Frequently Asked Questions
What is infertility?
Infertility is the inability to conceive after a year of regular,
unprotected intercourse. Couples who have known barriers to fertility,
such as endometriosis, polycystic ovarian syndrome(PCOS), male factor
infertility, irregular cycles, etc., do not need to sit out the
traditional "waiting period "for one year to seek expert care for
Why should I seek treatment from an infertility specialist rather
than from my OB/GYN?
A reproductive endocrinologist or an infertility specialist, specializes
in treating infertility, and is far more likely to have the experience
necessary to identify and treat your problem than an OB/Gyn. It
can be a tremendous waste of time, and money that you could put
toward treatment with a specialist who can get to the root of your
How long after HCG does ovulation occur and how to I know ?
Ovulation occurs 36-40 hours after the HCG injection. Eggs will
release in this timeframe if they have not been retrieved. This
is adequate time for planning any form of treatment. Frequently,
the ovulation is associated with mild discomfort felt in the lower
abdomen and is confirmed by doing a serial ultrasound follicular
monitoring by the doctor.
How long do sperm live after timed intercourse or after IUI ?
Normal, healthy sperm live approximately 48-72 hours. We do know
that washed sperm can survive in the IVF incubator for up to 72
hours. That would be considered the upper practical limit.
How long are eggs able to be fertilized?
Eggs are able to be fertilized for about 12-24 hours after ovulation.
The older the woman, the shorter this time becomes.
How long does it takes for fertilization to occur ?
Fertilization occurs within 24 hours after ovulation.
How soon can I take my pregnancy Test?
The earliest that a sensitive blood test can pick up any HCG at
all is 5-7 days after ovulation. Your quantitative serum beta test
can be reliable about 10-12 days after ovulation, if you have not
taken a HCG booster. If you have taken a HCG booster, then you may
have a reliable test at 14 days past ovulation. The serum beta HCG
is the most reliable test. Your HCG level has to be above 50 units
in the blood to get a positive result for urine pregnancy tests.
Which is the first day of the cycle ?
D1 is the first day you see a red flow, not just intermittent spotting.
There is no universal rule for the cutoff time for that date. But
most often D1 is considered the first day of full flow that begins
before mid-afternoon.( some doctors believe in 8pm as the cutoff
time and some will take it as the noon. However, this helps in giving
some flexibility in starting treatment especially in women with
I have just had a 3- day FSH test taken, and would like to know
If these bloods were drawn on day three of a cycle, the results
would imply decreased ovarian reserve or eggs available. FSH is
more of an indirect measurement of ovarian reserve. This is specially
true if you are above 37 years of age, or you have had previous
cycles which were not as expected in the ovarian stimulation.
Your doctor will also advise you for the same if she suspects any
hormonal imbalance or PCOS or if you have irregular cycles
How do we know if the sperm count is adequate for IUI ?
Besides the number of sperm, the percentage with rapid forward-progressive
motility and with normal morphology at the time of insemination
are important to know. If this functional sperm count exceeds 1
million, chances for pregnancy with well-timed IUI are excellent.
I am concerned about the size of my follicles, and the timing of
my HCG shot. How big should my lead follicle be before I take my
HCG shot? How much do follicles grow each day ?
A lead follicle should be at least 16-17 mm when the patient is
on urinary gonadotropins for ovulation induction, it should beat
least 18 mm on a recombinant FSH , and should be about 22 mm on
Clomiphene citrate therapy. Other measurements such as E2 and progesterone
should be used to indicate maturity.
Follicles grow 1 to 2 mm a day both while taking ovulatory stimulants
and after the HCG shot.
I have leftover cysts on my ovaries. My doctor wants me to sit out
a) What causes these cysts?
A corpus luteum, or functional cyst, is simply a leftover follicle
that has outstayed its normal lifespan. Sometimes, they continue
to produce progesterone and estrogen, which may delay the arrival
of the next period.
Will they go away?
Functional cysts almost always go away with time. Birth Control
Pills are sometimes prescribed for a month or two, to hasten their
resolution. They never need any other intervention. If not, relieved
by medication, they may not be functional cysts and need further
How big do they need to be to reduce chances of pregnancy?
Research has shown that any cyst 10 mm or larger is associated with
a lower chance of getting pregnant. Those that had a 10 mm cyst
at the beginning of a cycle had half the pregnancy rate of those
who had no cysts. It does not eliminate your chances of pregnancy,
but it does sharply decrease them, through two mechanisms. First,
physically, they can crowd out the development of new follicles.
Also, if the cyst is secreting hormones at the wrong time of the
cycle, it interferes with the chemical balance required for good
quality ovulation and drastically reduces the chances of pregnancy.
It is normal to have small cysts, which may be very small leftover
follicles or follicles that are preparing for the next cycle. Anything
under 10 mm shouldn't be cause for concern as long as your baseline
hormone levels are in range.
How long should I use Clomiphene before I move to Injectables /
The vast majority of Clomiphene pregnancies occur during the first
4-5 ovulatory cycles. If after the first 3 attempts at a reasonably
high dosage, there is no response, you might consider moving on
to Injectables earlier. The average number of cycles on Clomiphene
before moving on is three to six.
What is the maximum recommended dosage for Clomiphene?
The maximum dosage is 250 according to manufactures. It may be wise
to move on if there is no response to 150 mg, as the risk of antiestrogenic
side effects of Clomiphene increase sharply as the dosage goes up.
Also, with the recent recommendation of the Royal college of Ob-gyn
and the American college of Ob-gyn, Clomiphene use should be restricted
to maximum of 12 months in your lifetime.
How many times should I try IUI before moving on to IVF?
Once a patient has had 3-6 IUI cycles with injectables, they might
consider moving to IVF as the chance of a successful IUI cycle is
Should I be taking Clomiphene on days 3-7 or on days 5-9?
In theory, days 3-7 of Clomiphene lead to more follicles and fewer
side effects on the lining and the mucus. It seems to make a difference
for some women and does not make any difference in others. What
is important is that it should be used for a maximum of 6 cycles
continuously and not more than 12 months in all.
Why should my physician mix my Clomiphene treatment with injectables?
Mixing injectables and Clomiphene is an attempt to get some of the
stimulant, cervical mucous, and lining benefits of injectables without
spending as much money as would be required by doing only injectables.
This will be helpful in patients who do not respond with clomiphene
and need more drugs for stimulation
How long should my husband abstain from coitus before the IUI? His
semen analysis is normal.
For most men, a 1-3 day break is ideal. That gives the "sample"
an opportunity to regenerate. Too "old" of a sample raises the risk
of poor motility, white cells, and other problems.
How should my IUIs be timed?
In most cases, doctors who do two IUIs do the first about 24 hours
after the HCG shot and the second about 48 hours after the shot.
Some studies have shown that doing one IUI about 36 hours after
the HCG is equally effective. However, some recent research suggests
that higher pregnancy rates may be achieved by doing two IUIs, one
at 12 hours past the hCG shot and one at 34 hours. However, your
doctor will decide depending on your current stimulation cycle.
What is the standard IVF protocol?
There are several variations on the IVF protocol. This description
is of a standard long "down regulation" protocol. When the patient
is under 35 and has a history of good response to stimulation. In
the long down regulation protocol, you start the cycle before your
stimulation and retrieval cycle. On D3 of that cycle, your FSH level
is measured. On D21, you do a progesterone test to see if you have
ovulated. Starts the GnRH shots once a day. The dosage varies from
doctor to doctor to some extent. Your period should arrive close
to its due date. On D1 or 2, you are tested to ensure that medication
has shut down your own hormone system. If you are adequately suppressed
and an ovarian scan shows no cysts, you will usually start injectables
on D2 or so. Your medication dosage depends on your diagnosis, age,
and response history if you have taken injectables before. After
three days of ovulatory stimulants, your follicles and Estradiol
levels will be checked. E2 levels above 100. If needed, your medications
will be adjusted. You will go in a few days later for a second round
of blood work and an ultrasound follicle check.
that, you might report to your clinic daily for blood work and ultrasounds.
Once your follicles have reached an appropriate size and your E2
levels are good, you stop the stimulation and GnRH, and are given
the hCG shot, in the presence of good blood flow. The eggs are retrieved
using an ultrasound probe that has a needle at the end of it. They
put the needle through the vaginal wall and aspirate the follicles.
You will generally start progesterone immediately following the
Sometimes, your doctor may change this protocol to a "short protocol",
This decision is done during the planning of your cycle, and depends
on the indication and other factors involved in individual case.
I hear so much about taking baby aspirin, should I be taking it
Many infertility specialists are using this as part of their protocol,
especially for patients with histories of miscarriage and lining
This decision will depend on your individual case history and the
ovarian response to the stimulation drugs.
Should I take progesterone supplementation during treatment?
Most patients on progesterone during the luteal phase automatically.
The underlying concept is that if you wait and find out if the progesterone
is low, even at seven days past ovulation , it can be too late because
the lining may not be receptive to implantation. Low progesterone
can cause implantation failure, because its role is to vascularize
and maintain the uterine lining, which is where implantation takes
place. Some women require more progesterone support in the luteal
phase than others and this depends on your baseline hormone levels.
However, all patients undergoing an IVF cycle will be given progesterone
in the luteal phase. This can be either as injectables, or tablets.
. There are four different common methods of progesterone supplementation:
progesterone in oil shots , progesterone suppositories or vaginal
capsules, vaginal gel, and oral progesterone. Discuss the best medication
method and dosage with your doctor.
My doctor wants to me to "coast" for a while on this cycle. Why
is he slowing me down?
The idea of coasting is either to get a too-high level of Estradiol
to drop a bit or to slow down development- generally eggs are of
better quality if the patient has at least 7-8 days of stimulation.
In addition, they may possibly want to slow down some of the lead
follicles and get some of the smaller follicles to catch up a little,
several studies have shown that coasting does not reduce success
rates for a cycle, and it can also reduce the risk of ovarian hyperstimulation
I heard that multiple cycles with fertility drugs increase the chance
of getting ovarian cancer. Is this true?
No. there is no evidence that shows a statistically significant
increase in the ovarian cancer risk. Many studies have shown that
there is no direct relation with cancer, however, there is a limit
on the use of Clomiphene for more than 12 months during the patients
life-time and hence the doctor may stop Clomiphene and switch over
to using injectable gonadotropins for ovarian stimulation.
My doctor has recommended a hysteroscopy, laparoscopy, or folloposcopy.
Where can I get more information?
If ther is a suspicion of any other pelvis pathology, the doctor
will advise for a laparoscopy and hysteroscopy for it. Also, in
patients where the response to treatment is not up to the expectations,
the doctor will ask for it to rule out other causes of failed treatment
Often, this may be combined as an operative procedure for correction
of any associated pelvic pathology.
Do your chances increase with each consecutive cycle?
No, each cycle is independent. Your per-cycle chances do not increase.
I had my egg retrieval. I had more eggs/ fewer eggs that I expected.
The number of eggs retrieved is largely a function of age, responsiveness
and the stimulation protocol, good monitoring, and a bit of luck.
If there are too many eggs, there may be a possibility of you developing
ovarian hyperstimulation, and your doctor will counsel you for the
same. Sometimes, the doctor may also advise cancellation of the
current cycle, if the risk is very high.
If there are too few eggs, there maybe another stimulation, which
may be needed and your doctor will advise the same. Or, she may
ask for certain additional tests to find out the cause of this unexpected
result to prevent its recurrence in the next cycle.
I am afraid that I might have ovarian hyperstimulation. What can
you tell me about this ?
First, if you are concerned about the possibility of OHSS you should
call your clinic as soon as reasonably possible. OHSS (Ovarian Hyperstimulation
Syndrome) is when you have an unusually large number of mature follicles
that release. When these follicles release, there is an unusually
high concentration of estrogen-rich fluid in the peritoneal cavity,
and the ovaries are generally enlarged far beyond their usual plum
size. In milder cases, women experience bloating and some pain from
the oversized ovaries.
The treatment then is just a matter of rest and staying well hydrated.
In more severe cases, the estrogen in the peritoneal cavity causes
fluid to leak out of the circulatory system into the peritoneal
cavity. This can cause marked discomfort and bloating, and can cause
difficulty breathing due to pressure on the diaphragm. In the most
severe cases, the leaking of the fluid will lead to hypovelmic shock
and organ damage because of a lack of perfusion. Generally you do
not see severe OHSS until the Estradiol gets into the 5000+ range.
As long as your doc keeps a close eye on your dosage and development,
the chances of anything other than mild discomfort are minimal.
My progesterone was very high. Does this mean I am pregnant?
It does not mean you are pregnant. Nevertheless, it is a good indicator.
If you have good progesterone levels, that means that a pregnancy
that is trying to implant will have a better chance of finding a
good receptive environment.
My breasts are tender, or I have cramps, or am irritable, nauseated,
or bloated, or, I am gaining a small amount of weight. It is not
yet time for my pregnancy test. Could these be signs of pregnancy?
You are probably feeling the effects of the hormones you are taking.
It's really too early to be feeling anything as a result of a pregnancy.
Implantation normally takes place about 5-10 dpo, but even after
that it takes a couple of days for the hCG to build up in the blood
stream. The presence of these symptoms does not indicate pregnancy,
and the absence of them does not indicate a failed cycle.
My period has been usually light or heavy since my last cycle with
Clomid or injectables. Or, I have not ever gotten it yet, although
my beta was negative. Is this normal?
Yes, it is normal for menses to be light, heavy, or simply different,
due to the hormone levels being different. Also, progesterone supplements
can delay the onset of menses. Most women don't start their periods
until the progesterone levels drops to somewhere between 2-4, which
may take a few extra days.
What constitutes early or late ovulation? Does late ovulation decrease
There is not complete agreement on this. You might consider "too
early" to be cycle day 10 and "too late" to be day 20. There are
two problems with late ovulation. The first point is that you obviously
you have fewer chances over a given time period. Second is the fact
that late ovulation you may be releasing eggs that have not been
matured properly. It is also possible that the other parts of the
reproductive system are not in sync with the egg. That is not a
say you cannot conceive if you ovulate late- it happens all the
time. It is just that your chances are somewhat reduced.
My doctor says I am not ovulating regularly. How could I get my
period if I do not ovulate?
Menstruation only requires development and shedding of the endometrium
in response to alternating levels of estrogen then progesterone
in the blood stream. These hormones can be produced by the ovary
even when an egg does not mature or release.
I am concerned that I may have poor egg quality. How can I determine
my egg quality?
You can get somewhat of an idea from the size of the egg and the
estradiol level at midcycle. But other factors arise as you get
further into your 30s. you really can't diagnose egg quality until
you get the eggs out of the follicles, put them under the microscope,
and see how they behave. There are some less invasive screenings
for ovarian reserve/egg quality such as the Clomiphene challenge
test, FSH, and Inhibin B, but they are also not as accurate as looking
at the egg directly.
What causes "chemical pregnancies"?
Many early pregnancy failures are due to genetic abnormalities,
mainly "trisomies" where an extra chromosome is present in what
should be a pair. The earlier the failure occurs after implantation,
the more likely it is to be genetic. You can also have implantation
problems that would cause chemical pregnancies such as hypercoagulation,
failure to from the needed blood vessels, or autoimmune issues.
It is important to remember that, chemical pregnancies are early
miscarriages, not abnormal hormones as the name may imply.
Should I avoid exercise after ovulation?
Swimming and any other low impact exercise that doesn't over exert
you are fine. It's best to avoid things like jogging and high impact
aerobics. Avoid picking up anything too heavy during the waiting
period (greater than 15 lbs.).
Should I avoid air travel or ground travel after my transfer?
Just don't overdo it. Air travel is fine as long as the pressure
is maintained, which it generally is in commercial aircraft.
What is a sample protocol for IUI?
The simplest protocol is Clomiphene 50-100mg 3-7 (or5-9) of the
cycle. With the addition of vaginal ultrasound monitoring on the
day of the LH surge or by day 14 if no LH surge, you may be given
a HCG injection and IUI performed 36 hours later. Adjustments in
the ovulation induction protocol can be made in subsequent cycles
depending upon your response.