human Follicle Stimulating Hormone
 RI  Reproductive Immunologist
 RIP  Reproductive Immunophynotype
 ROS  Reactive Oxygen Species
 RPL  Recurrent Pregnancy Loss
 RSM  Recurrent Spontaneous Abortion
 RX  Prescription
 SA  Semen Analysis
 SART  Society for Assisted Reproductive Technology
 s/b, S/B  Stillbirth
 SCORIF  Stimulated Cycle Oocyte Retrieval
 SHG, SonoHSG  Sonohysterogram
 SI  Secondary Infertility
 SLE  Systemic Lupus Erythematosus
 SPA  Sperm Penetration Assay
 SPALS  Subsequent Pregnancy After a Loss Support
 S/S  Signs/Symptoms
 STD  Sexually Transmitted Disease
 SubQ  Subcutaneous Injection
 SUZI  Sub-zonal Insertion
 T1  Type 1 Diabetic – Juvenile Diabetes
 T2  Type 2 Diabetic – Insulin Resistant, Adult Onset
 T4  Thyroxine
 TEBG  Testosterone-Estradiol Binding Globulin
 TDI  Therapeutic Donor Insemination
 TESA  Testicular Sperm Aspiration
 TDI  Therapeutic Sperm Extraction
 TET  Tubal Embryo Transfer
 TL  Tubal Ligation
 TORCH  Toxoplasmosis, Other, Rubella, Cytomegalovirus & Herpes Test
 TR  Tubal Reversal
 TRH  Thyroid Releasing Hormone
 TSH  Thyroid Stimulating Hormone
 TTC  Trying To Conceive
 TTCAR  Trying to Conceive After Reversal
 TX  Treatment
 TZD  Thiazolidinediones
UR  Urologist
 US  Ultrasound
 UTI  Urinary Tract Infection
 V  Vasectomy
 VR  Vasectomy Reversal
 WBC  White Blood Count
 WHR  Waist to Hip Ratio
 WNL  Within Normal Limits
 ZIFT  Zygote Intra-fallopian Transfer

 

Glossary of Terms

Glossary of Terms

When a couple or a woman starts the journey of TTC or IF, an overwhelming majority doesn’t know where to start. Thus, it important to understand the basic principles of reproductive physiology, as well as some of the medical terms and acronyms associated with these journeys. Below you will find a non-exhaustive list of terms.

Abortion, Spontaneous: Pregnancy loss by any cause before 20 weeks of gestation.

Adhesion: Scar tissue that abnormally attaches to internal organs, such as the fallopian tubes, ovaries, bladder, uterus or other internal organs. Adhesions can wrap up or distort these organs, limiting their movement, function and cause infertility and pain.

American Society of Reproductive Medicine(ASRM): (formerly the American Fertility Society or AFS) Large multidisciplinary patient and physician organization serving as a platform for new ideas, education and advocacy in fertility and reproductive medicine issues. ASRM is a leading advocate for patient care, research and education.

Amniocentesis: A procedure done in the second trimester of pregnancy that can detect many fetal abnormalities. It is performed by sampling a small quantity of the amniotic fluid that surrounds the fetus with a needle under ultrasound guidance.

Aspiration: Removal of fluid and cells by suction through a needle. This technique applies to many procedures in reproductive medicine.

Assisted Hatching (AH): Placing a small opening in the “shell” that surrounds every embryo. This assists the embryo in breaking out of this shell and extruding itself to implant in the endometrium. This is done my embryologists in the laboratory prior to embryo transfer in IVF cycles.

Assisted Reproductive Technologies(ART): A group of fertility therapies that employ manipulations of the oocyte (egg) and sperm in the laboratory in order to establish a pregnancy. These include IVF, ICSI, donor egg cycles, assisted hatching, preimplantation genetic diagnosis (PGD) and others.

Basal Body Temperature (BBT): The body temperature at rest taken in the morning before arising from bed. Successive BBT’s can be measured orally each morning and recorded on a calendar chart. These charts can be studied to help identify the time of ovulation, or even if a patient is ovulating at all. Menstrual calendar information is also an important part of a BBT chart. An ovulation predictor kit (OPK) can be used instead of daily temperature readings.

beta HCG: see Human Chorionic Gonadotropin (hCG).

Capacitation: The process that sperm must undergo in order to fertilize an oocyte (egg).

Cervical Factor: Infertility due to a structural or hormonal abnormality of the cervix. This can be induced by previous surgery on the cervix (such as a LEEP or cone procedures) that leaves the cervical canal scarred or closed, termed stenosis. Also applied when there are factors associated with the cervix which inhibit sperm function such as thickened mucus which prevents the sperm from traveling through the cervix into the female reproductive tract. Cervical factor infertility can usually be overcome using inseminations of sperm past the cervix into the uterus.

Cervical Mucus: Normal secretions of the cervix which change in volume and consistency throughout the menstrual cycle. Its quality is a reflection of hormonal stimulation.

Cervix: The lower section of the uterus which protrudes into the vagina and serves as a reservoir for sperm. Its anatomical functions include being a natural barrier to the inner uterus, and also keeping pregnancies from delivering prematurely.

Chemical Pregnancy: A positive pregnancy test, but with levels of pregnancy hormone (beta hCG) too low for ultrasound documentation of a pregnancy. Typically this definition includes pregnancies that have low beta hCG levels that spontaneously decline without any further development.

Cleavage: Division of one cell into 2, 2 into 4, 4 into 8, etc. This is measured in the embryology laboratory during IVF cycles.

Clinical Pregnancy: A pregnancy in which the beating fetal heart has been identified by ultrasound.

Clomiphene Citrate (Clomid): An oral medication used to stimulate the ovaries and/or synchronize follicle development.

Congenital Anomaly: A non-hereditary characteristic, or defect, developed before birth. These can include very minor irregularities, such as curvature of the second toe so it overlaps the third toe, or can be a more major anomaly such as a heart defect.

Corpus Luteum: A special gland that forms from the ovulated follicle in the ovary. It produces progesterone during the second half of the menstrual cycle which is necessary to prepare the uterine lining for implantation. It also supports early pregnancies by secreting the necessary hormones until the placenta becomes fully functional between 8-10 weeks of gestation.

Cumulus: The cloud-like collection of supportive follicle cells that surround the oocyte (egg).

Cryopreservation: Controlled freezing and storage. This may be employed for sperm, embryos and oocytes (eggs).

Cyst: A fluid filled structure. Cysts may be found anywhere in the body, but in reproductive medicine, we primarily refer to them in the ovaries. Ovarian cysts may be normal or abnormal depending on the circumstances. Often they are just follicles that have not been fully reabsorbed from previous menstrual or treatment cycles. They are very common in both natural and stimulated cycles.

Donor Egg Cycle: The use of donated eggs from an anonymous or known donor. These eggs are harvested via an IVF cycle performed on the donor. The resultant eggs are inseminated with sperm and then form embryos which are transferred into the womb of the intended parent.

Donor Embryo Transfer: The transfer of embryos resulting from the oocyte (egg) and sperm of another patient, who may be anonymous or known, to an otherwise infertile recipient

Donor Insemination: The introduction of sperm from an anonymous volunteer donor into the vagina, cervix, or uterine cavity in order to achieve a pregnancy.

Ductus/vas Deferens : A thick walled tubular structure running from each testis into the ejaculatory duct. These structures carry sperm from the testicles to the epididymis to the penis for ejaculation. The vas deferens can be scarred or damaged by surgery, trauma or infection to the point where it does not allow sperm to pass through.

Ectopic Pregnancy: A pregnancy implanted outside the uterus; most often in the fallopian tube. This is also termed a tubal pregnancy. This can usually be diagnosed in its early stages by following the pregnancy hormone, beta HCG, very closely during the early part of pregnancy. Left undiagnosed and untreated, an ectopic pregnancy can have serious medical consequences.

Egg Retrieval: The procedure during an IVF cycle where the oocytes (eggs) are harvested through a minimally-invasive surgical procedure. This is done under light anesthesia so that patients are sleeping during the entire process. Typically takes about 30 minutes total.

Embryo: The term used to describe the early stages of fetal growth. Strictly defined from the second to the ninth week of pregnancy but often used to designate any time after conception.

Embryo Transfer: The procedure of transferring embryos back in to the endometrial cavity (womb) of a patient during an IVF cycle. It occurs on the third or fifth day after an egg retrieval.

Endocrinology: The study of hormones, their function, the organs that produce them and how they are produced.

Endometrial biopsy: The extraction of a small piece of tissue from the endometrium (lining of the uterus) for microscopic examination.

Endometrial Cavity: The space in side the uterus that is created by the inner lining of the uterus that responds to female hormones during the menstrual and treatment cycles. This lining, when properly prepared, forms the area of attachment and implantation of the embryo. Commonly referred to as the womb.

Endometriosis: The presence of endometrial tissue (tissue that normally lines the uterus) in abnormal locations such as the ovaries, fallopian tubes and abdominal cavity. These lesions lead to local irritation and inflammation that can cause scarring to occur which can bind-up pelvic organs to the point of dysfunction and pain. Click here for more in depth information.

Endometrium: The inner lining of the uterus that responds to female hormones during the menstrual cycle and treatment cycles. This lining, when properly prepared, forms the area of attachment and implantation of the embryo. A portion of this lining is shed each month during menstruation.

Epididymis: Portion of the male genital tract next to the testis where sperm maturation is partially accomplished. Receives sperm from the testis and continues as the ductus (vas) deferens.

Estradiol: The principal hormone produced by the growing ovarian follicle. It is frequently measured in the blood to gauge the strength and development of your follicles during treatment cycles.

Fallopian Tube: The anatomic and physiologic connection between the uterus and the ovary which serves to transport the oocyte (egg) and sperm. It is also the site of fertilization and supports and transports the conceptus in route to the uterus.

Fertilization: Union of a sperm with an oocyte (egg) to facilitate creation of a genetically unique embryo.

Fibroids: Overgrowth of the muscular tissue of the uterus. Fibroids are typically knotty masses of benign muscle tissue that can distort the shape and function of the uterus. They are typically classified into three categories: sub-mucosal, intramural and serosal. Sub-mucosal fibroids are found in the uterine cavity and impair implantation. They need to be removed in order to conceive. Intramural fibroids are problematic when they become severely enlarged or impinge on the uterine cavity. Sub-serosal fibroids generally are left alone during fertility treatments.

Fimbria: The soft and supple finger-like extensions of the fallopian tube that aid in gathering in the oocyte (egg) at ovulation.

Follicle: A fluid-filled pocket in the ovary that houses the microscopic egg. Each ovary has many follicles within it. Follicles start out extremely small and then grow larger under the influence of hormones (and the medications that mimic these hormones). Follicles are lined with granulosa cells which produce estrogen and nourish the oocyte (egg). Each Follicle contains a single oocyte.

Follicle Stimulating Hormone (FSH): A hormone produced by the pituitary gland in the brain that stimulates the ovarian follicles to grow and develop. FSH is measured in the blood at specialized times during the menstrual cycle to help measure ovarian reserve.

Follicular Phase: The menstrual cycle is divided up into two main parts- the follicular phase and the luteal phase. The follicular phase refers to the first half of the cycle, from onset of menses to ovulation, and lasts approximately 14 days. It is associated with developing follicles that produce estradiol.

Gamete Intra-Fallopian Tube Transfer (GIFT): An older method of assisted fertilization that involves surgically removing an egg from the ovary, combining it with sperm, and immediately surgically placing the egg and sperm into the fallopian tube. Fertilization takes place inside the fallopian tube.

Gestation: Pregnancy. Gonadotropin: Hormones that stimulate the ovary.

Gonadotropin Releasing Hormone (GnRH): Hormone produced by the hypothalamus in the brain that stimulates the pituitary gland to secrete gonadotropins.

Human Chorionic Gonadotropin (hCG): A hormone of early pregnancy that is monitored to determine viability of the gestation. This hormone is also used as an injection to induce ovulation and maturation of the oocyte (egg) in ovarian stimulation protocols.

Human Menopausal Gonadotropin/Humegon (HMG): A purified extract of LH and FSH, the hormones secreted by the pituitary gland to stimulate the ovary. It is a commercial preparation used by injection to facilitate development of multiple follicles in treatment cycles.

Hypothalamus: A portion of the brain that stimulates the pituitary gland to secrete LH and FSH in order to stimulate ovarian follicle development. The hypothalamus acts as the “pacemaker” for many important hormone-driven processes, controlling the production and periodic release of hormones from the pituitary gland.

Hysterosalpingogram (HSG): An x-ray procedure to examine whether the fallopian tubes are patent (open) or not. This test helps determine if the tubes are blocking sperm from reaching the ovulated eggs through the fallopian tubes. Special x-ray dye is gently injected into the uterus and then x-ray pictures are taken to see where the dye travels.

Hysteroscopy/Hysteroscopic surgery: Minimally invasive surgery in which a small telescopic camera, much like a laparoscope, is placed through the cervical canal into the uterine cavity. This allows direct visualization of the endometrium, the lining of the uterine cavity (the womb) – where pregnancies implant. This surgical technique is minimally-invasive, well-tolerated and performed in a day-surgery center. It allows removal of any impediments to implantation such as polyps or fibroids in the uterine cavity.

Implantation: The attachment and embedding of the conceptus (embryo) into the lining of the uterus.

Insemination: Transfer of sperm for the purpose of establishing a pregnancy. Inseminations are performed by placing a small, soft catheter through the cervix into the uterine cavity and depositing the concentrated and activated sperm.

Intracytoplasmic Sperm Injection (ICSI): Placement of a single sperm into a single oocyte (egg) by penetrating the outer coatings of the egg. This technique is used in cases where there are very low sperm numbers, motility or morphology. ICSI is also used for patients who have had previous IVF cycles with failed fertilization.

Intra-Uterine Insemination (IUI): is a technique that transfers sperm directly in to the uterus. It bypasses the vaginal and cervical defense mechanisms of the female reproductive tract and allows better sperm delivery to the fallopian tubes. This allows the sperm and egg to interact in close proximity. It is a very common treatment for mild and moderate deficits in the semen analysis. IUI is typically used in conjunction with medications that increase the number of eggs per cycle and triggering of ovulation. The goal is to have more ÒtargetsÓ for the sperm (eggs), perfect timing and better sperm delivery.

In Vitro Fertilization (IVF): A powerful procedure to help patients conceive pregnancies. IVF entails stimulating your ovaries to develop multiple follicles. This is achieved with injectable medications. The goal of IVF is to produce a large number of growing follicles, then harvest the eggs inside the follicles through a short surgical procedure performed in our office. The eggs are then inseminated with sperm in the laboratory, sometimes using ICSI, in order to create embryos that can then be transferred back to the endometrial cavity (the womb) of the patient. The name in vitro fertilization refers to the fact that the oocyte is fertilized by the sperm in the laboratory, rather than inside the female reproductive tract.

Laparoscope/laparoscopic surgery: A thin, lighted viewing instrument with a telescopic lens through which a surgeon views the exterior surfaces of a female’s reproductive organs and abdominal cavity. In this minimally invasive procedure, the laparoscope is placed through the belly-button in order to view and operate on the abdominal cavity and reproductive organs. This surgical technique is minimally-invasive, well-tolerated and performed in a day-surgery center. It allows your physician to diagnose and remove endometriosis, as well as re-open a blocked fallopian tube, amongst many other indications.

Luprolide Citrate/LupronT: A synthetic form of GnRH (gonadotropin releasing hormone- secreted by the hypothalamus) used to suppress ovarian function.

Luteal Phase: The menstrual cycle is divided up into two main parts- the follicular phase and the luteal phase. This refers to the second half of the cycle, usually the last fourteen days of an ovulatory. It begins from the time of ovulation to the onset of menses, but is prolonged during pregnancy cycles. It is associated with progesterone production from the corpus luteum that facilitates implantation of embryos and supports early pregnancies.

Luteinizing Hormone (LH): A hormone produced and released by the pituitary gland. In the female it is responsible for ovulation and the maintenance of the corpus luteum. In the male it stimulates testosterone production and is important in the production of sperm cells.

Luteal Phase Deficiency (LPD): Also called luteal phase defect. A deficiency of progesterone in the second half of the menstrual cycle when a pregnancy begins. Treatment involves supplementation with progesterone and other measures.

MetrodinTM: Human FSH prepared in an injectable form for ovarian stimulation.

Media: Fluid containing nutritive growth substances enabling cells to survive in an artificial environment.

Menses: A “period”. Cyclic (monthly) flow of blood (menstruation) signifying ovulation, but failure to achieve pregnancy. Onset of bleeding is considered cycle day 1. The purpose of a natural menstrual cycle is to produce one follicle and ovulation per month, each and every month that pregnancy is not achieved.

Micromanipulation: The name of a group of laboratory techniques that allow sperm, eggs and embryos to be performed under the guidance of the microscope.

Oocyte: The female germ cell often called an egg.

Ovary: The female sex gland with both a reproductive function (releasing oocytes) and a hormonal function (production of estrogen and progesterone).

Ovulation: The release of a mature egg from the surface of the ovary.

Ovum (ova or egg): Mature oocytes.

Pap test: A screening test to determine the presence of cervical cancer. It is done by gently touching a swab to the cervix to collect cells for examination by a pathologist.

PergonalTM: A purified extract of LH and FSH, hormones secreted from the pituitary gland which stimulates the ovary. It is a commercial preparation used by injection to facilitate the development of multiple follicles in reproductive treatment cycles.

Pituitary Gland: A small organ at the base of the brain that secretes many hormones, including LH and FSH in response to signals from the hypothalamus.

Polycystic Ovarian Syndrome(PCOS): A common endocrinologic condition that causes hormonal imbalances in women of reproductive age. It can lead to dysfunctional ovulation, infertility, weight gain, pre-diabetes and an increase in the male hormone, testosterone. Click here for more detailed information.

Polyp: An overgrowth of the glandular surface of the endometrium. Polyps are often removed by hysteroscopic surgery to remove any impediments to implantation.

Polyspermy: Abnormal condition where the oocyte is fertilized by more than 1 sperm.

Post-Coital Test (PCT):The microscopic analysis of a sample of vaginal and cervical secretions that has been collected after sexual intercourse. This test allows your physician to see if sperm survive in your reproductive tract. It has largely been superceded by the semen analysis, but there are still some clinical indications for the PCT.

Preimplantation Genetic Diagnosis (PGD):A technique for identifying genetic or chromosomal information about embryos before transferring them back to a patient’s endometrial cavity (the womb). It entails taking a biopsy of the embryo on day three after egg retrieval. PGD can be employed to identify embryos that carry a genetic disease that may be asymptomatically carried by the parents, or it may be used to identify explanations for Recurrent Pregnancy Loss and improve pregnancy outcomes in selected patients.

Progesterone: A hormone produced by the ovary which prepares the uterus for implantation and supports the early pregnancy.

Pronucleus: A specialized stage of the oocyte and sperm nucleus before they join to create a genetically unique embryo. After this union the conceptus is referred to as a zygote.

Pronuclear Stage Tubal Transfer (PROST or ZIFT): An older procedure in which oocytes are harvested and inseminated in the laboratory before surgically transferring these very early zygotes into the fallopian tubes. This procedure has been replaced by standard IVF.

Recurrent Pregnancy Loss (RPL): when a woman has experienced two consecutive early pregnancy losses.

RESOLVE: is a non-profit organization with an established, nationwide network of chapters mandated to promote reproductive health and to ensure equal access to all family building options for men and women experiencing infertility or other reproductive disorders. www.resolve.org

Semen Analysis: Examination of the male ejaculate under the microscope to determine the number of sperm, their ability to move forward (motility) and their shapes (morphology). The semen analysis is a cornerstone of the evaluation of couples experiencing infertility. The sperm counts, motility and morphology all provide important information about how the sperm will perform in treatment cycles.

Single Embryo Transfer (SET) or Elective Single Embryos Transfer (eSET) – is a specific definition of only transferring a single embryo at the culmination of an IVF cycle.

Sperm Antibody Test: In some couples blood, semen and/or cervical mucus contain substances which hinder sperm action through an allergic or immune reaction.

Sperm Penetration Assay (SPA): A test where sperm are incubated with non-viable hamster eggs to determine the capacity of the sperm to fertilize.

Society for Assisted Reproductive Technology (SART): Regulatory and consultative organization of the American Society for Reproductive Medicine responsible for assisted reproduction. This organization works with the CDC to publicly post fertility rates of all IVF centers in the USA.

Testicular/Epididymal Sperm Aspiration (TESA): The surgical removal of sperm directly from the testis or the epididymis using a needle for aspiration. This procedure is used for men who have no sperm in their ejaculates or have had vasectomies in the past. Sperm obtained through TESE requires ICSI to ensure fertilization of the oocyte (egg).

Trans-tubal Embryo Transfer (TET): Replacement of a cleaving conceptus into the uterine tube rather than into the uterus. This is an older procedure that has been replaced by standard IVF

Transvaginal: Through the vagina.

Tubal Patency: Lack of obstruction of the Fallopian tubes.

Ultrasound: High frequency sound waves that can be used painlessly, safely, and without radiation, to view the internal portions of the body. Ultrasound is especially useful for visualizing the female reproductive organs and pregnancies.

Unexplained InfertilityInability to identify the cause of infertility despite a complete evaluation of semen, ovarian reserve, ovulation, endocrinologic disorders and pelvic anatomy.

Uterus: Womb. The reproductive organ that houses protects and nourishes the developing embryo and fetus. It consists of the cervix, the endometrium and the muscular layer that comprises the body of this reproductive organ.

Varicocele: A varicose vein around the ductus (vas) deferens and the testes. This may be a cause of low sperm counts, motility and morphology and lead to male infertility.

Zygote: A conceptus in which the genetic material (pronuclei) of the egg and sperm have united.

Zygote Intra-fallopian tube Transfer (ZIFT):Oocytes (eggs) are aspirated, are fertilized in the laboratory and surgically transferred into the fallopian tubes before cell division. This procedure has largely been replaced by standard IVF.

Sources: Reproductive Medicine Associates of Connecticut and RESOLVE.

 

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