10 Things I Would Tell My Sister if She Was Starting Fertility Treatment

Welcome to a no-nonsense blog on fertility treatment penned by none other than Dr. Robin Fogle. If you're embarking on this path or supporting a loved one through it, prepare for a dose of unfiltered guidance from a trusted fertility specialist.

To be fair, I don't have a sister, just a brother in Texas who drives an enormous pickup truck. But if I did, here are some 'tough love' things I would tell her that I might not say so bluntly to my patients.

1. I don’t have to fully understand the cause of your infertility in order to get you pregnant.

The mystery of your unexplained infertility does not have to be solved in order for my treatment to work. There is a reason it’s called ‘unexplained infertility’. If I knew the cause, I promise I would tell you. Trust me, I have a list of patient-related questions for God when the time comes. But for now, if I can't figure out the cause of your infertility, no amount of googling is going to get you any further.

2. There is more than one way to skin a potato.

There are many things in the world of fertility treatment that have to be exact: the trigger time before egg retrieval, the day of implantation for an embryo transfer, etc. But there are also lots of things that don’t have to be exact. For example, 'timed intercourse' can mean lots of different things – sex every day in the fertile window, sex every other day in the fertile window, sex on the day of the LH surge, and the day after.

If your doctor seems nonchalant about whether you have sex every day or every other day, it's not because they don't care. It's because it probably doesn’t matter for most couples. Another example is the timing of an IUI – should it be 24 or 36 hours after the LH surge or trigger? Should we let you detect your own LH surge or instead offer you a trigger shot? Studies show it doesn't matter. So you may hear us recommend various things at different time points. When things require precision, you’ll get precise instructions.

3. Don't do more than three IUIs (and two is probably enough).

Before IVF (in vitro fertilization) became as effective as it is today, we didn't have many options to offer patients. We routinely started by offering a medicated IUI (intrauterine insemination) cycle. But we know that if an IUI hasn't worked by the 3rd cycle, it probably isn't going to.

It may sound like a great treatment, but the success rates are actually quite low, ranging anywhere from 5 to 15% per cycle depending on the age of the person undergoing the procedure. The low success rates are due to the 'unexplained' part of unexplained infertility. If the tubes aren't functioning well, an IUI will never work. Just because your HSG is ‘normal’ doesn’t mean your fallopian tubes are functioning. If there is a genetic problem rendering the sperm unable to bind to the egg shell, IUI won't work. If there is a genetic problem with the zona pellucida (egg shell) precluding fertilization, IUI won't work.

Starting with IUI may be a reasonable idea, but give it the old 'college try' and move on after two or three cycles.

4. IVF is the best resort, not the last resort.

Patients are appropriately scared to move into IVF treatment. Some of that fear comes from the belief that they have reached rock bottom in terms of treatment options. But in a perfect world, where climate change didn't exist and IVF was free, we would prefer to start with IVF in many cases because it overcomes so many of the 'unexplained' parts of unexplained infertility. And depending on the clinic and a patient's age, an embryo transfer from IVF can yield anywhere from a 40-70% chance of a live birth, rates which are significantly higher than any achieved through IUI.

5. In real estate, they say it's all about location, location, location. In IVF, it's all about the lab, lab, lab.

It’s nice to have a doctor who is up to date on the literature and treatment options and has a good bedside manner. But at the end of the day, if you are doing IVF, then the most important component for success is the quality of the IVF lab – and they definitely aren’t all alike. Whereas a good IVF lab can maintain the integrity of good embryos and support them in continued growth, a suboptimal lab can compromise good embryos to the point of nonviability.

But no matter how good a lab is, it can’t make good embryos from poor-quality sperm and eggs. That’s beyond our current technology and why we sometimes make the recommendation to use donor eggs or sperm.

6. Supplements aren't going to counteract other things you are putting in your body.

Everyone wants a quick fix for the things that ail them. And though I’m not opposed to supplements (though most have little legitimate data to support their benefits in fertility treatments), I find it ironic that someone will take ten different (unproven) supplements but turn a blind eye to the foods they are eating or the amount of movement they are getting.

The most important medicine is what we eat. I am a big fan of antioxidants – so eat them in salads, fruits, and vegetables. I am also a big fan of stress relief – so exercise. And I am a big fan of decreasing inflammation – so work towards a healthy weight.

If you aren’t committed to those things first, popping a few pills isn’t going to do much good.

7. A chromosomally normal embryo isn't necessarily a 'normal' embryo.

Unfortunately, despite the progress we’ve made in the field of infertility and IVF, there are still lots of embryos that we transfer that don’t turn into babies. We make the mistake as providers of referring to our chromosomally normal (euploid) embryos as ‘normal,’ so when they don’t work, our patients are bewildered.

What one must understand is that having normal chromosomes is only one, albeit extremely important, piece of the puzzle. Most embryos that don’t implant or fail shortly thereafter were probably never actually “normal.” If they were, they would have continued to grow and progress.

Other components, like genes (there are approximately 100,000 in the human genome) and energy production, also have to be normal. But sadly, we don’t have clinically applicable ways to investigate these things. So, an embryo with the correct number of chromosomes may or may not be normal - the only way to find out is to transfer it and see what happens.

8. You’ve heard the saying: It isn't you, it's me. In IVF, the saying is: It isn't the uterus, it's the embryo.

When patients don’t get pregnant after an embryo transfer, they almost universally start asking the following: What did I do wrong? What is wrong with my uterus? Do I have an autoimmune condition killing my embryos?

These questions inevitably lead to a deep, dark dive into the World Wide Web. There, they may find clever marketing for tests that investigate the endometrial receptivity, markers of inflammation or endometriosis, and tests to investigate the microbiome or the immune system. For 95% of these patients, none of those shiny, cutely named tests are applicable or warranted. The vast majority of failed transfers happen because the embryo was, in fact, not normal (see #7) and was never going to make a baby no matter where, when, or to whom it was transferred.

Data now tells us that 95% of patients will have a live birth if they proceed through three consecutive euploid embryo transfers. In other words, once you find the right embryo, the uterus won’t pose a problem.

9. Your doctor wants you to be pregnant almost as much as you want to be pregnant.

It seems like this should go without saying, but when emotions are high, and hope is low, hearing it out loud can help.

If I recommend a particular test or supplement, I really do think it’s important.

If I recommend against a test or supplement, I really don’t think you need it.

If I ignore your Google research, try not to be offended. It took me seven years of postgraduate training after medical school to learn this stuff and another 16 years (and going) of learning new things every day about infertility. All of that knowledge and experience is going to be packaged into my recommendation for you.

10. Perseverance pays off.

Today, I had a patient ‘graduating’ with an eight-week ongoing pregnancy. She said in astonishment, “Wow, I can’t believe we started this one year ago.” Although I respect that one year is a long time of tears and frustration, I have plenty of patients who have been with me for two, three, or even four years. In almost every one of those cases, the patients who kept at it were ultimately successful in having a baby one way or another.

So, think of your infertility journey as a marathon, not a sprint. If you are one of those who graduate after only a 10k or half marathon, consider yourself truly lucky and keep rooting for your friends who are still on the racecourse.