Online Health Chat with Dr. Jeffrey M. Goldberg
January 26, 2011
Cleveland_Clinic_Host: Given the intricate nature of the human reproductive system, it is not surprising that approximately one in every six couples will be unable to conceive a child after trying for one year. Cleveland Clinic fertility experts provide the full range of state-of-the-art services for the diagnosis and treatment of infertility, including in vitro fertilization. Cleveland Clinic infertility specialist Dr. Jeffrey M. Goldberg, Head, Section of Reproductive Endocrinology and Infertility, will provide answers on in vitro fertilization, sterilization reversal, infertility surgery, and general infertility questions.
Jeffrey Goldberg, MD, received his medical degree from The University of Medicine and Dentistry of New Jersey, New Jersey Medical School in Newark, N.J. in 1983. He completed a residency in obstetrics and gynecology at Emory University in Atlanta, Ga., and a fellowship in reproductive endocrinology and infertility at The Ohio State University in Columbus, Ohio, where he remained on faculty until joining Cleveland Clinic in 1991. Currently, he is Head of the Section of Reproductive Endocrinology and Infertility at Cleveland Clinic and is a professor at Cleveland Clinic Lerner College of Medicine. He is also the director of the Reproductive Endocrinology and Infertility fellowship program.
Dr. Goldberg is board-certified in obstetrics and gynecology and subspecialty board-certified in reproductive endocrinology by the American Board of Obstetrics and Gynecology. His clinical interests are advanced endoscopic surgery, microsurgical tubal anastomosis, in vitro fertilization, and reproductive endocrinology. His research interests include endometriosis, reproductive surgery, and in vitro fertilization.
Dr. Goldberg has published more than 200 scientific articles, abstracts, and book chapters, and co-authored two books on gynecologic endoscopic surgery. He is a Fellow of the American College of Obstetrics and Gynecology and is a member of the American Society for Reproductive Medicine, The American Societies for Reproductive Endocrinologists and Reproductive Surgeons and The American Association of Gynecologic Laparoscopists. He serves on The American Society for Reproductive Medicine Practice Committee, the board of directors of the Society of Reproductive Surgeons, and is an ad hoc reviewer for several journals, including Fertility and Sterility, The American Journal of Obstetrics and Gynecology, Obstetrics and Gynecology, and Human Reproduction.
He was co-recipient of the Computerworld Smithsonian Research Innovation Award for robotic surgery, received the American College of Obstetricians and Gynecologists National Faculty Award for excellence in resident education, and has been selected as a Top Doc in Cleveland and Best Doctors in America since 2001.
Cleveland_Clinic_Host: To make an appointment with Jeffrey Goldberg, MD, or with any of the other specialists in our Fertility Center at Cleveland Clinic, please call 216.444.6601. You can also visit us online at www.clevelandclinic.org/obgyn.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Jeffrey Goldberg, M.D. We are thrilled to have him here today for this chat. Let’s begin with the questions.
hardy09: I have irregular periods. What does that signify for me in terms of getting pregnant?
Dr__Jeffrey_Goldberg: Women with irregular periods may still conceive on their own, but if they have infrequent, unpredictable cycles, it will be difficult. The evaluation is to see if there are any underlying causes that can be treated specifically, such as abnormal thyroid function or an elevated prolactin level. Also, women with polycystic ovary syndrome as a cause of their irregular cycles are at higher risk for diabetes and need to be checked for that. If the evaluation is normal, we will begin treatment with Clomid or Femara to regulate the cycles.
JL_ong: My husband and I are both in our late 30s and we have been trying to have a baby for almost a year now. Should we start to think about consulting a fertility doctor?
Dr__Jeffrey_Goldberg: Yes. Even though the definition of infertility is one year of unprotected intercourse without conception, couples in whom the woman is over age 35 are advised to have an evaluation after six months of trying to conceive. Women with irregular periods and or pelvic pain, men with sexual performance problems, and couples who are stressed from their inability to conceive should also seek evaluation earlier than one year.
A fertility doctor is an ob/gyn who has completed several years of additional training in a reproductive endocrinology and infertility fellowship program. Cleveland Clinic is fortunate to also have one the few male infertility specialists in the country, so we are able to provide comprehensive care for all causes of infertility. The physicians work as a team along with dedicated infertility nurses and embryologists.
tenshy: My husband and I have tried for almost two years (32 and 31 years old respectively) and have gone through several tests. So far, all have come back normal. How long should we continue trying for a natural pregnancy? What are our chances statistically at this point?
Dr__Jeffrey_Goldberg: It would be reasonable to begin treatment at this time with Clomid or Femara combined with intrauterine insemination, provided your uterine cavity is normal, your tubes are patent, and your husband has a normal semen analysis. Without treatment, you have about a 2 percent chance each cycle, so it is still possible to conceive but it certainly takes longer. Fortunately, at 32, you are still young from a reproductive standpoint.
santana: I have been using birth control pills for more than 10 years. I would like to get pregnant, and I am concerned that being on the pill this long may interfere with my chances of getting pregnant.
Dr__Jeffrey_Goldberg: Birth control pills do not lead to infertility. Fertility is fully restored once the pills are discontinued. For women with endometriosis, a progressive disease that may compromise fertility, being on the pill may actually help preserve fertility potential. However, there is no medical treatment for endometriosis in women who are actively trying to conceive.
JW: My question is: I am 30 and my husband is 36 (and has four children from a prior marriage) with no chromosome issues in either of our families. Due to antibodies present in his sperm because of vasectomy reversal, we had turned to infertility treatments. We first had two failed IUI’s and then moved on to IVF. The fresh transfer, two embryos, did not result in pregnancy and we froze three embryos. We had one single successful pregnancy via FET with no more frozen embryos. Our pregnancy ended at 12 weeks due to severe Trisomy-21. We had all the genetic testing done at Magee’s Women Center (CVS). So my question is: once we are ready to jump back on the bandwagon, what are our chances of this happening again, the chromosome issues? Our chances were so low to begin with. It’s really heart wrenching, and we’re wondering if we should do chromosome testing on the embryos prior to implantation.
Dr__Jeffrey_Goldberg: I'm sorry to hear about your misfortune. Trisomy 21 (Down Syndrome) is usually due to the chromosomes not separating equally right after a normal egg is fertilized by a normal sperm. These are sporadic errors and you are at no higher risk for another bad outcome. Based on your age and the fact that you did conceive, your prognosis is excellent that you will succeed again and that the pregnancy will be normal.
Vrandi: How can you determine the cause of infertility?
Dr__Jeffrey_Goldberg: A complete medical history will identify many potential causes. Regular, predictable monthly menstrual cycles are good evidence of ovulation. Standard, basic tests include a semen analysis to check the number, motility, and shape of the sperm, and a hysterosalpingogram (HSG - X-ray dye test) to check the uterus and fallopian tubes. The HSG test takes about three minutes and can even increase the pregnancy rate for several months afterward. Additional tests - such as hormone levels, hysteroscopy, or laparoscopy - may be recommended. The latter two are outpatient procedures that utilize a slender fiberoptic scope to evaluate and treat conditions in the uterine cavity and pelvis, respectively. These conditions include polyps, fibroids, scar tissue, cysts in the ovaries, and endometriosis. Treatment options for the specific problems identified are discussed with the couple and may include fertility drugs, artificial insemination, minimally invasive surgery, or in vitro fertilization (IVF). All variations of IVF are available, such as donor sperm, donor eggs, and gestational carriers.
parat: My husband has an appointment to have a sperm analysis done. Can you please tell me what they test for and what the results could mean?
Dr__Jeffrey_Goldberg: The semen analysis looks at the volume to see if there is a possible duct obstruction, as well as the sperm count and percentage of the sperm that are moving and normally formed. The normal values are based on population averages and not on fertility, so many pregnancies have been established by men with an abnormal semen analysis. However, if a repeat analysis done a month after the first is also significantly abnormal, the partner should be referred to a male infertility specialist. If there are no treatable causes for the abnormality, options may include artificial insemination, in vitro fertilization with ICSI (intracytoplasmic sperm injection - to inject a single sperm into each mature egg), or artificial insemination with donor sperm.
julie: I have had my tubes tied. What are my options for getting pregnant again?
Dr__Jeffrey_Goldberg: There are two options, tubal ligation reversal and IVF. The former is an outpatient surgical procedure performed under general anesthesia. A 2-inch side-to-side incision is made just above the pubic bone. The ends of the blocked tubes are opened and reconnected under an operating microscope. Assuming there is an adequate length of normal tube to repair, and there are no other infertility factors, the pregnancy rate is essentially the same as the general fertile population.
IVF involves about a month of daily injections of fertility drugs to stimulate multiple eggs to mature (instead of the one egg that is ovulated each month normally). The woman is monitored with ultrasounds of the ovaries and blood estrogen levels every few days while on the medications. Once the eggs are mature, they are collected with a vaginal ultrasound-guided needle. It takes about 15 minutes and the patient is under anesthesia so there is no discomfort. The eggs are then fertilized with the partner’s sperm in the lab and the embryos (fertilized eggs) are placed in the uterus with a small catheter through the cervix three to five days later. The number of embryos transferred is based on the woman’s age, the number and quality of available embryos, and prior attempts. Any additional embryos that are developing normally may be frozen for later use.
The advantages of tubal reversal are that it is a one time minimally invasive procedure that restores the normal fertility rates. The patients can try to conceive each month without any further treatment and can get pregnant more than once. The disadvantages are the risks of surgery: bleeding, infection, damage to organs and reactions to anesthesia; all of which are extremely low. The advantages of IVF are that it is nonsurgical and has a high per cycle pregnancy rate. The disadvantages are that it is more inconvenient, more expensive (especially if it requires more than 1 treatment cycle) and has the risks of multiple pregnancy and ovarian hyperstimulation syndrome.
sk: Hi Dr. Goldberg, I am going on my fourth year of infertility treatment. Our next step is IVF, but that has been on hold since I have had an HPV flare-up with a LEEP six months ago. I have moderate dysplasia currently and will have a follow up Pap in March to see if I was able to clear it through diet. I also have a 2 mm cyst on my ovary (I was told from endometriosis but I have no known symptoms) and removing it surgically was recommended. My question is: do you think my pregnancy chances are better if I remove the cyst or do the IVF cycle? I have been against the surgery, but if you feel it would make a big difference I would consider it. Thank you so much.
Dr__Jeffrey_Goldberg: If IVF really is your best option, then there would be no benefit to having surgery to remove the small cyst (I assume you meant that the cyst was 2 cm, not mm). However, if this is a persistent cyst felt to be an endometrioma (endometriosis cyst), removing it and treating all endometriosis implants and scar tissue may improve your fertility and make IVF unnecessary. Another reason to consider an outpatient laparoscopic procedure to treat presumed endometriosis would be for pain relief which fortunately, you don’t suffer from. The HPV and dysplasia don’t factor into the fertility picture.
ap5438: When I first met with my doctor, we decided to try four cycles with Clomid, hCG, and timed intercourse, and if that didn't work we would do further testing. She had mentioned a hysterosalpingogram (HSG). At the beginning of January (after my second Clomid cycle), I had a positive pregnancy test but miscarried a week later. Would an HSG still be something to consider if we're not successful with the Clomid in the next couple of cycles?
Dr__Jeffrey_Goldberg: I suspect you conceived in spite of being on Clomid rather than because of it. Clomid alone in women with regular cycles is of marginal benefit. Adding hCG for timing intercourse only adds expense and inconvenience. I would recommend trying on your own for a few months if your cycles are regular, or resuming Clomid if they are not, then schedule the HSG.
olyloft: Is there a more effective drug than Clomid to use with artificial insemination?
Dr__Jeffrey_Goldberg: There are three types of fertility drugs that are used in combination with artificial intrauterine insemination (IUI) for unexplained infertility. Clomid (clomiphene) is usually the first-line treatment. It is given daily by mouth for five days. Femara (letrozole) is used exactly as Clomid, but it works through a different mechanism. Both increase the monthly pregnancy rate from about 2 percent with unexplained infertility to about 10 percent with IUI and both have about a 5 percent to 10 percent risk for twins compared to 1% in the general population.
The gonadotropin drugs, FSH (follicle stimulating hormone), are given as a daily injection - similar to an insulin shot - for about a week. The patients are monitored with vaginal ultrasounds and blood estrogen levels to adjust the dose according to the response, and to time the IUI when the eggs are mature. The pregnancy rate per cycle is up to 20 percent, similar to the fertile population, but with a 25 percent chance for multiple pregnancy.
The majority of the multiples are twins, but triplets or more are possible, as is the ovarian hyperstimulation syndrome. The injectable drugs are also expensive and the required monitoring adds to the cost.
olyloft: I have used Clomid several times with intercourse and three rounds of insemination. I never had more than one mature follicle. And I'm having no success with pregnancy. What do you recommend?
Dr__Jeffrey_Goldberg: We'll usually try Clomid with insemination for unexplained infertility for up to six cycles for women under 35 and up to three cycles for women 35 and older. The next step is a discussion of continuing the inseminations with an injectable fertility drug for up to three more cycles versus going directly to in vitro.
ap5438: I've read that Clomid can negatively affect cervical mucus. Does this reverse once a patient has stopped taking Clomid? Is this also a problem with Femara?
Dr__Jeffrey_Goldberg: While Clomid may negatively affect cervical mucus, it may not be of any clinical concern. We stopped doing post-coital (after sex) tests to look at the sperm in the cervical mucus more than 15 years ago, as it was totally useless for predicting pregnancy or guiding fertility treatment. In any case, Femara does not affect the cervical mucus. The bigger concern with Clomid is that it may make the uterine lining less receptive. Femara avoids that as well, but studies comparing the two medications found similar pregnancy rates.
lofto: I have gone through two rounds of artificial insemination, then had seven fibroids removed from my uterus. I then had another artificial insemination - all without luck. Do you feel I would be a candidate for in vitro? What is the success rate of in vitro?
Dr__Jeffrey_Goldberg: There are several factors that would influence your chances with in vitro. The most important is your age. Additionally, if there are any residual fibroids that are distorting the cavity of the uterus, the implantation rates can be impaired. Also, artificial insemination without the addition of fertility drugs is usually no better than timed intercourse, so you may have other options besides in vitro.
olyloft: I have gone through all the tests to see why I am not able to get pregnant. With no explanation. We have tried artificial insemination three times without any luck. My husband has passed all his tests also. What do you recommend?
Dr__Jeffrey_Goldberg: Assuming you have unexplained infertility, artificial intrauterine insemination (IUI) alone is no better than timed intercourse. Adding a fertility drug like Clomid to IUI for three to six cycles, based on your age, would be the recommendation. If unsuccessful, seek a consultation with a reproductive endocrinologist.
olyloft: What is the success rate for in vitro? And what is the cost associated with in vitro?
Dr__Jeffrey_Goldberg: The success rates depend primarily on the age of the women. They are also influenced by the number of prior attempts and the reason for needing in vitro in the first place. For young women with normal uteri, the pregnancy rates in our lab are 60 percent to 70 percent.
General Questions about Fertility
rhg12345678: A fertility book I'm reading talks about "embryo glue" to help implantation. They suggest using "particular types of culture media” that actually coats the embryo with these sticky proteins so it "glues" itself to the endometrium until it implants. Do you use this? Would you suggest this if the first IVF attempt fails?
Dr__Jeffrey_Goldberg: There are some studies that used "embryo glue," usually hyaluronic acid, to increase embryo implantation in the uterus. However, it really doesn't work well, and most labs - including ours - don't use it. There are no "tricks" to improve implantation, which is the rate-limiting step in the IVF process. Part of the limitation is due to the fact that a high percentage of embryos are genetically abnormal naturally, and "embryo glue" won't overcome that.
ccsam: Hi Doctor, I came to know about a website http://www.conceiveplus.com/. I just wanted to know if this medicine is genuine and safe? I’m 28 years old, female, married about three years, have no children yet, have PCOD, got treated. My doctor advised me to have ovulation pills, T-OVOFAR 50, for five days, simultaneously detect on LH card test to see ovulation signs to proceed with conception.
Dr__Jeffrey_Goldberg: I just looked up the website. They are selling a vaginal lubricant. I can't comment on whether it will improve or diminish your chances, as there are no data on it. If you need a lubricant, there are several options that won't compromise your fertility, such as mineral oil or Pre-seed. T-OVOFAR is clomiphene citrate, better known as Clomid. It is a very commonly prescribed fertility drug. It is used for women who don't have regular menstrual cycles. It is also used in combination with intrauterine insemination for couples with unexplained infertility.
tenshy: We were advised by my husband's urologist that canola oil was more suitable for lubrication than Pre-seed. What is your advice on this?
Dr__Jeffrey_Goldberg: Any lubricant that doesn't interfere with sperm function is fine. These include canola or mineral oil or Pre-seed. Other lubricants, such as K-Y or Surgilube should be avoided.
rhg12345678: How critical is diet to help embryo quality? Example: many fruits and vegetables-no caffeine etc.
Dr__Jeffrey_Goldberg: There are no good data to support the concept of a "fertility diet." It is recommended that alcohol and caffeine be limited and both partners need to stop smoking. All women attempting to conceive should be taking a folic acid (foliate) supplement to reduce the risk of certain birth defects. Women at the extremes of weight have reduced fertility, so attempting to get to an ideal weight may be helpful.
expert: Can a female who went through menopause get pregnant with infertility treatments? Would they have problems carrying a baby?
Dr__Jeffrey_Goldberg: Technically, a menopausal woman with a normal uterus can get pregnant using donor eggs. The uterus would be prepared to be receptive with estrogen and progesterone, which would be continued till around 10 to 12 weeks gestation. Older women are at increased risk for high blood pressure and diabetes during pregnancy.
truelife: Does acupuncture really work for infertility?
Dr__Jeffrey_Goldberg: We offer acupuncture as a technique to help patients deal with the stress of going through infertility treatment but not as a fertility-promoting treatment itself. The poor quality studies yielded mixed results. Some showed higher pregnancy rates, some no difference, and one even showed lower pregnancy rates.
Cleveland_Clinic_Host: I'm sorry to say that our time with Jeffrey Goldberg, M.D., is now over. Thank you again Dr. Goldberg for taking the time to answer our questions about infertility.
Dr__Jeffrey_Goldberg: Thank you very much.
- Cleveland_Clinic_Host: To make an appointment with Jeffrey Goldberg, MD, or with any of the other specialists in our Fertility Center at Cleveland Clinic, please call 216.444.6601. You can also visit us online at www.clevelandclinic.org/obgyn.
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