Tag: infertility treatments

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.

 

What fertility treatments are permitted on Shabbat?

What fertility treatments are permitted on Shabbat?

Diagnosis & Treatment on Shabbat

What treatments are permitted on Shabbat? What tests can be done on Shabbat? Is there a difference between the way treatment should be performed on Shabbat as opposed to any other day?
There is some discussion among the Rabbis as to the halachic status of couples experiencing fertility issues. Some rabbis are of the opinion that such couples are considered slightly ill since they are not actually suffering from a specific medical condition. However, most Rabbis do consider them to be ill, even though their lives are not in danger.

It is essential to note that a sick person suffering from a non-life threatening condition is:

  • permitted to take medicine
  • permitted to transgress certain rabbinic prohibitions for the purpose of treatment
  • permitted on Shabat to ask a non-Jew to perform certain types of work for him for the purpose of treatment
  • In light of this most authorities will permit certain tests and treatments on the Sabbath or festivals.

Monitoring Ovulation

There are three basic methods to test ovulation

  1. Basal Body Temperature (BBT): Normally one is prohibited from measuring their temperature on Shabbat as it falls into the category of “measuring”. Measuring for the purpose of the mitzvah is permitted. In this case, measuring BBT to achieve pregnancy is part of the mitzvah of procreation. It is therefore permitted on Shabbat (only when using a non-digital thermometer).
  2. Home Ovulation Testing Kit: The urinalysis strips used in this test change color to indicate ovulation. Normally one is prohibited from coloring on Shabbat as it falls into the category of “dying”. Since the strip is immediately discarded, this type of coloring is a rabbinic prohibition. It is therefore permitted, as noted above.
  3. Blood Test and Ultrasound (BW/US): The drawing of blood on Shabbat is a Torah prohibition. US involves the use of electricity, which is also prohibited on Shabbat. Since there are permissible methods of achieving the desired information, this method is not permitted on Shabbat.
  4. Other Tests: Most other types of evaluation testing are not time specific. Whenever testing can be performed during the week it is prohibited on Shabbat.

Ovulation Induction

Clomiphene Citrate (CC): Taking medication is normally prohibited on Shabbat. As stated above one who is ill can take medication to treat their illness, in this case, fertility. As such CC or other such fertility medications can be taken on Shabbat. One should be careful not to tear the letters on the wrapping on Shabbat and it is advisable to prepare the tablets before Shabbat when possible.
Injections: There are several halachic issues involved with administering injections on Shabbat. As noted above, drawing blood on Shabbat is prohibited by the Torah. At the present, all injections for ovulation induction are intramuscular or subcutaneous and do not require the drawing of blood. Therefore this Torah prohibition does not apply.
Assembling the needle: This falls into the category of building a vessel and is prohibited on Shabbat. Therefore when possible the needle should be attached to the vial before Shabbat. One should be careful not to compromise the sterile environment that is essential for treatment. In cases where this is impossible, a non-Jew can be asked to assemble the needle or it can be done in an unusual way. Please consult your Rabbi in such a case.
Sterilizing the injection site: One may not use cotton wool dipped in alcohol to clean the site of the injection, which is included in the prohibition of “squeezing”. One should use a pre-prepared alcohol swab of synthetic material, or pour alcohol directly onto the skin and then wipe off the excess with cotton.
In light of the above, it is preferable not to administer injections unless this is absolutely necessary on Shabbat. When possible they should be administered before and after Shabbat. If this is impossible, it is preferable for a non-Jew to give the injection. In a case where no other possibility exists, the injections may be given by a Jew on Shabbat as described above.

Chorionic gonadotropin (hCG) injections need to be given at a particular time. In the case where the injection must be given on Shabbat. As above, it is preferable that this should be done by a non-Jew, but when this is impossible even a Jew may do so as described above.

Receiving an injection on Yom Kippur appears to be permitted and is not considered in the category of eating.

Intrauterine Insemination (IUI)

Sperm preparation for intrauterine insemination involves a number of actions that are forbidden on Shabbat such as the use of electricity and the separation of the sperm. It is preferable not to undergo such treatment on Shabbat. Therefore, when embarking on treatment the couple must inform their doctor that he must schedule their treatment such that it will not fall on Shabbat. However, since an IUI must be performed to coincide with ovulation this cannot always be avoided. In such a case the couple must consult their Rabbi.

All fertility treatments involving processing eggs, sperm or embryos require close rabbinic supervision. The supervisor must be available to come to the laboratory on Shabbat. In places where the clinic is not near a residential Jewish area, this may create extremely grave, and even insurmountable, difficulties.

In-Vitro Fertilization (IVF)

The halachic issues and solutions regarding IVF are similar to those of IUI. IVF involves days that the couple needs to be in the clinic and days when the medical staff work on the embryos but the couple need not be in attendance. While all efforts should be made to avoid a retrieval or implantation on Shabbat, it is permissible for a non-Jew to check embryos on Shabbat.

The couple must inform the doctor of these limitations and urge him not to schedule a Thursday, Friday or Shabbat retrieval. When retrieval does fall on Shabbat the couple must consult their Rabbi.

When egg transfers fall on Shabbat it can often be pushed off until after Shabbat, or brought forward to a Friday.

Supervision is required for an IVF and this may present problems if the procedure falls on the weekend, since the supervisor must be in attendance throughout the procedure.

Traveling to the Hospital or Clinic on the Sabbath

In the rare cases, such as in a case of ovarian hyperstimulation, where delaying treatment is potentially life-threatening, a woman may travel to the hospital by car on the Sabbath. However, with regard to all other types of fertility treatment that may be permitted on the Sabbath, many authorities do not permit traveling by car. In such cases, the couple should stay within walking distance of the hospital or clinic over the Shabbat.
Some rabbis hold that it is permitted for a non-Jew to drive a woman to the hospital on the Sabbath in order to undergo fertility treatment. It is preferable to make this arrangement with the non-Jew before the Sabbath and the non-Jew should open and close the door of the car if this causes the light to turn on and off.

Yom Tovim/Festivals

The laws of Shabbat are applicable to all the festivals. One should bear this in mind when scheduling treatment and avoid the times in the year when the festivals occur wherever possible.

Summary
Couples facing fertility issues are considered by the Halachah as ill
They are permitted to undergo testing and treatment on Shabbat if it is necessary and does not contradict a Torah prohibition

References: http://www.jewishfertility.org/diagnosis-treatment-shabbat.php

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