It's National Infertility Awareness Week and I wanted to take today to share something special I have been working on for you guys.
I recently had the opportunity to interview our IVF doctor, Dr. H. Randall Craig of the Fertility Treatment Center in Arizona, to gather some much-needed answers from him that you guys had submitted to me previously.
My hope is that these answers, that come straight from the source, can give you guys some helpful insight on your fertility journey. So let's get started...
What is the Most Common Cause of Infertility
Infertility: by far the hardest thing I have ever had to go through. It’s a rollercoaster ride of a few ups and then extreme downs that all mesh to mess with even stable person's sanity, let alone a gal hopped up on lots of extra hormones.
But what is infertility? Infertility means not being able to get pregnant after one year of trying, or six months if the woman is over thirty-five years of age. And it’s harder to get pregnant than you’d think. Ten to fifteen percent of couples throughout the United States have difficulty getting or staying pregnant. That’s a heartbreaking number, but if you’re struggling, it may bring you peace to know you are not alone.
But what causes infertility? Most cases of female infertility are caused by problems with ovulation. Some signs of this include irregular or absent menstrual periods. Ovulation problems are often caused by polycystic ovarian syndrome (PCOS), which is a hormone imbalance problem, and one of the most common causes of infertility.
Another common cause of ovulation problems is primary ovarian insufficiency (POI), which occurs when a woman’s ovaries stop working properly.
But there are so many things that can change a woman’s ability to get pregnant, including age, smoking, stress, excess alcohol use, poor diet, STI’s, BMI, endometriosis, thyroid levels etc. In fact, it almost feels like the stars have to align these days to get pregnant. As a result, more women than you’d think are turning to science for help, including me. In fact, it's one in eight.
And I turned to Dr. Craig and his staff at the Fertility Treatment Center in Tempe, Arizona.
What are the first steps you recommend to new, incoming patients before diving into a treatment plan?
Before diving into In Vitro Fertilization, I recommend making sure you feel comfortable with your doctor and the clinic you choose. It takes a team to make sure all of your questions are getting answered (sometimes, before you even know to ask them). Right away when I met Dr. Craig and his team I knew we were in the right place. Not only is he brilliant, but his entire staff is so friendly and helpful. And when you’re going through something as difficult as IVF, you want a clinic you feel comfortable with. And I also liked Dr. Craig’s plan of attack for our path to parenthood.
First, Dr. Craig likes to rule out potential fertility issues using the less expensive tests first, including checking estrogen, glucose and insulin levels, FSH, LH, Prolactin, TSH, and AMH. Phew, that was a mouth-full, but these can be done with a simple blood-draw thank goodness.
A semen analysis on your partner is also another suggested first step to accurately measure the number of sperm, motility (ability to move), morphology (shape and size) and the volume. This allows you to rule out if your struggles stem from your husband.
Both a hysterosalpingogram (HSG) X-ray is also typically ordered in order to check your tubal status and uterine size, shape, and position, as well as a Sonohystogram (SHG) to check the uterine cavity for septum’s/polyps. If this sounds overwhelming so far, that’s because it is. But the good news is, these tests are all very fast and can tell you a lot in just a short amount of time, putting you on the path to the answers that you’ve been seeking.
An ultrasound is also typically ordered to check for uterine pathology (fibroids, cysts) and discover antral follicle count (AFC).
And depending on the patient’s status, an IUI (intrauterine insemination) can be a great first step to try before diving into IVF. While success rates are much lower with an IUI than IVF, it may be the right move if you and your partner have no known fertility issues or if IUI happens to be covered by your insurance and does not dip into your IVF coverage.
If you don’t fit into the criteria above or you have a limited amount of time, money, energy and mental health to spend on your fertility journey, then you may want to consider diving right into IVF thereafter.
When it comes to IVF, are success rates any higher with a frozen embryo transfer (FET) vs. fresh transfer?
According to Dr. Craig, the answer is yes, but that depends on the specific program. If the program has really good freezing technology, frozen success rates are usually 15-20% higher. Here’s why: when you do an ovarian stimulation protocol with fertility drugs then your estrogen levels are increased by about 10 times their normal levels (a necessity in order to get those eggs). However, the estrogen also oversaturates the uterine lining, which cuts your pregnancy rates… sometimes in half. If your clinic has good freezing technology, then if you were to freeze the embryos, come back the next month, thaw out the embryos and they lose minimal or no efficacy, and you have optimal lining and estrogen levels, your pregnancy success rates would increase 15-20%.
For my Arizona readers, what is one of the main advantages to working with your clinic, The Fertility Treatment Center?
Dr. Craig humbly stated, ‘The Fertility Treatment Center has got Dr. Jun Tao.’ He has consistently been achieving some of the highest frozen embryo transfer success rates in the country. In other words, he is a wizard in the lab. He uses his own patented fertility devices, including his own embryo transfer catheter system, called the gated side-port catheter, which prevents contamination of embryos and thus, significantly improves pregnancy rates.
When you put a catheter through cervical mucous it collects junk as it goes through, usually accumulating right into the port. So now you have bacteria, mucous and debris in there, which all gets spit back out when you place the embryos in the uterine cavity. With Dr. Tao’s patented catheter, the side port prevents the collection of bacteria and debris through the front by allowing the main catheter to go through the mucus. Then, once it gets into your cavity, the door opens to let another catheter out, which has remained clean, and the embryos come out of the side port and, as a result of this invention, Dr. Craig’s team gets a nice big boost in pregnancy rates.
What supplements would you recommend taking during a frozen embryo transfer (FET) cycle?
Dr. Craig recommends some supplements and does not recommend others: he does not recommend Vitamin E or Vitamin A. Those are oil-soluble vitamins. If you build up too high of a level, fetal liver can be damaged. So he recommends keeping those low.
The B vitamins are the co-enzymes for the folic acid system (B6 and B12’s), so he recommends those because everyone should be on folic acid. However, the B Vitamins should come with your standard prenatal pills so you should not have to take any additional supplements UNLESS you have a positive MTHFR test. Then, the dose should be doubled (take additional folic acid and B6, B12). If you have a double positive MTHFR, then Dr. Craig recommends tripling the dose.
If your MTHFR test comes back negative then everything is normal and you can take your standard prenatal.
Dr. Craig also recommends CoQ10 to his patients because there is a possibility that it may help increase a woman’s egg quality. While there is no existing evidence to solidify these findings since all studies have been successfully made on mice, there is no evidence that there is any harm in using CoQ10 since this enzyme is present in every cell of the body and produced within cells.
What supplements do you generally recommend taking during an egg retrieval cycle?
Dr. Craig generally recommends prenatal vitamins, L-Methyl Folate, CoQ10 and sometimes, DHEA, depending on the patient, to help recruit extra follicles.
You should also consider increasing your folic acid consumption (to at least 400mcg QD) as well as Omega-3’s (Fish Oil) to at least 1000-2000mg QD. These can improve semen parameters, particularly morphology, as well as provide higher fertilization and implantation rates.
What type of diet do you recommend adhering to during fertility treatments?
We all know the word ‘diet’ can be a little alarming. Especially when IVF is so demanding and draining (mentally, physically, emotionally), the last thing you want is to put extra pressures on yourself. So I like to keep things a little simpler by, you guessed it, keeping my favorites in rotation in moderation.
I like to try and eat clean (plenty of fruits (including pineapple), vegetables and lean proteins), avoid preservatives and added sugars. But it’s ok to indulge every now and then, especially if it makes you happy. At the end of the day, that's the best thing you can do for yourself is minimize pressures and stress.
If you are a female over 37, or a male over 40, you should increase antioxidant consumption according to Kristina Bauer, Dr. Craig’s (incredible) PA-C. You can easily do this by throwing more Vitamin C, drinking green tea, espresso coffee, and dark chocolate into the mix.
But what about coffee and alcohol? I am a big coffee drinker (a cup a day keeps my work in play), and a glass of rosé every now and then is great for my mental health. And the good news is, you don’t need to cut either out completely. However, Dr. Craig recommends limiting caffeine to one serving a day and limiting alcohol to four or fewer drinks per week during treatment. For the most part, I cut out alcohol completely during IVF altogether, except for the very very rare or occasional sip or glass. My rule of thumb is, if it makes you feel good, do it! If it's going to stress you out if you do it by worrying about the effects, then just skip it. I think stress can be worse in some instances.
The one thing you should absolutely cut out though? Smoking! Various studies have demonstrated reduced ovarian reserve, semen quality, fertilization and an increased risk for miscarriage.
Would you recommend avoiding any scented products leading up to your egg retrieval or embryo transfer (not just on the day of your transfer)?
We all know you shouldn’t wear any scented products to your embryo transfer because embryos are particularly sensitive to volatile fumes. But what about leading up to your transfer? For me, personally, I cut out all scented products as a precautionary measure a few weeks prior to my FET, as well as all throughout my first trimester of pregnancy. That meant no nail polish, removers, perfumes, scented body wash etc. The one caveat I allowed post-transfer was deodorant. Because lawdddd knows those hormones made me sweat like a pig.
But two things you should be avoiding are parabens and phthalates. And I know, they’re. in. every. thing. But if you can reduce your exposure, it’s likely a wise move. Both have been linked to reductions in sperm quality and quantity as well as produce an undesired effect on women’s reproductive health. You can reduce your exposure by checking labels and using organic and scent-free makeup, skincare and body products.
And as far as post-transfer goes, it’s probably not a good time to repaint or renovate the house or get down and dirty with smelly cleaning products.
Are there any at-home remedies you would recommend doing or taking to maintain a pregnancy?
If you have followed our story at all, then you know we sadly endured back-to-back miscarriages of our two sets of twins. Truly, it was the hardest thing we have ever had to go through. So if someone said wearing a paper bag over my head for four months would prevent another miscarriage, I would have done it. So I was surprised when Dr. Craig shared the following with me while undergoing our IVF treatments:
If you have a history of recurrent miscarriage, Dr. Craig recommends using Alcohol-Free Crest Pro Health Mouthwash (I rinsed my mouth with this both morning and night every day both leading up to our FET and throughout my entire pregnancy with Luna). The mouthwash may be helpful to eliminate oral bacteria, which make some unknown substance that can cause the uterus to contract.
Dr. Craig also recommends his patients who have recurrent miscarriages to take 500mg of L’Arginine twice daily. It helps to increase blood flow to the uterus and ovaries which helps promote a healthy environment for the baby.
If you have had a poor retrieval cycle yielding low egg count or eggs of poor quality, what would you recommend doing differently to increase the outcome?
As anyone naturally would, the first thing you do is analyze the cycle in detail to figure out why it failed.
Dr. Craig likes to start by looking at the preparation cycle: he will switch from a progestin-based birth control pill to an estrogen-based birth control pill (or no birth control pill, depending on what he sees). Next, he looks at the stimulation protocol. Dr. Craig has 48 different protocols and the first one that will be prescribed is the one that has historically worked best in your category (age, sperm quality scores, FSH (follicle stimulating hormone), AMH (anti-müllerian hormone), etc.).
If you don’t get pregnant, he has 47 more protocols to choose from based on your results. He looks at your max estrogen levels, analyzing if they dropped more than 15%, whether the progesterone levels jumped ahead of cycle, and many more. Based on these findings, he will go back and pick out the next best protocol. Two-thirds of the time the second cycle works distinctly better than the first because you now have a track record to reference. What this means for us, unfortunately, is that IVF can be the world’s most expensive test. So it’s no wonder we’re willing to do whatever it takes to make this work.
Does undergoing IVF give you the highest chance possible of pregnancy?
Given the high cost of IVF, you may be wondering if it’s right for you and whether it will give you your best chance at the baby you’ve been dreaming of. The good news is, IVF is generally successful and, according to Dr. Craig, IVF has the highest successful pregnancy rate because you can better detect what may be causing the issue.
As mentioned above, IVF can be the world’s most expensive test. And there are four main factors your doctor will be able to find out about you during an IVF cycle:
First is your egg to follicle ratio. This is typically low for IVF patients, but you won’t find out until you do In Vitro. The second factor is egg maturity – the follicles may look good during your ultrasounds, but are your eggs mature? The third factor is fertilization rate. According to Dr. Craig, approximately seventy-two percent of your eggs should be mature, but it may be lower. IVF will help you to determine whether this is an issue. And finally, the fourth factor is embryo development rate. Human cells divide every ten hours after fertilization, but suppose it’s every eighteen in your case. IVF allows your doctor to find this out and fix the issue.
Thankfully for us, your doctor can typically fix these issues as you go, which is why IVF provides much higher pregnancy rates than other methods.
In my case, my eggs had a low maturity rate. What do you recommend to your patients in this instance?
When your egg maturity is low, the primary method is utilizing Lupron, a man-made hormone injection, to increase maturity. However, it is a fine balance as too much Lupron can decrease egg count. So, in essence, with the use of Lupron you may be trading count for quality. Dr. Craig tries to hit the ground somewhere between the two in order to maximize egg quality without risking quantity.
If you are in an older age category, Lupron can drag the cycle down. In this instance, Dr. Craig recommends what is called a Lupron-flare protocol in which he prescribes Lupron for four days only at the beginning of the cycle and then has the patient quit. This allows the cycle to get some maturity effect, but not enough to drag the cycle down later on. The idea is that Lupron will stimulate a release of a large amount of FSH (follicle stimulating hormone) that will jump-start (flare up) the follicles so that you might have a better ovarian stimulation with more mature follicles and more eggs for IVF.
Does PGS (genetic screening of your embryos) weaken the embryo’s to the point that you wouldn’t recommend it to patients on their first round, or is it something you’d recommend to all patients from the get-go?
If I had asked this question to Dr. Craig a year ago, he would have said ‘do it’ on eighty-percent of patients. Now, however, he will only do it for specific cases, like recurrent miscarriage patients or if there is a specific genetic disorder in the family (examples include cystic fibrosis or muscular dystrophy).
The reason for this change in attitude is due to new data being released last summer that showed that doing PGS for the ‘routine patient’ might actually slightly decrease pregnancy rates. And here’s why:
When you perform PGS on an embryo, cells are removed, which, in turn, can weaken the embryo. In past years, doctors would have considered this a risk worth taking on routine patients. However, according to this recent study, PGS is much more complex than simply calling an embryo “normal” or “abnormal,” as sometimes embryos can be both. This means that if your PGS embryos come back 'normal,' there is still a chance they may actually be ‘abnormal.’ Likewise, if it says ‘abnormal,’ there is also a chance that it’s actually ‘normal.’
Think of a classic soccer ball: like embryos, most have a mix of black and white facets on the outside. If you biopsy from a white part, you’ll think the entire embryo is entirely normal. If you biopsy from a black part, you will think it’s entirely abnormal. But if you happen to biopsy from a seam, you might get a mix of black and white cells. These are deemed ‘mosaics,’ which are categorized as ‘abnormal,’ but may still actually be normal and, given the opportunity, could lead to potentially different biopsy results every time.
These ‘abnormal’ embryos have been shown to have the ability to “self-correct” during early development. So, what does this mean? This means that many couples have been discarding what could very well be normal embryos that could have gone on to produce normal, happy, healthy babies.
And I get it; most couples would not choose to deliberately transfer an embryo categorized as 'abnormal.' But what happens when you have an inability to produce ‘normal’ embryos according to genetic testing? That could mean the end of the fertility train. Perhaps you can’t afford to do another cycle, you’re ‘aging out’ or simply ready to give up. It is estimated that over 20,000 women in the past two decades have possibly lost the opportunity to have a child due to the inaccuracy of PGS.
So don’t throw in the towel if you happen to produce a high number of ‘abnormal’ PGS-tested embryos. Dr. Craig has had several successful pregnancies that resulted in transferring a high number of PGS-tested ‘abnormal’ embryos. So there’s hope for us all.
However, there are a few ‘abnormal’s’ Dr. Craig believes in: if the embryo comes back as abnormal with trisomy 21 (an extra copy of chromosome 21, the most common cause of Down Syndrome), that’s probably real, he says.
For my first pregnancy that resulted in miscarriage, I had a large subchorionic hematoma (accumulation of blood that is the result of when the placenta detaches from the original site of implantation and can cause vaginal bleeding). Is this more common with IVF patients? And what can be done to minimize the hematoma?
Most subchorionic bleeds resolve on their own and the women go on to have perfectly healthy pregnancies. If Dr. Craig sees a subchorionic hematoma on a patient, he likes to strategically cut back on aspirin and Lovenox, both blood thinners. However, while more common in IVF patients, only around one perfect of all pregnancies have a subchorionic bleed. So if you see blood, don't panic.
What do you recommend your patients do post-transfer to maximize their chances of embryo implantation?
Let’s talk post-transfer activity levels: strict bed rest increases your miscarriage rate and decreases your pregnancy rate as much as forty-percent because you stagnate blood-flow away from the uterus. So Dr. Craig does not recommend laying flat in bed post-transfer.
But, you don’t want to go out and run a half-marathon either because that deprives your central arteries of blood pressure and it all goes up to the muscles (again, away from your uterus).
Dr. Craig prefers to prescribe ‘princess status’ to his patients. You can go up and down stairs, you can sit on the couch, get up, make a sandwich, take a nap, use the bathroom. Movement is good but he wouldn’t recommend high impact or, particularly, any strain on the abdomen or lower back. So don’t be scared to get out there and walk your dog, but maybe avoid the gym for a bit.
I personally preferred to ‘lay’ on the couch with my back and knees propped up to promote blood-flow to my uterus while I watched happy movies that made me smile or laugh (usually Shrek was my go-to). I’d get up to use the restroom, get a glass of water or make myself lunch and I only used the stairs twice a day (once down, and once up).
What about heat and cold post-transfer?
In Chinese medicine, one of the factors facilitating successful embryo implantation is a “warm womb.” Dr. Tao recommends keeping your feet warm by wearing socks post-embryo transfer, as well as avoiding the consumption of cold or icy foods and drinks until your pregnancy is well established. This also means no swimming. The thought here is that by keeping your extremities warm and your abdomen warm, the blood-flow will remain near your uterus to assist in implantation.
On the other hand, it is important not to get overheated (no hot showers, baths or saunas), and no heat packs on your tummy. Warm ones are ok if you feel chilled in the abdomen, but you don’t want to draw the heat away from your uterus.
I liked to take warm showers, drink warm beverages (warm pomegranate juice and honey-lemon water), eat warm foods and I avoided cold ones, including salads.
Do you recommend the use of acupuncture to increase the success of the cycle?
Let me tell you, having never used acupuncture treatments prior to undergoing IVF, I wasn’t that thrilled at the prospect of adding more needles to my baby-making regimen. But I will say that I found them relaxing and helpful on the day of transfer and thereafter. But here’s the 411 on acupuncture:
Dr. Craig suggests the use of acupuncture, but only at certain times during the cycle. Acupuncture during the follicular phase and before egg-capture is bad as it decreases pregnancy rates by thirty to forty percent. Yes, you read that right. Yikes. BUT, if you do acupuncture the day of transfer (just before and just after transfer) your pregnancy rates go up as it increases blood flow to the ovaries and uterus while relaxing uterine spasms, making your uterine ‘oceans’ nice and calm rather than stormy waves for your embryos.
I then continued acupuncture treatments (once more before our blood draw date and, if I became pregnant and my HCG levels were rising), I did acupuncture a few more times throughout my first trimester.
What are some ways to thicken the uterine lining?
What doctors like to see if a nice, thick uterine lining in preparation for your embryo transfer. Dr. Craig likes to look for a uterine lining of at least 6mm; 7mm is better and 8mm or more is optimal.
He says you can do three things to thicken your uterine lining: the first is taking the right amount of estrogen, prescribed by your doctor. The second is the use of three ‘endometrial disruptions’ during the preparation cycle (I have talked about these previously here). The third is adding in G-CSF (a bone-marrow hormone injection med) every three days during the frozen transfer cycle.
If none of these methods work, Dr. Craig will resort to a hysteroscopy during the prep cycle and will do a full hysteroscopic disruption to produce a nice, thick lining.
What can my husband do to improve sperm quality?
There are prescription medications available to help improve sperm counts and motility in specific patient populations. He can also supplement with L-carnitine (amino acid). Eating a clean diet with plenty of fruits and veggies, limiting caffeine and alcohol and daily exercise can help improve sperm counts, as well as avoiding smoking/tobacco products, marijuana, and testosterone injections. He should also be avoiding exposure to heat as much as he can (i.e. saunas, hot tubs, steam rooms etc…). Also, according to Kristina Bauer, Dr. Craig’s PA-C, antioxidants have been known to help sperm function as well as Zinc, Vitamin C and Omega 3’s.
What are some ways to avoid endometrial fluid?
Unfortunately, Ben and I had a canceled transfer cycle day-of our expected transfer, which was utterly heartbreaking. All of that hard work and weeks of preparation (those fun shots and crazy hormones) for nothing… and all due to fluid in my endometrium. When you literally hear your biological clock ticking loudly in your ear, every set back can feel like a giant roadblock. So, what can be done to prevent this?
Dr. Craig likes to use Vitamin E to help decrease fluid. In fact, for every transfer following our canceled transfer, I took Vitamin E as a precaution to prevent fluid accumulation. I talk more about it here. You can take up to 800mg a day up until embryo transfer day and then stop. It clears your system in three days and it’s fine after that. But, you just don’t want to be taking it while actually pregnant, as, as mentioned above, it can cause fetal liver damage.
Dr. Craig also mentioned that lots of endometrial disruptions during the preparation cycle will help to decrease fluid. They aren’t fun, but they are worth it.
What is an ideal BMI and can that affect success rates?
Like many things in life, moderation is best when it comes to fertility. Women who fall outside the ‘ideal’ BMI (either under or overweight) are likely to have reduced pregnancy success rates with IVF.
Dr. Craig says if it’s below eighteen you don’t have enough internal steroid production (progesterone and estrogen) to maintain a good uterine lining and good blood-flow. However, you can easily substitute that with medications. But if your BMI is large, you have the opposite problem. All of that extra fat tissue produces estrogen which is hard to block and can affect uterine lining.
Doctors like to see a BMI of between 20 and 25. But that’s not to say it’s time to drastically change your lifestyle and start some intense diet. Again, it’s all about living life in moderation. Aim for eating a healthy diet, a moderate amount of exercise that your doctor feels comfortable with (for us, it was sometimes a modified bed rest), and that’s ok. You do what you can.
What are some ways to stay positive during fertility treatments?
Phew, are you still with me? If you are, I applaud you. So, I saved one of the most important questions for last: how to stay positive during fertility treatments.
The most important step for me was to seek support from wherever I could Ben (my hubs), my family, my friends, and fellow IVF warriors like you. A great source of help can also come from joining infertility support groups, like my Facebook Group, filled with women going through the exact same thing. It helps to lean on whomever you can.
I also always loved reading IVF success stories to give me hope and remind myself that it works (just try searching the hashtags #ivfsuccess #ttccommunity #ttcsisters and #rainbowbaby for children after loss).
You also need to do what makes you happy. Whether that’s light/moderate exercise, meditation, deep breathing exercises, guided imagery, acupuncture or counseling.
And at the end of the day, remember that IVF, although a very scary and daunting journey, is a scientific miracle that gives us a fighting chance at that family we've been dreaming of that we wouldn't have otherwise. So, for me, it helped to remind myself that undergoing IVF treatments was an exciting endeavor because it put me that much closer to our miracle.
And please just know that I am here for you guys. You are always welcome to shoot me an email, a DM or comment on my blog. I am here for you. And you can do this.
A Discount to The Fertility Treatment Center
If you are local here in Arizona and considering pursuing fertility treatments, mention me and this article and receive a discount on your new patient consult ($99 instead of $300).