1/8 couples have trouble getting pregnant or sustaining a pregnancy. Infertility can be caused by a number of things: 1/3 of the time it is something with the female partner, 1/3 of the time it is something with the male partner, and 1/3 of the time it is both. Female issues leading to infertility include lack of ovulation (releasing an egg) or diminished ovarian reserve (less eggs), blocked tubes, uterine structural abnormality (polyps, fibroids, septum), or hormonal imbalances (thyroid, prolactin). Male issues leading to infertility include low sperm count, low sperm motility, abnormal sperm morphology, hormonal imbalances. If you have not gotten pregnancy after one year of trying (if less than 35 years old) or 6 months of trying (if 35 years or older), then you should reach out to a specialist.

IUI - intrauterine insemination
An IUI is a very easy in-office “procedure” where we insert a tiny catheter through the cervix into the uterus. We deposit a sample of processed sperm into the uterus, bypassing the vagina and cervix. By processing the sperm, we remove the surrounding fluid and make the sample more concentrated. By putting the sperm closer to the fallopian tubes and egg, we aim to increase the chance of fertilization and making an embryo.
IUI is used in the setting of infertility with lower sperm counts, donor sperm for same-sex couples or single parents by choice, and for couples with unexplained infertility - when IUI is combined with ovulation induction (usually with oral medication).
Success rates depend on the diagnosis, but are typically 15-20% per cycle. Remember the normal conception rate for young couples without infertility is only 20-25% per month. It may take a couple cycles to conceive. The decision on how many total cycles to try before moving to something like IVF is based on diagnosis, age, labs - so be sure to talk to your doctor and make that decision together.
The most uncomfortable part of an IUI is usually just placing the speculum - just like we use in a typical gynecology exam. Most women do not even feel the catheter.

IVF is short for in vitro fertilization. We are able to increase pregnancy rates by combining the egg and the sperm outside the body, then place that embryo inside the uterus (womb). With this process we are able to help couples start a family despite many causes of infertility.
How does the IVF process work?
- At the start of your period (with some exceptions), you come in for an ultrasound to look at your ovaries and confirm you are ok to start.
- You use injectable medications that stimulate many follicles (small cysts containing eggs) to grow. Instead of only stimulating 1 mature egg to grow, we take over the system to make many eggs grow. You will also take a medication to prevent you from ovulating/releasing these eggs too early.
- We monitor your ovaries with ultrasounds and labs. This usually starts on the 5th or 6th day of medications.
- Once your follicles are big enough to contain a mature egg, we give you a trigger shot to push the eggs through the final step of maturation.
- Before the eggs are ovulated/released, we go in and take the eggs out of each follicle. This is called an egg retrieval and is done under anesthesia.
- The eggs are then combined with sperm using traditional IVF or ICSI.
- The newly formed embryos are cultured to day 3 or day 5, then transferred back to your uterus. The embryo transfer only takes a few minutes.
- If you are planning a frozen embryo transfer, then the embryos are frozen on day 1, day 3, or days 5-7 for a future embryo transfer. The day of freeze depends on your age, history, number and quality of embryos.
- You will need to take progesterone for a fresh or frozen transfer. Usually you start this 2 days after the retrieval if you plan a fresh transfer. The preparation for a frozen transfer is a bit different
- We then check a pregnancy test within 2 weeks of the embryo transfer.
This can seem like a lot for anyone who has not gone through IVF, and even for those who have. As always - I’m happy to answer any questions!

PCOS, or polycystic ovarian syndrome, is diagnosed by having 2 out of the following 3 characteristics: irregular periods, signs of high male hormone levels such as dark hair on the face or chest/acne/elevated testosterone, or polycystic ovaries on ultrasound. PCOS is actually a spectrum of reproductive disorders and women can have varying presentations.
Often women with PCOS struggle with infertility. The reason you have irregular periods is because your ovaries are not ovulating, or releasing an egg, every month. Luckily we have oral medication we can use to help you release an egg and get pregnant.
Women with PCOS often struggle to lose weight. This is not your fault! A healthy diet and regular exercise can help. I usually recommend a Mediterranean diet, with a focus on plant-based foods and protein with limited carbs, and at least 30 minutes of exercise 5 days per week. Sometime women need medication such as Metformin, especially if they are diabetic or trying to get pregnant.
Women with irregular periods are at higher risk of endometrial pre-cancer and cancer, so they should be started on some form of hormonal medication. This can be birth control pills/patch/ring, a progesterone pill every month or 3-4 months, or a progestin containing implant or IUD. Many of these medications also can help with the signs of high testosterone. There are other medications to help, such as spironolactone, but you need to be sure to be on a reliable form of birth control with this medication.
1 in 10 women struggle with PCOS.
September is PCOS Awareness Month. I have the privilege of caring for many women with PCOS. While this is a chronic medical condition, we have great options to keep you healthy and help you start a family if desired. If you have irregular period or struggle with acne/abnormal hair growth, be sure to reach out to talk with your doctor.

10% of reproductive aged women have endometriosis. Endometriosis is characterized by painful periods or pain during sex or bowel movements. Women can also present with chronic pelvic pain or gastrointestinal problems (diarrhea, constipation, bloating). Endometriosis is caused by cells from the endometrium (inside lining of the uterus) that are present outside the uterus, in the pelvis and abdomen. This causes inflammation and irritation, leading to pain and scarring.
On average, women with endometriosis are diagnosed 7-9 years following the onset of their symptoms - which can start during their teen years.
Endometriosis is a cause of infertility and pelvic pain. Most patients benefit from hormonal treatment with oral contraceptives containing estrogen and a progestin, or a progestin alone. A progestin containing intrauterine device (IUD) can also be beneficial, with low levels of circulating hormones. Some patient require surgical management of their endometriosis, but hormonal treatment following surgery is often recommended to prevent recurrence of the disease. Hormonal treatments are contraindicated when considering pregnancy, so be sure to reach out to a specialist if you are having difficult getting pregnant.
If you are one of the 1 in 10 women who struggle with endometriosis - I am here for you. I know your pain and will always be always a shoulder to lean on. We are a team and will work together to fight this disease.

The semen analysis is a very important part of the infertility work up. 1 in 8 couples struggle with infertility. About 1/3 of the time this is due to a male factor, and 1/3 of the time this is due to both male and female factors. An important step to see if male factor infertility is at play is to do a semen analysis.
We look at multiple things - sperm count being the thing most people are familiar with. Ideally the sperm count is above 39 million/mL. We also look at motility - how many of the sperm are moving. Ideally this above 40%. We also look at total volume. We like this to be above 1.5 mL. Combining these three values together, we calculate a total motile count (TMC), which can be helpful in counseling towards an intrauterine insemination (IUI) or in vitro fertilization (IVF) versus intracytoplasmic sperm injection (ICSI). We also evaluate sperm morphology/shape, but this test is rather subjective and less important if all other parameters look normal.
If anything on the semen analysis is abnormal, we usually repeat the test in one month because these parameters can change in the setting of stressors like a recent illness. If anything remains abnormal, we usually follow up with hormonal testing, possible genetic testing, and referral to a specialist in male infertility.
We always take a thorough history evaluating for a history of childhood illnesses or surgeries, ongoing medical conditions, prior exposure to toxins/chemotherapy, excess exposure to heat (hot tubs, saunas, biking). We recommend against the use of tobacco and illicit drugs, as well as excessive alcohol intake.
Good news about male infertility - we have many ways to help couples get pregnant!

HSG stands for hysterosalpingogram.
This test, also known as a “tubal dye study”, is part of the workup for infertility. We inject a radio-opaque (shows up on x-ray) dye through the cervix, into the uterus, and out the tubes. All while taking x-ray images (see second photo).
We are looking at two things with this study:
1. Does the inside of the uterus (endometrial cavity) look normal? This is where the embryo implants, so we want to be sure there aren’t any polyps or fibroids or scar tissue.
2. Are both of the tubes normal? We want the dye to spill out into the pelvis through the tubes, proving they are open. We also look to see the shape of the tube is normal. Distended, fluid filled tubes (hydrosalpinx) can affect implantation and lead to infertility.
The test is very quick but you can have some cramping, so I recommend taking ibuprofen before.
Another option to evaluate the uterus and tubes is a HyCoSy or FemVue.

HyCoSy stands for Hystero-Contrast-Sonography. This an alternative to the HSG to evaluate the uterus and tubes. Instead of using dye and x-rays, we use saline and ultrasound. Another name for this is a FemVue.
We use a small catheter to fill the uterus with saline. By separating the walls of the uterus, we can check for fibroids, polyps or scarring. By mixing air with saline to make bubbles, we can then check to be sure the tubes are open.
I like this test because you can get a full picture of the uterus and ovaries with the ultrasound, as opposed to seeing only the outline of the uterus and tubes with the HSG. However, anyone with a history of tubal surgery or significant scar tissue may be better served with an HSG.

If you are trying to get pregnant (or not), timing is very important. There is a “window of implantation” of only 24-48 hours when the egg can be fertilized. So you want to have sex or do an insemination at the right time around ovulation.
How do I know if I am ovulating?
If you are having regular periods (between 21-35 days), then you are likely ovulating.

Best ways to time sex when trying to get pregnant:
Should I check my temperature?
Body temp drops a bit before ovulation and rises some after, but body temperature varies significantly based on time of day and the environment. This method is not very reliable, but if you are rigorous about checking the same time every day, you may be able to track a pattern.
What about cervical mucous?
Progesterone levels cause cervical mucous to thicken but progesterone only increases after you ovulate. So you may miss ovulation if you are monitoring your discharge. Always better to have the sperm waiting for the egg.
So how do I accurately plan sex?
The second half of the cycle after ovulation (luteal phase) is fixed at 14 days. So subtract 14 from your cycle length and that is typically the day you ovulate. Easy!
Ex) 28 day cycle - 14 = ovulation on cycle day 14
Hate math?
I recommend intercourse every other day from cycle day 10 to 21. Even easier!
I always recommend patients use ovulation predictor kits when trying to conceive so they can most optimally plan their time in the bedroom.

Embryo transfer day is the culmination of all of our efforts throughout the IVF cycle. We finally get to put back the embryo (or embryos) that we have worked so hard to create.
This is a quick procedure in which we place a speculum and thread a thin catheter through the cervix into the uterus. This is done under ultrasound guidance with special care not to touch the top of the uterus.
We use abdominal ultrasound or transvaginal ultrasound to help guide the catheter. We also usually do a mock embryo transfer 1-2 months prior so we know exactly how to get into the uterus and how long it is from the cervix to the top of the uterus.
The embryo is microscopic, so we can’t see it on ultrasound. We put small air bubbles on either side of the fluid containing the embryo. These show up as bright white dots. I always tell patients to look for the shooting stars!

Have you ever wondered how we choose which embryo to transfer?
We base the decision on embryo grading! We grade embryos based off how they look under the microscope on day 3 and on day 5 and typically transfer the highest grade embryo first.
Day 3 - cleavage stage:
We grade day 3 embryos by the number of cells present, with the optimal number being 8 but ideally between 6-12. We also look at the cellular debris (fragmentation) and the how similar each cell is in size (symmetry).
Day 5 - blastocyst stage:
By day 5 we like to see a blastocyst - an embryo with an outer ring of cells called the trophectoderm (TE - this becomes the placenta) and inner cell mass (ICM - becomes the embryo) with the rest of the ring filled with fluid. I think of it as a big beach ball filled with water and a smaller solid ball.
The ICM and TE are scored just like grading in school: A-D. High quality embryos usually have A and B grading.
Higher embryo grade is associated with a higher chance of having normal chromosomes and higher pregnancy rates, but even poor quality embryos can be euploid and lead to a healthy baby (many moms I know can speak to this personally).
If we do genetic testing (PGT) then we pay less attention to the grading. When choosing between multiple normal/euploid embryos, we usually choose the one with the best grade, unless the parent(s) have a sex preference.

OHSS, ovarian hyperstimulation syndrome, is one of the risks of IVF. OHSS is caused by over-active ovaries leading to electrolyte abnormalities and fluid collection in the abdomen or the lungs.
Risk factors for OHSS include:
• AMH > 3.4
• AFC > 24
• development of > 25 follicles
• peak estradiol levels > 3500 pg/mL
• > 24 oocytes retrieved
Symptoms include abdominal distinction, nausea and vomiting, shortness of breath, low urine output and dark urine, diarrhea and weight gain following retrieval.
There are some things we can do to decrease the risk of OHSS. The first is to freeze all the embryos and plan for a frozen embryo transfer the next month. If you get pregnant in a fresh cycle with a high risk of OHSS, the hCG continues to stimulate the ovaries, worsening the disease.
When we do a freeze-all cycle, we also use a Lupron trigger instead of hCG when possible, which decreases the risk of OHSS. We give cabergoline when we need to use an hCG trigger. We also recommend salty foods and drinking gatoraid instead of water.
We diagnose OHSS with pelvic ultrasound, labs, and exam. Usually we can manage symptoms outpatient, but sometimes women require hospitalization.
While IVF has significantly advanced reproductive medicine, it is not without risk. Be sure to discuss any concerning symptoms with your doctor so they can catch OHSS early and make the best decision for your transfer.

There are many ways to induce ovulation, including oral medications and injections.
𝙒𝙝𝙮 𝙬𝙤𝙪𝙡𝙙 𝙨𝙤𝙢𝙚𝙤𝙣𝙚 𝙣𝙚𝙚𝙙 𝙤𝙫𝙪𝙡𝙖𝙩𝙞𝙤𝙣 𝙞𝙣𝙙𝙪𝙘𝙩𝙞𝙤𝙣 (𝙊𝙄)?
If you don’t have regular periods every month, then you likely aren’t ovulating normally. The most common cause for this is PCOS. Thyroid disorders, poorly controlled diabetes or high prolactin can also cause irregular periods, but in these cases, you would treat the disorder. In the setting of ovulatory dysfunction, you can use OI medications to cause release of an egg (or multiple eggs).
𝙒𝙝𝙖𝙩 𝙞𝙛 𝙄 𝙝𝙖𝙫𝙚 𝙧𝙚𝙜𝙪𝙡𝙖𝙧 𝙥𝙚𝙧𝙞𝙤𝙙𝙨?
Sometimes we use medications in ovulatory women for ovulation super-induction. We do this in the setting of unexplained infertility (pairing OSI with intrauterine insemination/IUI), endometriosis, diminished ovarian reserve, or tubal disease affecting one side. In this case, we are recruiting more follicles than what the body is doing naturally.
𝙒𝙝𝙖𝙩 𝙢𝙚𝙙𝙞𝙘𝙖𝙩𝙞𝙤𝙣𝙨 𝙖𝙧𝙚 𝙪𝙨𝙚𝙙?
Clomid and Letrozole are the most common medications. Clomid tricks your brain into thinking estrogen levels are low, so more Follicle Stimulating Hormone (FSH) is produced. FSH stimulates follicle recruitment and development. Letrozole lowers circulating estrogen levels, leading to increased FSH secretion.
Letrozole is usually better tolerated and has a lower twin rate (2-5%) compared to clomid (8-10%), so I usually start with letrozole. Pregnancy and live birth rates are higher with letrozole versus clomid in PCOS patients.
Adding Metformin can be helpful for women with PCOS, especially those who are overweight (BMI >28 kg/m2) and those with insulin resistance/pre-diabetes.
We don’t use injectable medications as much any more due to the risk of multiples (20%).
𝙒𝙝𝙖𝙩 𝙖𝙧𝙚 𝙩𝙝𝙚 𝙨𝙪𝙘𝙘𝙚𝙨𝙨 𝙧𝙖𝙩𝙚𝙨?
Depending on your diagnosis, pregnancy rates are about 10-20% per cycle. Cumulative pregnancy rates range from 30-50% in 3 cycles. 80-90% of women who will conceive on OI or OSI will do so in the first 6 cycles, so we usually recommend moving to IVF at that time.

Ovulation Predictor Kits, or OPKs, can be very helpful when trying to conceive.
𝙃𝙤𝙬 𝙙𝙤 𝙩𝙝𝙚𝙮 𝙬𝙤𝙧𝙠?
OPKs measure the hormone LH, which triggers ovulation.
Ovulation occurs 34-36 hours after the start of the LH surge and about 10-12 hours after the LH peak.
We usually recommend having intercourse the day of positive OPK and the 1-2 days following.
The egg only lives for about 24 hours, so it is better to have sperm around prior to egg release.
Most people with 26-30 day cycles ovulate around days 12-16, so you should start checking on day 10 and check around the same time every day.
𝙎𝙚𝙚𝙢𝙨 𝙚𝙖𝙨𝙮. 𝙒𝙝𝙖𝙩’𝙨 𝙩𝙝𝙚 𝙘𝙖𝙩𝙘𝙝?
OPKs are the most reliable for people with regular periods.
If you are having a period every month, then you are ovulating.
If you don’t have regular periods, then you are likely not ovulating on your own and should speak to your doctor about next steps.
Some people have chronically high LH levels, so OPKs will always be positive. If this is the case for you, you should also speak to a doctor.
𝙃𝙖𝙫𝙚 𝙧𝙚𝙜𝙪𝙡𝙖𝙧 𝙥𝙚𝙧𝙞𝙤𝙙𝙨 𝙗𝙪𝙩 𝙙𝙤𝙣’𝙩 𝙬𝙖𝙣𝙩 𝙩𝙤 𝙪𝙨𝙚 𝙊𝙋𝙆𝙨?
Another option is to just have intercourse every other day from cycle day 10 to 20.

Let’s chat donor sperm IUI.
IUI, or intrauterine insemination, is placement of prepared sperm into the uterus. This can be used for lower sperm or unexplained infertility. Donor sperm IUI is often used for female same-sex couples and for single mothers by choice.
Donor sperm IUI can either be done after natural ovulation (tracked by urine or blood LH levels) or after using ovulation-induction medications such as clomid or letrozole. If women do not ovulate regularly on their own, then these oral medications are necessary. But if women have regular periods, then natural cycle IUI is a great option.
A new study showed that ongoing pregnancy rates were only slightly higher with medications (15.4% vs 14.9%) but with a 4.5x increased risk of multiple pregnancies. Overall, for women with regular periods, natural cycle donor IUI has similar pregnancy rates and a much lower risk of multiple pregnancy.

Source: Carpinello et al, F&S Oct 2020

What is AMH?
AMH, or anti mullerian hormone, is a hormone measured in your blood that we often use as a marker of ovarian reserve (how many eggs a woman has left). This hormone is secreted by the support cells of the eggs (granulosa cells) so we think: more eggs = more support cells = higher AMH.
However - estimating ovarian reserve is truly a guess at best, and we don’t use AMH alone. We also look at FSH and estrogen levels, and often an ultrasound to look at the number of early (antral) follicles you have. But none of these tests are perfect.
Most importantly - AMH does not predict fertility! Hvidman and colleagues looked at AMH in fertile and infertile women under the age of 40 and found no difference in levels. Many other studies have shown the same. AMH and should not be used to predict fertility.
The most important predictor of your fertility if your age. As women age, egg quality decreases. We are born with all the eggs we will ever have, so as we get older, there is an increase chance of spontaneous genetic mutations in the eggs. This can lead to difficulty getting pregnant, increased chance of miscarriage, and genetically abnormal embryos.
So what is AMH primarily used for? While AMH and other tests can give us an idea of ovarian reserve, and spark conversation on family-building goals, we mainly use AMH to dose IVF medication.
If you are thinking about “testing your fertility”, be sure to speak with a specialist. And if you are delaying starting family for any reason (work, education, partner, etc), you can consider freezing your eggs or embryos. Again, speak with a specialist about these options so you can do what is best for you and your ultimate family building goals.

Reference: Hvidman, HR 2016

I often get asked by patients with PCOS about metformin and fertility.
Metformin is a medication used to treat diabetes, increasing insulin-sensitivity and decreasing blood sugar levels. We often start Metformin for women with PCOS trying to conceive who are obese or have evidence of insulin resistance on exam or labs.
There have been many studies evaluating metformin to increase ovulation and pregnancy rates in women with PCOS. While more women ovulate while taking metformin compared to placebo, this is likely due to the weight loss many women have while taking metformin. Losing as little as 5% of your body weight can stimulation ovulation and increase pregnancy rates.
Ovulation, pregnancy and live birth rates are lower with metformin alone than with clomid alone (an oral ovulation induction medication). Combination of metformin + clomid increases ovulation rates but there is no difference in live birth rates. For women who are clomid resistant, metformin + clomid does increase pregnancy rates.
Studies have also shown decreased miscarriage rates in women who stayed on metformin through the first trimester, so we often continue patients on metformin if they conceive on the medication.
If women with PCOS undergo IVF, we often put them on metformin because they have a decreased risk of ovarian hyper stimulation syndrome (OHSS).
While metformin does not appear to be the secret medication to improve all reproductive outcomes for women PCOS, it is very helpful for specific indications.

References:
Clark, HR 1995/Legro, JCEM 2016
Legro, NEJM 2007
Jakybowicz, JCEM 2002/Sohrabvand, WIMJ 2009
Palomba, F&S 2011

Nausea and vomiting is incredibly common in pregnancy. 50-80% of women have nausea in pregnancy and 50% have vomiting. Most of these symptoms start around week 9 and improve by week 12/13.
What causes N/V of pregnancy? Truthfully - we don’t know. There are likely a number of causes including elevated hCG (pregnancy hormone) and estrogen levels, but thyroid function and genetics can also have an effect.
Good news - only 3% of women go on to develop severe symptoms and hyperemesis gravidarum.
Also good news - we have MANY options to treat these symptoms.
Starting a prenatal vitamin at least one month before you conceive can be preventative. Conservative treatments include eating small frequent meals, ideally with high protein, avoiding spicy or fatty foods, eating bland/dry foods, ginger teas/candies. Some women benefit from acupressure bands on the wrist.
We usually start medical treatment with vitamin B6 (pyridoxine) and an antihistamine (doxylamine). This med treats nausea and is preventative. If this doesn’t work, we can try reglan (metoclopromide) tablets or compazine (prochlorperazine) suppositories. Zofran (ondansetron) is another helpful medication, but this can interact with other medications and we usually wait to start this until after 10 weeks. If you have heart burn, pepcid (famotidine) can be helpful.
If you are significantly dehydrated or are losing weight, then you need to be seen in the hospital for IV fluids with sugar electrolytes.
Good news - even with significant nausea/vomiting, there is little to no harm to the baby.