Online Health Chat with Dr. Jeffrey M. Goldberg
July 20, 2011
Cleveland_Clinic_Host: Given the intricate nature of the human reproductive system, it’s 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. In this chat, Cleveland Clinic infertility specialist Dr. Jeffrey M Goldberg provides 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 holds the rank of 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 the effect of bariatric surgery on fertility.
Dr. Goldberg has published more than 200 scientific articles, abstracts, and book chapters and has 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 is the chair of the American Society of Reproductive Surgeons Practice Committee and serves as 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: Welcome to our Online Health Chat with Dr. Jeffrey M. Goldberg. We are thrilled to have him here today for this chat. Let’s begin with some of your questions.
Improving success rates
danielle: I went through IVF 20 years ago and did not conceive. Have the fertility treatment options (medications, IUI, IVF) improved since the late 1980s?
Dr_Jeffrey_Goldberg: In vitro fertilization (IVF) success rates have dramatically improved in the past 20 years, from under 10 percent to over 35 percent per cycle on average. Pregnancy rates with frozen embryos have also gone way up. In addition, ancillary procedures, such as intra cytoplasmic sperm injection (ICSI) for severe male factor infertility, have only become available within the past 10 years. Another improvement is that most of the medications can now be given as subcutaneous injections (under the skin with a tiny needle) versus intramuscular injections which required someone to give the shot in the "butt" muscle.
AliseC: Artificial Insemination success rates seem very low. How can you increase success rates?
Dr_Jeffrey_Goldberg: First, we have to put things in perspective. The monthly pregnancy rate in the fertile population is only about 20 percent. The monthly pregnancy rate with unexplained infertility is 2 percent to 3 percent. Treatment with artificial intrauterine insemination (IUI) alone is of little benefit. Combining IUI with an oral fertility drug, such as Clomid® (clomiphene) or Femara® (letrozole) yields about a 10 percent pregnancy rate per cycle. This is typically tried for up to six cycles, at which time we may continue the IUIs, substituting the more potent injectable fertility drugs for pregnancy rates of up to 20 percent per treatment cycle, i.e., back to the normal baseline rate. This is usually tried up to three cycles before moving on to IVF.
boomboom: 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.
please_help: When the doctors talk about the size of follicles, what does that mean in terms of chance of success?
Dr_Jeffrey_Goldberg: The follicles are the cysts within the ovaries that contain the eggs. The follicles grow as the eggs mature. The follicle ruptures at ovulation and the egg is released. We measure the size of each follicle every few days when women are taking injectable fertility drugs in preparation for IUI or IVF in order to adjust the medication dose according to the responsiveness of the ovaries and to time the IUI or egg collection optimally. Ideally, we want two to four mature eggs for IUI. Too many can increase the risk for multiple pregnancy and over-stimulate the ovaries. We hope to retrieve 10 to 20 eggs for IVF.
play_on: A fertility book I'm reading talks about "embryo glue" to help implantation. They suggest using "particular types of culture media" that actually coat 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.
go_ahead: How many ‘tries’ before giving up? At what point do you tell your patient that there is no hope? I have 10 failed ‘attempts’ (IVF and IUI’s). Is it realistic to keep trying?
Dr_Jeffrey_Goldberg: This is a difficult question to answer. I like to meet with patients after each failed cycle to review it and discuss the next treatment plan. I feel patients need realistic expectations, and I tell them what their chances are with another attempt. They can then make an informed decision regarding whether they wish to keep trying. Many patients run out of emotional and financial reserves before we advise that they stop trying.
Tubal ligation reversal or IVF
cheers: 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 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.
Ella: We have been TTC for 1.5 years. We have been to a fertility specialist who thinks I have endometriosis (one 2.5 cm persistent possible chocolate cyst and pain during month). Otherwise healthy (egg health perfect, AMH perfect, progesterone is 11.6, I am ovulating and HSG was fine). My husband has male factor infertility (2 SAs: 1-3 million/ML concentration, 3-7.5 million count, 20 percent motility, and 4 percent to 6 percent morphology). The doctor recommended IVF and we have chosen not to pursue that. Is there any benefit to me having laparoscopy to achieve pregnancy? I have put it off because my pain is tolerable, and I don't want to have surgery unless necessary
Dr_Jeffrey_Goldberg: Endometriosis is diagnosed and treated by laparoscopy as an outpatient. Treatment may relieve pain and improve fertility. I would agree with your doctor that IVF is your best treatment option if your husband's semen analysis can't be significantly improved. In this case, treating the endometriosis first won't improve your chances with IVF, so there would be no benefit, especially since you don't have bad pain.
Ella: If I have the laparoscopy, how likely will the endometriosis reappear and how soon could that start to happen? And with his male factor infertility, will my surgery even help us conceive?
Dr_Jeffrey_Goldberg: Endometriosis is a progressive disease that can get worse until menopause, at which time it regresses. It may recur following complete surgical removal, but it's usually not rapidly progressive. I recommend that women with endometriosis take birth control pills to keep the disease suppressed whenever they are not pregnant or trying to conceive. Laparoscopic treatment of endometriosis may improve fertility if there is also a mild male factor. More severe male factor infertility is best treated by IVF. In that case, we would advise treatment of endometriosis only if there is a large endometriosis cyst (endometrioma).
Ella: You mentioned laparoscopy isn't necessary if we do IVF. What if we choose not to do IVF? With his male factor infertility, how much would laparoscopy help us, if at all?
Dr_Jeffrey_Goldberg: The chance for success with severe male factor infertility is low even with a normal fertile female partner. I don't suspect that treating the endometriosis would substantially improve the odds of conception.
AliseC: In dealing with male infertility, what are the common treatments? I have heard that Clomid® is a standard treatment. How does that compare to how women are treated with the same drug?
Dr_Jeffrey_Goldberg: Treatments for male infertility may include antibiotics for infection, surgery to relieve blocks in the sperm ducts, and hormones, which may include Clomid®, to correct specific abnormalities. Clomid® is not very effective for unexplained male infertility. Since most male infertility is unexplained, the usual treatments are artificial insemination if the numbers are adequate or IVF if they are too low.
kronos: 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® is usually the first-line treatment. It is given daily by mouth for five days. Femara® 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. Both have about a 5 percent to 10 percent risk for twins.
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.
red_aster: 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, but studies comparing the two medications found similar pregnancy rates.
mi532: Does acupuncture 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.
bethj: How critical is diet to embryo quality; for example, eating 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.
london_tower: What role does weight play (both being overweight or underweight) in infertility? Is it the same for men and women?
Dr_Jeffrey_Goldberg: Extremes of weight, both under and over, reduce fertility in both men and women.
down_town: How does a couple choose a fertility specialist or institution? What do you look for? For example, why would I choose the Cleveland Clinic over another program?
Dr_Jeffrey_Goldberg: You should check to see that the fertility doctors are board certified reproductive endocrinologists. This means they have spent several years obtaining additional training in infertility beyond a general OB/GYN residency. You can check the national IVF registry to see the number of cycles performed annually and the success rates by the women's age.
The Cleveland Clinic has six boarded reproductive endocrinologists and also has one of the few male infertility specialists in the country. We offer the full range of reproductive services for both male and female infertility, including medications, IUI, and IVF. We are internationally known for our surgical experience. Our members have written several textbooks, serve on the board of the reproductive societies, and are actively involved in research to continue to improve outcomes. We also have many locations for patient convenience, as well as specially trained nurses for patient education and emotional support.
Cleveland_Clinic_Host: I'm sorry to say that our time with Dr. Jeffrey M. Goldberg is now over. Thank you again Dr. Goldberg for taking the time to answer questions today about infertility
A remote second opinion may also be requested from Cleveland Clinic through the secure eCleveland Clinic MyConsult Web site. To request a remote second opinion, visit www.eclevelandclinic.org/myConsult.
If you need more information, click here to contact us, chat online or call the Center for Consumer Health Information at 216.444.3771 or toll-free at 800.223.2272 ext. 43771 to speak with a Health Educator. We would be happy to help you. Let us know if you want us to let you know about future web chat events!
Some participants have asked about upcoming web chat topics. If you would like to suggest topics, please use our contact link www.clevelandclinic.org/webcontact.
This chat occurred on July 20, 2011
This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. ©Copyright 1995-2011 The Cleveland Clinic Foundation. All rights reserved.