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Tuesday, June 24, 2008

Barren Advice: Ten

This is the tenth installment of Barren Advice. You can ask questions that are fertility or non-fertility related.

Barren Advice is posted each Tuesday. If you have your own question for Barren Advice, click here to learn how to submit. Please weigh in with your own thoughts in the comment section and indicate which question you're addressing if there are multiple questions in the post.

Dear Mel:

I'm having a bit of a crisis of confidence, of the how-infertile-am-I-*really* variety (warning - all this may just be the Clomid talking). I've always been averse to medical intervention for anything that isn't a clear and specific injury or illness. In the realm of infertility, there seems to be a lot of ambiguous or conflicting information. For example, take luteal phase length supposedly anything under 10 days is too short, and yet I can plug in "Short Luteal Phase (<10)">

Although I do appear to have ovulation problems and DH's s/a was less than optimal, we haven't been trying all that long (about a year), so it's not clear how much these things are reducing our odds. How do I sort out which reproductive issues are definitely a problem and really do require medical help, versus those that doctors think are probably a problem but don't really know for certain?

--Kate of "No Blog" Fame

The heart of this problem comes with linguistics. Infertility is a bit of a misnomer. A large portion of those diagnosed as infertile are actually subfertile. After all, if you were not fertile at all, there would be nothing one could do to help you along. It would be like trying to grow a flower in concrete. Some people in the community are the equivalent to concrete (and I say this in the most loving way)--nothing they could do would give them the ability to become pregnant. Either they are completely sterile and do not produce any sperm (and this is different from a low sperm count which also isn't getting anyone pregnant) or they are missing necessary reproductive organs such as their ovaries or uterus. The rest of us are actually more accurately subfertile. We're more like poor soil--add some nutrients, change the seeds you're using, adjust some details--and, hopefully, plants will grow.

And that is what makes this suck so hard.

If we were infertile, we could make neat decisions. We could accept our limitations and we'd know the right time to move on. But we're not. We're subfertile and that's where things get grey and we enter an analogy akin to gambling. How many IVF cycles should you do with your eggs? What if the next one was the one that would have worked? What if we had held off one more cycle before starting treatments--could we have gotten pregnant and avoided all of this? Too many questions linger like that when the boundaries aren't clearly defined and it's hard to walk away from the table once you start gambling. Because that's sort of the allure of gambling--there's always the chance of the next time.

Therefore, I think a lot of this has to do with what type of stakes you're comfortable laying on the table: not when life is good and you're at the casino for a lark; but if you were playing for something really important to you. Are you the type who would rather watch the game for a bit and figure things out and decide if you really want to enter? Are you the type who jumps into the game and places everything you've got on the table, even before knowing whether the dealer is working with blackjack or 5-card draw (can you tell that everything I know about poker I learned from Intellivision)?

Let's strip the analogy away and ask this question: are you the type who feels it's worth the risk of losing time or chances in order to work on the problem sans treatments? A lot of people feel this way and many are successful. If you try enough times, chances are, you will win. You're not guaranteed to win because the statistics remain the same each time you try. If you have a 1 in 4 chance, you will still only have a 1 in 4 chance, but you'll have it 15 times. Please don't ask me about this fuzzy math.

Or are you the type who needs this to happen for your own sanity. Please do not disregard mental health--your soul, your emotions, your heart need to be given as much care as your body. Separating them is detrimental to your whole. Therefore, if you would treat an ulcer, you should also treat the stress that caused the ulcer (if stress caused the ulcer). If infertility is affecting someone emotionally, I think it's worth treating all medical issues--the reproductive health and the mental health. Sometimes, treating the infertility by default treats the mental health issues.

I once asked my RE how my mother got pregnant with me when she couldn't get pregnant with treatments (yes, I'm an off-cycle baby) and he explained it this way. Every subfertile woman creates perhaps one or two good eggs every once in a while. They may have happened before we started trying or they may happen when we're 41. We just don't know. It is the perfect cycle where egg quality and uterine lining come together. If you are having unprotected sex every single cycle around ovulation; never taking a month off, you will hopefully catch that egg and have it fertilized and implant. And you will carry it to term. That's how people become pregnant after adoption or how they become pregnant after stopping treatments. Or how they become pregnant naturally after 8 failed IVF cycles.

Some people are willing to wait for that cycle. Some people luck out and inadvertently find that cycle. And other people are not willing to sit around for something that may or may not occur. I didn't fall into the first category, I am here on this earth due to the second category. But my heart feels best (and this is personal for me) with that third category. That's how I chose treatments. I don't know if it's helpful to hear how someone else reached the decision to plow ahead.

No really, the beauty of a blog advice column is that you get to weigh in with your two cents too. Let the questioner know if you support the advice, add to the response, or dispute it completely. I would love people to add how they decided whether or not to enter treatments.

Leave a comment in the reaction box below--only keep in mind that conflicting advice is embraced and rudeness is not. Want to ask your own question? Click here to see what you need to send in order to be included in a future Tuesday's installment of Barren Advice


Andria and Co. said...

I fall into that subfertile category. I had a first pregnancy, healthy and no complications. Then miscarried. And, miscarried again. Three times, for kicks. I had an HSG, a lap, and endometriosis pits were found. Also, it was found that I had a luteal phase defect, and when I was pregnant, my progesterone level was practically non-existant.
I could get pregnant on my own- I had done it four times before. But, I couldn't wait. I didn't want another year or two of "what-ifs" So, I went on clomid, had an IUI, and was pregnant the first time. Had two, lost one.
He was born last November.

Samantha said...

I think Mel is onto one problem with the whole "infertility" diagnosis. Classifying yourself as infertile is vague, and the treatment is just as vague. Truthfully, doctors don't know how to make you pregnant. They have some ideas on how to make you ovulate, they can wash sperm, can fertilize eggs, and can put embryos right back in your body, but pregnancy? That's where chance steps in. I think that's another reason it's hard, because you while you can have that lucky cycle, or never have that lucky cycle, there's no way for doctors to actually create that lucky cycle for you in its entirety. At the end, you still need that luck.

That said, I also think you can fall back on the medical definition of infertility: if you've been trying for over a year, and nothing's happened, that's when the medical community says there seems to be a problem (you might find out earlier, like me, if you never ovulate, which makes it really obvious). If you are concerned about how much is too much when it comes to medical treatment, there are steps which are not too invasive and might help make conditions better for pregnancy to occur. Your comfort level and your body's response will dictate what you want to do.

SarahSews said...

When we got to the year mark with no pregnancy despite obvious ovulation (I charted and used OPKs and was a hawk about watching my signs), I was frantic for help. I wanted to be pg yesterday. When absolutely no issues showed up on our tests I was disappointed. I wanted something to fix and I wanted it fixed fast, I didn't care about the labels. Before we began though I decided that I wasn't comfortable doing IVF. The expense took the gambling to a whole other level that I just couldn't stomach.

We ended up doing 8 medicated cycles (clomid, femara, injectables), 6 with IUI. We had one barely there pg in the year of treatment. We were told we were decent candidates for IVF, and I really wanted to give it all we had, but I put it off. We couldn't afford the gamble and as much as I wanted to do it, I couldn't stomach the risk. We got pg a year later on our own. We miscarried and got pg again the very next cycle. I'll never know how on earth it happened then when it stubbornly refused to happen before, even with help.

Does a pg without intervention mean we were never infertile? Hell no. Nothing can erase those three long years of trying without success. It just means we got super super lucky. And if anyone had told me that if I just waited it out it would eventually happen on its own, I think I would have lost my mind waiting.

Everyone has limits. If you can figure out what yours are, for now, it might help you navigate this unfamiliar terrain. If you don't find success within those limits, give yourself time to see if they need to be adjusted.

Targetgirl said...

While agree with most of the advice, I take serious issue with this...

"If we were infertile, we could make neat decisions."

My husband is infertile and our decisions were not neat. They were messy, heart wrenching, and did not put us on an easy path. Yes, one door was shut, but it opened up a whole other host of problems. I doubt you were trying to do so, but minimizing the issues a truely infertile couple (or individual) faces is not accurate or helpful.

The Town Criers said...

Hey Targetgirl, my thoughts were definitely not that the decisions on the other end are neat and easy (choosing a donor, making adoption decisions, choosing a clinic), but deciding whether or not to seek help is. If you can't conceive without assistance, there is no point in "waiting it out" as the questioner asks. You know decisions must be made (either treatments entered or adoption pursued) in order to move forward.

I think the question was at its heart asking how one knows what to do when they don't have a clear situation.

The Town Criers said...

...And just to make it clear: this is no way speaks to the emotional side. There is a process of mourning your fertility or needing assistance or choosing a different path. All choices come with huge emotions that must be dealt with as well.

I was only addressing the idea of knowing whether or not you need to seek assistance.

nycphoenix said...

When we decided to have a child, there was no question about using intervention: we're lesbians so at the very least we had to use donor sperm. We had to have a lot of discussions on what procedures we were comfortable with but as the months and years pass we found ourselves moving the line again and again. So I guess I want to say that its great to plan and discuss and decide what you will or won't do but don't be too hard on yourself if you change your mind 384754938 times after the plan.

In the end: seven at home inseminations using three different male friends, three IUI cycles with clomid and injectables and two different sperm donors and 2 IVFs with another new donor and ICSI and AH. No pregnancy.

What Mel said is true, doctors can fiddle with some of the circumstances but in the end that can't get you pregnant. In my case, we can't seem to find the good egg from my ovaries that will fertilize and implant.

Tash said...

Excellent analogy here, Mel. I think part of the problem too is that some of us have rather hazy diagnoses like NoBlog Kate. I don't have many classic symptoms of PCOS, but weak ovulation plus hypoglycemia plus low progesterone rang some warning bells, and bam, second month of met both times and I got pregnant (and years of unprotected sex have proven that I'm rather unable to do this without). I too have a short LP, and it's unclear whether or not it's related to the mild IR, or my exercise regimen, or something else entirely, so they put me on progesterone too.

I guess what I'm saying is that while the end result was glaring (I was unable to get pregnant) I didn't have a tidy "problem" so to speak: It wasn't classic PCOS, or endo, or a blocked tube. It was a subjective analysis (my RE's words), and he threw some treatments at the wall to see what stuck. Sometimes I think IF (or as you say, subfertility) is like this. And for someone who likes a neat "you have x, so here's some y to take for it" these explanations can be hard to wrap your head around.

In the end, I was desperate, and willing to try whatever they gave me.

loribeth said...

It took me 22 cycles over more than two years before I got pregnant on my own, only to have the pregnancy end in stillbirth at 26 weeks. We ttc on our own (this time with charts, basal thermometers & OPKs) for nearly a year after that before I persuaded dh that we owed it to ourselves to do some testing & find out if there was a simple reason why we weren't getting pg(&, with my 39th birthday approaching, I knew there wasn't any time to lose).

It's a slippery slope, of course. We did the usual tests, then started out with a monitored natural cycle, then moved on to several rounds of clomid. (I figured why go straight to IVF & spend all that money & undergo all those intrusive procedures when it might work on the cheap with clomid?) We had to go to an infertility counsellor to come to an agreement on what to do next. She encouraged us to set a limit (if only to review it later), and we decided on three IUIs with injectables. When those all failed, I was a complete wreck and dh was adamant that we were done. Had he been more encouraging, I might have gone for IVF, but I figured if I couldn't hack the much greater stress. The money factor was also not insignificant, and when we took all the factors into account, we didn't think our odds of success were all that great.

It's maddening, because there are very few clearcut answers when it comes to infertility or treatment. There is always some new carrot they can hold out for you -- a new treatment, tweak your protocol. The gambling analogy is so apt. Someone (I forget who) wrote on their blog recently that if you went to Vegas & wanted to put the same amount of money that you spent on fertility treatment on one roll of the dice at the same odds, they'd laugh at you. And yet we do it...!

Star said...

For me, I would think the answer to whether or not to seek treatment or keep trying on my own would hinge on age; that and how less-than-optimal the S/A was, and how serious the ovulation problems are. Perhaps that was part of Kate's question, wanting to find that out. I had a ton of questions when I started treatments too: they seemed far too one-size-fits-all at first. My diagnosis is PCOS, but my hormone levels are all normal except for one (17-hydroxyprogesterone), and I never had ovarian cysts or many of the other symptoms. I wanted to know exactly what was "wrong" with me and exactly what each test result meant.

The way I dealt with all that uncertainty and wanting to know what was wrong and how much it would impede pregnancy is to do a crapload of research online. That way, I went into my appointments armed with at least a reasonable level of knowledge about what was going on, what the various options were, and the like. I was lucky to find a doctor (second one I saw) who was not upset by that -- some doctors hate being questioned. The first RE I went to was very arrogant and condescending. He also turned out to be wrong about which treatment regimen would be most effective for me and in interpreting the results of my husband's S/A. Thank god we got a second opinion! So, that may be another option that might help clarify things for you.

I also thought Mel's response was right on.

Nicky said...

I, too, struggled a lot with the idea of when to seek treatment. Everyone says "try for one year, then talk to a specialist," and I know a lot of people who don't even wait the one year. I was the opposite. After one year, I held onto the belief that so far, we were just unlucky. I was so frightened of getting on the IF treatment train, I needed to be absolutely sure, in my heart, that it wouldn't happen on our own. I reached that point after 2 years.

I got pregnant fairly quickly once I had help (Clomid with a few IUIs), and indeed, the ovulation problems that the Clomid was fixing were serious enough that the likelihood of getting pregnant without the medicine were VERY slim. Still, I don't regret waiting that extra year. Yes, it would have been nice to have gotten pregnant a year earlier. But I was miserable on Clomid, and I don't think I could have gone through with several cycles of it if I wasn't convinced that it was the only way.

midlife mommy said...

I have nothing to add, but I wanted to commend you on capturing things so well. As I read, I kept nodding and saying to myself "yes, yes, exactly!" It is the being in the gray area that makes things so hard.

Alex said...

Infertile here -- DH has had a vasectomy and failed reversal. So for us the need for treatment (IVF + ICSI or donor sperm) was clear. That said, I was told due to high FSH on my side that I'd never conceive with my own eggs, yet I did 4 IVF cycles with my own eggs, the last of which resulted in our son. For me the question I came back to over and over again when contemplating treatment was, "If this doesn't work, will I be glad I tried it anyway?" Of course it's always hard to answer that definitively until you get the phone call telling you the beta is zero (or...pick the failure point of your choice; for me it was always implantation but I realize there are any number of other points where things can go to hell in a bucket), but I always felt the answer for me, before each cycle, was "yes," and 75% of the time I found out for sure after that phone call that I was right about that (the fourth cycle, since that was when DS was conceived, I never had to face the real answer to that question).

Beyond that, though I think a question raised by Kate's original question and as yet unaddressed is ... do the treatments available have anything to offer you? And I think for many in this community (the subfertiles rather than the infertiles) that is a really difficult question to answer. The point here is that it may be necessary to ask not just "Does treatment improve your odds of conceiving?" but "Could it actually make matters worse?" There are the emotional and financial costs of treatment, of course, but personally I suspect -- though I've never seen this systematically reported -- that for some subset of subfertile women, in particular (since most of the interventions available work within our bodies, not our male partners' bodies), available treatments can actually make things worse -- they thin our linings, or mess up our eggs in some as-yet undocumented but real way, or otherwise reduce, rather than increase, our prospects for achieving a viable pregnancy.

I can provide a concrete, if unproven (only suspected), example of this -- myself. My DH had no sperm making it to the outside world, so natural conception was impossible. Despite my high FSH, I was a decent responder to stims and always had good embryos, but they didn't implant. After failed IVF #3, I finally got a subclinical thyroid problem diagnosed and treated; I think that's what led to the success of cycle 4. High estrogen levels -- which stims were producing in me, as they are supposed to -- stress the thyroid, so had I not needed IVF due to DH's problem, my thyroid problem might not have interfered with my embryos' ability to implant (and I cannot prove that it did interfere, I just suspect that it did). As was, I was lucky; I managed to get both problems -- DH's and mine -- solved in a single cycle and to get pregnant (and stay that way for an appropriate amount of time). But had I not needed treatment due to his problem, I might not have had a problem at all.

It may not be helpful to point this quandry out since I have no idea what one can do about it -- I mean, I personally am grateful that, while I wasn't a good candidate for treatment it was at least clear that by pursuing treatment I improved my odds of conceiving. But if you, like Kate, are debating the merits of treatment, well, yikes, it's a tough, tough call.

Nic said...

I do sympathise. I think only you will know when is the 'right' time to move further into the 'infertility' zone. For us it was a moving goalposts scenrario. When we started out I was absolutely, 100% against IVF, had no intentions of going down that road. Step by step, slow stage by slow stage our 'little' problems revealed themselves to be bigger. At any point we could have stepped back. First a teeny problem with thyroid, then some slightly worse sperm issues, then actually some rather serious morphology problems, and finally the immune beast. Perhaps because with the UK National Health System, which has a large element of waiting, the decision of whether to 'wait and see' was already a done deal as we had to just to go through all the testing stages. By the time it got to IVF we'd already been going it alone for a good 2-3 years. I know that isn't long in some people's perspective, but I was also the wrong side of 30.

I wish you luck with your progress, hopefully something will click into place soon, either on your own or with whatever you and your doc decide to go forward with.

Queenie. . . said...

I didn't even know I needed this advice until I read this.

It's true--doctors don't agree about fertility. Like Kate alluded to, my doctor doesn't believe in LP defect. Yet there are clearly so many who do. This has made it difficult for me to make a decision about how to proceed from here, because I was questioning myself for worrying about it so much when my doctor wasn't. But suddenly, your advice has made it crystal clear--it's not about treatment, per se, but about deciding what kind of person I want to be, in terms of my fertility. Thanks, Mel!

Tara said...
This comment has been removed by the author.
Geohde said...

I'd add that testing only goes so far- like any medical investigation, tests of fertility related disprders do not provide Y/N answers. In fact, in med school, we spent quite a lot of time looking at the statistics of testing- it gets a bit complicated whne you have to consider the prevalence of the disorder, the pretest probability, incidence of true positives, false positives false neg's etc to get a feel for what a test can and can't tell you.

Additionally, in the world of infertility/subfertility (sterility is when it is impossible to concieve with your own gametes), not every paramater can be tested. Hence the diagnostic catch-all of 'unexplained', which may be due to multiple minor issues that don't turn up on standard testing, or aren't tested/testable at all.

But Mel's right, it's a numbers game, and even with very low per-cycle odds, people do eventually concieve. Personally, I couldn't wait for that and went the IVF/ICSI route, but everybody is different.

I always say do now what you would regret not trying down the track.


Targetgirl said...

I was just able to get back to this today. I guess I misunderstood the intent of your comment on "true" infertiles, though I have to say the decision to seek treatment can still be hazy, so I believe there is no real "neat" path. Thanks so much for clarifying, I appreciate your quick and caring response.

Deborah said...

I definitely fall in the infertile catergory. However, I would have never known this if I hadn't gone for serious medical intervention, as everything on the surface appeared normal-I ovulated regularly, my cycles and uterus were normal, and my husbands s/a were slightly off, but not enough to keep me from getting pregnant. If I had rested on this information, I would NEVER have gotten pregnant, not someday, not when I relaxed, NEVER. The only way I could know that both of my tubes were completely blocked was through surgery. My point is, sometimes what you think time will take care of-won't. Make sure that you get a complete diagnosis and that takes medical intervention.

Targetgirl said...

Anon, without knowing any of my history your comment is hurtful. I am very thankful for donor sperm. Good luck to you.