Online Health Chat with Julie Tan, MD
June 9, 2009 | Reviewed on January 20, 2014 by Julie Tan, MD
Cleveland_Clinic_Host: Infertility is a private problem, and knowing when to seek help can be difficult. Infertility is defined as the inability to conceive after a year of trying. But Cleveland Clinic fertility experts say that the "right" time to consult a specialist is when the couple sees the situation as a problem. Dr. Julie Tan will be available to answer your questions at 12 noon (EST) today.
Julie Tan, MD, is a member of Ohio's #1 Ob/GYN Program, the Cleveland Clinic Ob/Gyn & Women's Health Institute. She specializes in reproductive endocrinology and infertility at the Cleveland Clinic Fertility Center at Fairview Hospital.
Take advantage of this opportunity to chat live with Julie Tan, MD and get answers to common questions related to infertility and treatment options available. Dr. Tan will offer advice on preventing infertility, as well as medical and surgical techniques for improving fertility. This is your time to ask! During the next hour, Dr. Tan will answer your questions. First she will answer some of the most common questions she receives. The big concerns are how can a couple become pregnant? We hope that many of the online questions today will help you explore these topics further.
To make an appointment with Dr. Tan, or any of the other specialists at Cleveland Clinic Fertility Center in the OB/GYN & Women’s Health Institute, please call 216.444.4HER or visit the web at clevelandclinic.org/infertility
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Julie Tan. We are thrilled to have him her here today for this chat. Let’s begin with some of the general questions we have received.
Suzanne: My husband and I have been trying to get pregnant for well over a year. I am concerned that we may have a problem. What is our next step?
Speaker_-_Dr__Julie_Tan: Difficulty conceiving a child is not uncommon. There are millions of couples each year that are unable to become pregnant without medical assistance. Infertility is generally defined as not conceiving after one year of unprotected intercourse. At this point, couples may benefit from an infertility evaluation. Standard testing done by our Cleveland Clinic fertility specialists includes some blood work for hormone level, a hysterosalpingogram (HSG) to evaluate the uterine cavity and document that the fallopian tubes are open, and ,for your husband, a semen analysis to assess the number and quality of the sperm. The HSG is performed in the X-ray department by injecting X-ray dye through the cervix while observing on a TV monitor. Additional tests may be recommended by fertility specialists based on the individual patients’ history, physical examination and the results of previous testing. These may include additional blood work, ultrasound of the uterus and ovaries or laparoscopy.
Alison: When should a couple be evaluated for infertility?
Speaker_-_Dr__Julie_Tan: When a couple has failed to conceive after one year of trying, they should be evaluated.
Speaker_-_Dr__Julie_Tan: Because female age plays an important role in women fertility, women who are older than 35 should seek care after 6 months of failed to conceive.
Speaker_-_Dr__Julie_Tan: Women who have irregular period, PCOS, endometriosis or pelvic adhesion should seek care immediately. Women who suspected tubal or pelvic factor (for example-women with history of sexually transmitted diseases, pelvic inflammatory disease or ruptured appendicitis) should also seek care immediately. Couple who suspected male factor infertility (for example-history of surgery at genital area or have received chemotherapy in the past) should also seek care immediately.
Keira: Is infertility a woman’s problem?
Speaker_-_Dr__Julie_Tan: When talking about infertility, many people think that it is only female problems. In fact, only about one-third of cases are infertility due to the woman (female factors). In another one third of cases, infertility is due to the man (male factors). The remaining cases are caused by a mixture of male and female factors or by unknown factors. Thus, both partners should be evaluated at the same time.
yuanpiano: Hello doctor, I have asthma lately with itchy throat. Since I have asthma, can I have baby?
Speaker_-_Dr__Julie_Tan: Yes, there are many individuals that have asthma and are able to get pregnant. Your asthma should be well controlled prior to pregnancy. Discuss this with your physician.
callieandbob: If we have been trying for 8 months to become pregnant, is it wise to see a fertility specialist at this time? We have been using OTC ovulation tests and taking temperatures for 5 months. Does insurance cover initial consultations/education?
Speaker_-_Dr__Julie_Tan: If you are less than 35 years of age, it is not necessary to consult a specialist for one year. You can discuss this with your OB/GYN.
Speaker_-_Dr__Julie_Tan: If you are older than 35 yrs., this would be the time to discuss with a specialist.
Speaker_-_Dr__Julie_Tan: If there are any medical issues that might cause infertility or possible male infertility issues, definitely see a specialist earlier than later.
Speaker_-_Dr__Julie_Tan: In terms of insurance coverage, you would need to check with your insurance company as coverage varies.
cedarhills: I started menstruating when I was 9, will that have any effect on eggs, ovulation and pregnancy?
Speaker_-_Dr__Julie_Tan: The time that menstruation begins does not affect ovulation or pregnancy. Whether you start your period early or later does not correlate to infertility.
Speaker_-_Dr__Julie_Tan: On another note, the timing of menopause is not directly affected by the beginning of menses.
Texan4ever: What causes infertility?
Speaker_-_Dr__Julie_Tan: The most common causes of female infertility include fallopian tube damage or blockage, endometriosis, ovulation disorders, elevated prolactin, polycystic ovary syndrome (PCOS), early menopause, benign uterine fibroids and pelvic adhesions. The most common causes of male infertility include abnormal sperm production or function, impaired delivery of sperm and overexposure to certain environmental elements. General health and lifestyle issues can be the causes of infertility in both men and women. A new ANDROLOGY lab will open at the Richard E Jacob Avon Family Health Center to assess sperm for our male infertility patients.
spaldina: What is luteal phase defect? Does vitamin B-6 help to resolve it?
Speaker_-_Dr__Julie_Tan: Luteal phase is the phase from ovulation to the time menstruation begins. During that phase, your body is making a hormone called progesterone. This hormone is secreted in order for the uterus to prepare for pregnancy.
Speaker_-_Dr__Julie_Tan: Women with luteal phase defect have problems with making the hormone progesterone. Yet it is now believed that the real problem is stemming from ovulation issues and not hormonal issues during the luteal phase alone. Currently we would look at your ovulation history and if you have any problem with ovulation, then fertility drugs would be the treatment of choice.
Speaker_-_Dr__Julie_Tan: I have not seen any studies of Vitamin B6 treating this.
Hudson: Is overstimulation of the ovaries still a concern with fertility drugs? I experienced it over ten years ago and therefore have not tried IVF since.
Speaker_-_Dr__Julie_Tan: Yes overstimulation of the ovaries is still a concern. To prevent the overstimulation (also called ovarian hyperstimulation), the patient is monitored very closely while taking certain fertility drugs to prevent overstimulation.
Speaker_-_Dr__Julie_Tan: Currently the way the ovaries are stimulated with medications is improving than it was ten years ago. A younger patient can experience overstimulation due to amount of eggs. Now that you are older, there would be less chance of overstimulation. Again - discuss this with an infertility specialist.
rogerb: Do antibiotics lower sperm counts or motility?
Speaker_-_Dr__Julie_Tan: Antibiotics most likely will not permanently lower sperm count or motility. Illnesses that antibiotics may be prescribed for may alter the sperm count or motility for a short period of time. The sperm count will usually return to normal after the illness is gone. This question is often involves a male infertility specialist.
letterperfect: Can several years of birth control use (8-10 years) lead to infertility?
Speaker_-_Dr__Julie_Tan: No. Birth control pills (BCP’s) do not lead to infertility. Ovulation issues are not apparent when an individual is on birth control pills. Some women taking BCP's because they are having problems with their menstrual cycles may actually be having ovulation problems to begin with. Yet, this is not apparent until fertility comes into question.
Speaker_-_Dr__Julie_Tan: Bottom line, BCP's do not lead to infertility. Infertility is present due to other reasons.
newtonm: Is Depo Provera a bad birth control choice if one wants to become pregnant later in life? I heard it was very hard to get pregnant after using it.
Speaker_-_Dr__Julie_Tan: Once you stop taking Depo Provera it might take up to 6 months for ovulation to resume. That may be the reason why some feel that taking the drug makes getting pregnant harder. It is actually that you may not be ovulating. This is different for every person. In order to get pregnant, you have to ovulate. Once the medication is gone from your system you should not have a problem with conceiving.
Red: How does the Doctor determine what type of treatment to use?
Speaker_-_Dr__Julie_Tan: Specific treatment(s) for infertility will be determined by your physician based on your age, overall health, and medical history, extent of the disorder, cause of the disorder, your tolerance for specific medications, procedures, or therapies, expectations for the course of the disorder, and most importantly-your opinion or preference.
Speaker_-_Dr__Julie_Tan: Once a diagnosis is made, the specialist can work with you to determine the course of treatment. According to the American Society of Reproductive Medicine (ASRM), most infertility cases (85 to 90 percent) are treated with conventional therapies, such as drug treatment or surgical repair of reproductive abnormalities. Depending on the cause of infertility, there are many options to offer an infertile couple.
steffi: What are the treatment options for infertility?
Speaker_-_Dr__Julie_Tan: Infertility can be treated with medications, surgery, artificial insemination, or assisted reproductive technology. Many times these treatments are combined. In most cases infertility is treated with medications or surgery.
Speaker_-_Dr__Julie_Tan: Various fertility medicines are often used to treat women with ovulation problems. Doctors also use surgery (such as laparoscopy) to treat some causes of infertility. Many problems with a woman's ovaries, fallopian tubes, or uterus can sometimes be corrected with surgery.
Speaker_-_Dr__Julie_Tan: Intrauterine insemination (IUI) is another type of treatment for infertility. IUI is also called known by most people as artificial insemination. In this procedure, a very small catheter is inserted through the cervix (the opening of the uterus) and specially prepared sperm is injected directly into the woman’s uterus. It is an out patient procedure (just like having a Pap test). Sometimes the woman is also treated with medicines that stimulate eggs production before IUI. IUI is often used to treat mild to moderate male factor infertility, women who have problems with their cervical mucus or couples with unexplained infertility.
Speaker_-_Dr__Julie_Tan: Assisted reproductive technology, such as in vitro fertilization, is indicated in couple with severe male factor, tubal/pelvic factor infertility that could not be corrected with surgery or in couple that failed to conceive with other option that less invasive.
Cz1224: My Doctor has recommended laparoscopy. What can I expect?
Speaker_-_Dr__Julie_Tan: Cleveland Clinic infertility physicians are internationally recognized for their expertise in laparoscopic treatment and performed the world's first totally robotic surgery. Laparoscopy is an outpatient procedure which involves placing a thin camera (scope) through the navel to diagnose and treat conditions such as endometriosis, pelvic adhesions (scar tissue), fibroid tumors and tubal disease. Laparoscopy often allows the surgeon to make their diagnosis and to determine if the tubes are open, if scarring is present, or if there are uterine abnormalities. Many patients have had a previous laparoscopy(s). Dependent on the disease, it may be repeated by your Cleveland Clinic physician. The reproductive surgeon is highly trained in infertility treatment and advanced laparoscopic surgery.
halfgiggle: I have been diagnosed with scar tissue in one of my fallopian tubes. Should I continue trying to get pregnant or have surgery to remove the scar tissue?
Speaker_-_Dr__Julie_Tan: Assuming that the other fallopian tube is normal, you should be able to get pregnant. However, if you have been trying for more than a year, you should discuss with your doctor to see if there is a possibility to remove the scar tissue and also to determine if there is any other scarring in the pelvic area. In vitro fertilization would be your best option if it turns out that both of your fallopian tubes were scarred, or if you failed to conceive with other options.
ilyanakz: Are there fertility related medicines available that I can take?
Speaker_-_Dr__Julie_Tan: Yes, there are oral medications to restore regular menstrual cycles such as clomiphene citrate (clomid or Serophene) or letrozole (Femara), which work by causing the pituitary gland to secrete more FSH. The higher level of FSH stimulates the development of ovarian follicles that contain eggs and helping the ovaries release a monthly egg. This drug is considered safe, is fairly inexpensive, and carries less risk of multiple births than other drugs. Women who have polycystic ovary syndrome or menstruate irregularly apparently benefit most from this drug. Sixty percent of women on clomiphene citrate successfully ovulate, and about 30 percent of women become pregnant in the first three months of being on the drug. Side effects may include nausea, insomnia, breast tenderness and headaches. There are also injectable fertility drugs to stimulate several eggs to ovulate, which include Repronex, Gonal F, Follistim, Bravelle and Menopure, which is very effective in inducing ovulation when oral agents do not work. It can also enhance fertility by causing multiple eggs to ovulate during the cycle. (Normally, only one egg is released each month.) This therapy may also be offered for unexplained infertility or when other factors have been corrected but pregnancy has not occurred. It is given as a daily injection, like an insulin shot, for approximately 1-2 weeks. During this time, the patient is monitored with blood tests and ultrasound to optimize timing and reduce the risk of multiple pregnancies and to prevent over stimulating the ovaries.
happyp: After fertility drugs, what is done after multiple eggs are detected?
Speaker_-_Dr__Julie_Tan: If you are referring to IVF, when multiple eggs are retrieved and fertilized. A, a certain number of the embryos would then be transferred back to the uterus for hopeful implantation. The remaining embryos are then frozen.
In Vitro Fertilization (IVF)
josef: Tell me about In Vitro Fertilization?
Speaker_-_Dr__Julie_Tan: IVF is the most common assisted reproductive technology method and is the treatment of choice for couples if both fallopian tubes are blocked, or for severe male factor infertility as well as for all other causes, including unexplained infertility, when conventional treatment has not been successful. During the IVF process, the ovaries are stimulated with injectable fertility medications to mature multiple eggs. Once monitoring with ultrasound and blood tests indicate that the eggs are ready, they are collected surgically with an ultrasound-guided needle under deep sedation. The egg collection procedure takes about 20 minutes and is painless. Fertilization is accomplished by exposing the eggs to sperm in a culture dish, or by directly injecting a single sperm into each mature egg (intracytoplasmic sperm injection - ICSI). After fertilization, embryo development is monitored over the next 3-5 days at which time usually 2 to 3 embryos are placed into the uterus with a small catheter through the cervix. Excess embryos may be frozen for future use.
straub: I worry so much about the cost of In Vitro Fertilization, what is the success rate?
Speaker_-_Dr__Julie_Tan: In the early years of IVF, success rates were very low. Over the years the success rates for IVF have increased greatly. In-Vitro Fertilization is safe, time-proven assisted reproductive treatment with a very high success rate. The woman’s age is the strongest predictor of success.
bradfordboy: How long should you wait to implant frozen embryo's? Is there such a thing as waiting too long? I know sperm can be frozen for a very long time, but what about fertilized eggs?
Speaker_-_Dr__Julie_Tan: This depends on the length of time that the embryos have been frozen. Our current technology for freezing embryos is more advanced compared to 5 or 10 years ago. It is best to discuss with your fertility specialist to determine the viability.
caretoomuch: Does the size of the cervix opening determine the positive outcome in receiving the sperm?
Speaker_-_Dr__Julie_Tan: The size of the cervix has no impact on the ability to conceive. However, some cervical procedures such as cone biopsies, may cause scarring and problem with receiving the sperm.
catlady: Can infertility treatments or IVF help someone who is prone to miscarriages?
Speaker_-_Dr__Julie_Tan: Miscarriages occur due to many reasons. Talk to your physician to see if they can determine the cause and if IVF would help.
kaisia: What women can do to prevent infertility?
Speaker_-_Dr__Julie_Tan: There are many things you can do to before seeing a doctor for infertility. Healthy diets, regular exercise, maintain normal weight and healthy lifestyle would help improve your overall help and might help with your fertility. You should stop smoking cigarette, stop drinking alcohol, and cut down caffeine intake before trying to conceive. If you have any medical conditions, you should talk to your physician and make sure that they are under controlled before you are trying to conceive. Women should start prenatal vitamin with folic acid at least 3 months before trying to conceive. Lastly, since stress plays an important role in female reproduction, reduce stress level might improve your fertility.
Polycystic Ovarian Syndrome (PCOS)
abc123: Can Polycystic Ovarian Syndrome (PCOS) be overcome with fertility drugs? Success rates?
Speaker_-_Dr__Julie_Tan: Women with Polycystic Ovary Syndrome (PCOS) have difficulty with ovulation. Although the fertility drugs do not treat the syndrome, it can overcome the problem of ovulation. The chance of conception should be very good if the problem with ovulation is the only problem that you have.
Speaker_-_Dr__Julie_Tan: Up to one third of couple with infertility problems both have issues with fertility. Talk to your physician about fertility testing for both of you.
Dysmenorrhea (Painful Cramps)
longtallsally: Does extremely painful cramping during menstruation signal the possibility of infertility?
Speaker_-_Dr__Julie_Tan: Dysmenorrhea or painful cramps during menstruation can be caused from a variety of reasons. Some conditions that can cause painful cramping, for example, endometriosis, can be a cause of infertility. Yet many women with endometriosis have no problem trying to conceive. Speak with your physician to determine why you are having painful cramps.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Julie Tan is now over. Thank you again for taking the time to answer our questions about infertility.
Speaker_-_Dr__Julie_Tan: Thanks, it has been great chatting.
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