Dr Beth's Blog

Dr Beth Taylor MD, FRCSC

 

 

 

 

 

testicular sperm

I’m not sure what’s out on the fertility chat rooms, Facebook groups, Reddit posts, etc. but it seems people with unsuccessful IVF are talking more and more about sperm.  Lately people are starting to ask whether they should use testicular sperm instead of ejaculated sperm to improve embryo quality.

 

Let me review a couple of sperm concepts.  Roughly, if the sperm count is > 15 million and most of them are swimming couples (without any female factors) can conceive with sex.  If the sperm count is between 8-15 million then IUI often works, and below 8 million IVF with ICSI is needed.

 

This is simplistic. This is a gross generalization but it’s a place to start the discussion.

 

Now, if a couple needs IVF/ICSI then we extract eggs from the ovaries and the partner EJACULATES sperm.  We take that sperm and fertilize and eggs and watch as embryos develop.

 

If embryos develop poorly or are abnormal we explore whether the egg, sperm or both were the cause.  If we suspect sperm, what can we do?

 

  • Have the male take supplements, improve his lifestyle, treat a varicocele (if present)
  • Use donor sperm
  • Try with sperm we aspirate straight from the testicles/epididymus - TESA/PESA procedure

 

It’s been my experience over the years that the evidence has waffled back and forth about the value of ejaculated sperm when there is a reasonable number of sperm in the ejaculated sample, but has favoured testicular sperm when embryo development is poor.

 

Reviewing this topic on this rainy November day, it seems the controversy continues.  The latest study of about 160 couples undergoing ICSI and comparing ejaculated versus testicular sperm found NO benefit (Reference: Kendall Rauchfuss LM, Kim T, Bleess JL, Ziegelmann MJ, Shenoy CC. Testicular sperm extraction vs. ejaculated sperm use for nonazoospermic male factor infertility. Fertil Steril. 2021 Oct;116(4):963-970.). The authors concluded that testicular sperm was not better, but if you dig into the methodology of the study, explore the bias in selection of patients and look at the outcomes (higher live birth with testicular sperm, though not statistically different), I don’t think this study should necessarily be that influential.  Reading it did prompt me to go back over the other studies on the topic.

 

My synthesis is that there may be value to getting sperm from the testicles if the sperm parameters in the ejaculated sample are poor (low count, motility, high DNA fragmentation), particularly if there has been poor embryo development in s previous IVF cycle.  It is also a good reminder that poor quality sperm should be addressed: supplements, optimizing diet and lifestyle and addressing any correctable insults to the sperm (e.g. varicocele, if present).  Then if the ejaculated sample is low and the embryo development is poor consider testicular sperm before another IVF attempt.

 

Testicular aspiration of sperm isn’t taken lightly.  I would not start sending men for this procedure with low sperm counts - it is expensive (> $3000) and hurts. This a case where the doctor really needs to spend time with the sperm report, perhaps talk to the andrologists/urologists and really personalize the approach to maximize embryo health.

 

I suspect this is buzzing in chat-rooms these days is that some frequent or passionate poster had success when their doctor switched from ejaculated sperm to testicular sperm.  I’m glad this is being discussed.  We need to do everything to create the healthiest embryos and babies.

 

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

AMH

Credit companies try to convince us we should know our credit score.  Since I am not buying a house or a car I’m not sure why I need to know that number. The only numbers I have memorized are my phone number, street number, my SIN number and my visa number.  I would add one number to the list of “should know” for women trying to conceive: AMH.

 

Antimullerian Hormone (AMH) is a number women trying to conceive should know… at least roughly. Note: AMH is sometimes written as “Mullerian Inhibiting Substance” on some reports.

 

AMH is a hormone released by granulosa cells in antral and pre-antral follicles. In other words, it is a hormone made by the cells that surround immature eggs.  This means if you have a lot of immature eggs, then you will have a high AMH level which is good.  If you have a low AMH, then you have a low egg count or ovarian reserve.

 

Other measures of egg count or ovarian reserve are FSH level on day 3 of the menstrual cycle and antral follicle count (AFC) determined by transvaginal ultrasound.  The problem with the day 3 FSH is that it is not all that accurate, fluctuates with the cycle day, can’t really be interpreted if you don’t have a regular menstrual cycle and is useless if you are taking any hormones (e.g. birth control pill).  The problem with an antral follicle count (AFC) is that it is done by a vaginal ultrasound usually by an infertility specialist, so there is a barrier to getting this information quickly.

 

So, AMH is the best measure of egg count/ovarian reserve.  AMH can be drawn on any day of the menstrual cycle.  It is a bit suppressed if you are taking hormones like the birth control but can still be interpreted.

 

AMH is reported by labs either in pmol/L or ng/mL. Be sure to check the units because a 3 in ng/mL is excellent but bad in pmol/L, for example.

 

In BC, AMH is unfortunately not covered by our provincial health plan, which is wrong. It should be.  It costs about $70-90 depending on the lab you attend.

 

AMH allows a woman to know her ovarian reserve.  It also lets us estimate the best dose for IVF medications and predict how successful IVF will be.  It gives us a sense of the time until the start of menopause as well.

 

In my practice, I like everyone to have an AMH level when we first meet. I also do an AFC. I don’t repeat an AMH all that often unless more than a year has passed (and not always if I have a recent AFC), if the person has had ovarian or endometriosis surgery, if the IVF outcome was surprising, the person is over 40 and considering another IVF cycle (it can drop quickly in the 40s), or if a person requests it.

 

You don’t need to know your exact AMH level if you are trying to conceive, honestly, but knowing if it is high, low or average is really helpful.

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

CFAS meeting 2021

The Canadian Fertility and Andrology Society (CFAS) just had it’s annual meeting here in Vancouver.  Many people attended virtual and many in person. It felt odd to be in-person at a meeting but I think after 18 months of social isolation, being in a room of 50 people feels naughty.  It feels like you are doing something dangerous like sneaking out of the house as a teenager.  

 

We had to show proof of vaccination so there is some comfort in that, I suppose.  Like sneaking out of the house, but bringing your ID, phone and enough cash to get a cab  home.

 

Dr. Jason Hitkari was the president this past year.  He was terrific at leading the organization through the COVID storm.  At the meeting there was talk about COVID: no impact on fertility, some impact on clinic flow/ease for patients given the limitations on “non-essential” visitors to clinics, major impacts on our overall health care system.

 

There were talks on Artificial Intelligence. These sort of presentations give us a glimpse into the future of patient diagnostics, IVF embryo selection, patient education on treatment prognosis, etc. but I’m always looking for the talks that I can take back to the clinic that day and improve care.   AI will no doubt change our practice for the better but it will likely take a few years to be fully realized.  We current are using AI to present live birth rates for our egg freezing patients (Violet Reports).

 

There were some talks that affirmed the value of endometrial testing prior to a frozen embryo transfer. I always enjoy the research on environmental exposures and egg/sperm health (no surprise: BPA and bisphenol exposure is bad).  Our new physician, Dr. Cho presented a study examining live birth rates in women with repeated miscarriages (spoiler: they do better than the average IVF patient). Our Dr. Nakhuda spoke about IVF trigger medications – when to use which trigger.

 

The best part of the meeting was learning in one of my favorite formats: from humans, in person, who lecture and then generate a discussion on the topic.

 

Looking forward to more similar learning experiences as we get a handle on COVID and re-open the world.  Vaccination is getting us there.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

uterine septum

Hysterosalpingogram (HSG) is an important test of fertility. It assesses the uterine cavity and determines whether the Fallopian tubes are open.

 

When I was trying to get pregnant I had one.  Like my patients now, I experienced the pain of the process.  You call the HSG centre/hospital on the first day of your period.  They tell you they have no appointments available this month and to call back with your next menstrual cycle.  You eventually get an appointment for the test.  At the appointment you change into a hospital gown and go into a procedure room.  You lie on the table and the radiologist comes in to the room.  They tell you what to expect (all I was really thinking while he was talking was “how much is this going to hurt?”).  They put the speculum in the vagina and clamp the cervix.  A syringe injects dye through the cervix which causes cramps and (for me) a weird warm feeling in my pelvis.  They take a couple of x-rays for which you might have to shift your body around to help them get properly.  It hurts a bit (I know some people find it excruciating but most patients report mild/moderate pain for about 2 minutes).  That’s it. You head home waiting for the report.

 

Then a few days later your doctor gets the report.  My report read “the Fallopian tubes are patent.  There is a large uterine septum.”

 

Now what?

 

A uterine septum results when the uterus does not form properly as a fetus.  It is not all that common - only about 3% of all women have a septum but if you look just at women with repeated miscarriages or infertility it is closer to 15%.

 

Studies indicate that a uterine septum increases your risk of miscarriage and should always be removed in women with 2 or more miscarriages.  Septums do more than cause miscarriage though: they decrease the success rate of IVF and increase the risk of preterm birth, fetal growth restriction, malpresentation and placental abruption.

 

Now, the problem with studies on septums is that they include women with different sizes of septi and different reproductive histories.  There are not a lot of great studies out there on septum, honestly.  When I was in my fellowship studies at that time only suggested we should be removing septum in women with 2 or more miscarriages.  Since then more literature has suggested everyone with a septum should have it removed.

 

The best available evidence describing the potential impact of a uterine septum on IVF success  is derived from a study 289 embryo transfers that were performed before uterine septum surgery and 538 were performed after surgery.  IVF outcomes were compared with those of two consecutive embryo transfers in matched women without a septate uterus.  They found the septum reduced the chance of success 7 fold. Good evidence that septum should be removed before IVF.

 

Reference: Tomaževič T, Ban-Frangež H, Virant-Klun I, Verdenik I, Požlep B, Vrtačnik-Bokal E. Septate, subseptate and arcuate uterus decrease pregnancy and live birth rates in IVF/ICSI. Reprod Biomed Online. 2010 Nov;21(5):700-5.

 

 

There are no studies that suggest we should be removing septum in women who plan to conceive with intercourse or insemination - they just haven’t been done.  Knowing that septum increase the risk of miscarriage and failed IVF and knowing how septi might harm uterine function and implantation is enough for me to recommend all septums - big or small be removed.

 

I had my septum removed, after failed IUIs, in 2008.  I conceived in the cycle immediately after the surgery and gave birth at term to a healthy girl.  I then went on to have a few miscarriages but eventually gave birth to 2 more healthy children.

 

 

Getting an HSG can be a hassle and the test hurts BUT it is incredibly helpful to understand your uterine anatomy and status of the Fallopian tubes.

 

 

Disclaimer: septum, septate, septi, septums - I’ve these words them variably and in some places incorrectly in this text.  My autocorrect keeps switching them around!

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

sperm DNA fragmentation

Women often get a hard go in life. We usually make less money than men, we often bear the work of running a household and working full-time and we take the blame for a lot of fertility issues.

 

Gosh, I hate the word “blame,” but you know what I mean. Women’s age is a major factor in a couple’s fertility. Eggs do not age well.  Sperm don’t decline like eggs do with age, but still decline. With age, sperm fragmentation increases with age as well, making the sperm less likely to be able to fertilize an embryo or, if fertilization occurs, less likely to make a healthy embryo.

 

 

We do not routinely test for sperm DNA fragmentation at Olive as it has not correlated all that well with fertility.  Also, as I often explain to patients who ask about sperm DNA fragmentation testing, the treatment for highly fragmented sperm is these oral antioxidant supplements and life style changes:

 

  • N-acetyl cystine 600mg per day
  • Omega/fish oil
  • Coenzyme Q 10 300mh
  • Multivitamin (because it contains vitamin E, C and zinc)
  • Avoid: smoking, high trans-fat diet
  • Minimize: SSRI dose/use

 

This is good advice to follow, no matter the DNA fragmentation.

 

A study published this month in Fertility and Sterility looked at the impact of high sperm DNA fragmentation and IVF outcomes.  Interestingly, it does not impact IVF outcomes unless the woman’s age is > 40. The study found that when the woman’s age was over 40 there were significantly lower blastocyst development rates, lower pregnancy rates, and an increased miscarriage rate in IVF cycles with > 30% sperm DNA fragmentation compared with <30% fragmentation.

 

For women < 40 sperm DNA fragmentation  did not matter.

 

With this knowledge there are two possible approaches:

 

  1. Test every male whose female partner is > 40 for sperm DNA fragmentation and treat with the above supplements and life style changes if it is abnormal.
  2. Treat every male whose female partner is > 40 with the above supplements and life style changes.

 

 

Sperm DNA fragmentation testing costs about $600 so I have tended to ask men to follow the above advice and not bother with the test.  I say “if the test is abnormal this is the treatment but if the test is normal you likely should also do the treatment. So either way you should take the supplements and optimize your lifestyle.

 

 

Now, there are some men who would still benefit from testing sperm DNA fragmentation - ask your doctor if it makes sense for your unique situation.

 

Reference: Setti AS, Braga DPAF, Provenza RR, Iaconelli A Jr, Borges E Jr. Oocyte ability to repair sperm DNA fragmentation: the impact of maternal age on intracytoplasmic sperm injection outcomes. Fertil Steril. 2021 Jul;116(1):123-129.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

timing of frozen embryo transfer

We all agree fresh chicken tastes better than frozen. We’ve seen popsicles get a weird coating of ice when they have been in the freezer too long.  This life experience is why most people, when they initial approach embryo transfer, want a fresh embryo transfer.  They do not want a freezer burnt embryo. So it often comes as a surprise to people when they learn that frozen embryo transfer pregnancy rates are generally higher than fresh embryos transfers.

 

This trend, along with increased use of chromosomal testing of embryos (PGT), means that at Olive nearly 90% of all embryo transfers done in the past year were frozen embryos.

 

The reason fresh embryo transfer pregnancy rates are typically lower than frozen is because during IVF ovarian stimulation the woman’s hormones are very high - unnaturally high or “supraphysiologic.”  Such hormone levels have a negative impact on the uterine lining - where an embryo is placed. These unnaturally high hormone levels (largely estrogen) impact the stickiness or receptivity of the uterine lining.

 

So, for most people IVF is three months:

 

  1.  is priming or preparation
  2.  is ovarian stimulation, egg retrieval and embryo creation
  3.  is frozen embryo transfer

 

Now, is month #3 too soon to do the transfer?  Have a woman’s hormone levels gone to a natural level by the third month?  Would it be better to wait until month #4 to do the frozen embryo transfer?

 

A study published this month in Fertility & Sterility looked at this question.  The study was performed at Cornell University and examined natural cycle frozen embryo transfer performed in the first or second month after IVF and found NO difference in pregnancy rates suggesting there is no need to wait a month after an IVF cycle.

 

The timing of medicated frozen embryo transfer cycles has been examined as well in previous research, and again no difference was found between the women who had an embryo transfer in the first month after IVF or second month.

 

At Olive most of our embryo transfer cycles are medicated.  Natural cycle transfers have similar pregnancy rates to medicated if the woman is perfectly ovulatory.  Medicated frozen embryo transfer cycles have the advantage of being predictable, do not require ovulation and are able to benefit from endometrial receptivity testing (ERA).

 

I won’t get into great detail today on natural cycle transfers versus medicated (I generally favour medicated as we can do endometrial receptivity testing (ERA) and then be much more confident we have perfect timing for the embryo transfer), but will in another blog.

 

The message here is that there is no need to wait a month/cycle after IVF to have a frozen embryo transfer for most women.  Who SHOULD wait a cycle? Those who develop ovarian hyperstimulation syndrome (OHSS), those doing endometrial receptivity testing, and those who need uterine surgery to remove polyps/fibroids/scarring prior to a transfer.

 

Discuss the optimal embryo transfer timing with your doctor.  Ultimately everything is personalized but do not worry about do the transfer in the cycle right after IVF or in waiting a cycle.  There is no harm nor benefit to doing the transfer right away, or waiting.

 

Reference: Bortoletto P, Romanski PA, Magaoay BI, Rosenwaks Z, Spandorfer SD. Time from oocyte retrieval to frozen embryo transfer in the natural cycle does not impact reproductive or neonatal outcomes. Fertil Steril. 2021 May;115(5):1232-1238.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

we are all feeling it

The practice of infertility has really changed over the past decade. Dramatic changes in our understanding of embryo health, genetics, endometrial function, ovarian stimulation, etc. means the more and more people are getting pregnant than ever before.  Infertility treatment is really expensive, but for the science involved for the number of highly educated people needed to administer these treatments, it is actually less expensive than it certainly could be.

 

The pandemic has also changed infertility care, well not the science but the people.

 

I graduated medical school in 1998.  Since that time I’ve trained to be a family doctor, then an obstetrician and gynaecologist and then a fertility specialist (REI).  I’ve practiced in each of these three areas but none as long as I have in infertility.

 

When I first started practice I felt the system of doctor-centred care where in-person appointments were made for every single patient concern or test felt inefficient.  I saw people suffering with anxiety with questions that could be answered with a quick phone call or email.  I saw people lose precious reproductive time waiting for appointments when electronic communication could speed things up dramatically.   We needed a shift to patient-centred care.

 

I was among the first group of doctors who tried to solve these communication issues by emailing and phoning patients far more than our predecessors.  We moved to electronic records so patients could see their own results immediately.  I believe rapid access to results and a doctor or nurse improves the patient experience.

 

 

The pandemic has caused another shift in patient care as we move to virtual/phone/video interactions.  I think it is good, but not great shift.

 

One significant change I have seen in the past year is the temperament of some patients.  It’s been a hard year on everyone but now more than ever we are seeing patients let out their anger and frustration on us.

 

Not one day goes by that our front receptionist isn’t set to tears by a partner angry we cannot allow them into the clinic.  Not a week goes by a nurse doesn’t come into my office considering quitting because of an abusive phone call from a patient.  On-line we used to see about one negative review a month. Today alone I answered three such reviews: one was complaining about a doctor who hasn’t even worked here in a few years, the others accused us of being greedy, others questioned our integrity,  and the list goes on.  One of the negative reviewers conceived on her second IUI with us and complained that we encouraged IVF.  Why so many negative, hateful, angry posts?  If I am remembering pre-pandemic days, the person who conceived on their second IUI sent a thank you note, not any angry Facebook review!

 

Last year we helped over 4000 people.  We did our best.  We cried for patients, we cheered for patients, we answer scared phone calls from bleeding women at 1am, we stayed late and came early. We did everything we could to keep our prices low and our pregnancy rates high.

 

Personally, I think the majority of patients are happy with the care we provide and forgive our imperfections as they would hope to be forgiven in their lives, too.  I think 95% of patients lead with kindness and understanding, but those 5% are either increasing in number or becoming more vocal.

 

It is really disheartening and I am honestly worried that if these negative voices keep propagating it will get harder to keep people working in the area of infertility.

 

 

 

Me? I am going to keep going. I love this work. I’m 47 and have lots of years left to practice, improve pregnancy rates and help 100% of the people who reach out for care… the highest quality of care.  Perhaps once the pandemic settles, and our communal stress decreases, there will be more peace and less anger. For now I will keep hoping the good reviews outweigh the bad, the good feelings and good outcomes outweigh the bad, and that kindness and patience will become the dominant emotions we all lead with……

 

 

If I can help please email me btaylor@olivefertility.com

 

 

 

 

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

frozen embryos

Spoiler: your embryo can be frozen for years and years with no harm to the pregnancy rate.

 

You’ve probably seen those funny, though a bit mean-spirited, memes on-line about “Florida Man.”   “Florida man” does reckless, silly or illegal things much more often than men from other parts of the world, it seems.  Like “Florida man steals car in jail parking lot after being released on charges of stealing a car.”

 

Anyway, this past week Florida man came up again but this time it was a real story and a good news one.  A Florida man and his wife received a donated embryo that had been frozen for 15 year.  After the embryo transfer, she had a successful pregnancy and birth of a health son.

 

Embryos, particularly those that are fast frozen or vitrified, can stay frozen in liquid nitrogen for years with no harm.  A meta-analysis of studies examining the impact of duration of freezing on pregnancy outcomes was published in March 2021 which affirms this statement.

 

The authors of the analysis state that  “…no dose-response association was found between duration of embryo cryostorage and survival rate, implantation rate, miscarriage rate, clinical pregnancy rate or congenital malformation rate.”

 

This is important for everyone with frozen embryos to know, particularly those people who do not plan to use their frozen embryo(s) for several months or years. Not just in Florida, but at every good IVF lab in the world.

 

 

Reference: Ma Y, Liu X, Shi G, Liu Y, Zhou S, Hou W, Xu Y. Storage Time of Cryopreserved Embryos and Pregnancy Outcomes: A Dose-Response Meta-Analysis. Geburtshilfe Frauenheilkd. 2021 Mar;81(3):311-320.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

over the counter analgesics in pregnancy

Do you notice how IG influencers often start posts with “I always get asked about…”. Let me start this blog with that same phrase. Haha

 

I always get asked about medications in pregnancy.  Which ones are safe?  The FDA uses a class or category system for drugs in pregnancy:

 

Category A

Adequate and well-controlled studies have failed to demonstrate a risk to the fetus in the first trimester of pregnancy (and there is no evidence of risk in later trimesters).

Example drugs or substances: levothyroxine, folic acid

 

 

Category B

Animal reproduction studies have failed to demonstrate a risk to the fetus and there are no adequate and well-controlled studies in pregnant women.

Example drugs: metformin, amoxicillin

 

Category C

Animal reproduction studies have shown an adverse effect on the fetus and there are no adequate and well-controlled studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Example drugs: gabapentin, trazodone

 

Category D

There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks.

Example drugs: losartan

 

Category X

Studies in animals or humans have demonstrated fetal abnormalities and/or there is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience, and the risks involved in use of the drug in pregnant women clearly outweigh potential benefits.

Example drugs: methotrexate, finasteride

 

 

We follow this guidance.  Until 2019 we also leaned on the MotherRisk program out of Sick Kids Hospital in Toronto for advice and to stay up to date on the latest information on drugs in pregnancy.  Now, we look for data from several different sources.

 

In any case, I am often asked about the safety of medications in pregnancy.  The category of prescription medications are often known, but what about over the counter medications?

 

I am often surprised at what items people are taking based on non-medical advice and it worries me.  I am a worry wart (probably a good quality in a doctor, but it also means I bite my nails and lie awake worry about patients many nights).  I am also quite conservative in all my advice (e.g. I tell pregnant women not to have sex or exercise aggressively until successful past 8-10 weeks of pregnancy based on no good evidence).

 

Anyway, a very well done review of common over the counter medication (Tylenol/paracetamol, NSAIDs and aspirin) use in pregnancy drives home that being a worry wart about medications in pregnancy is a good idea.

 

Reference: Zafeiri A, Mitchell RT, Hay DC, Fowler PA. Over-the-counter analgesics during pregnancy: a comprehensive review of global prevalence and offspring safety. Hum Reprod Update. 2021 Jan 4;27(1):67-95.

 

What does this review of studies on over the counter analgesics tell us?

 

  • Aspirin is clearly safe.
  • NSAIDs (e.g. Advil) are clearly not safe
  • Tylenol is more controversial with some studies suggesting an increased risk of ADHD and ASD, while other studies not suggesting such an association.

 

The authors suggest (as they often do) that more research on duration and timing of exposure is needed.   I think this review is comprehensive enough and includes a large enough number of pregnant women that, from it, we can advice pregnant women to avoid over the counter analgesics like NSAIDs and Tylenol if possible.  Of course, everyone must weigh the risks of using these medications and the benefits.

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

treatment of miscarriage

I’d like a job that only involves delivering good news to people. No negative news. The CRA employee who tells people about larger than expected tax refunds or the dog breeder who tells you about the birth of your new puppy.

 

In health care, most jobs involve sharing good news and bad news with people.  The bad news  in fertility care is:

 

  • Your eggs or sperm are not healthy enough to make a child
  • You have no useable embryos
  • You are not pregnant
  • You are having a miscarriage

 

We tell people about miscarriage if the beta HCG blood levels are not rising they way they should or we do not see a healthy fetus on ultrasound.  If the miscarriage is diagnosed just based on an abnormally rising beta HCG blood level, then the management is typically just to wait for the period to begin. The period will often be heavier and longer than usual.  If the diagnosis of miscarriage is made with ultrasound then treatment decisions are discussed.  The possibly management options for later first trimester miscarriages are:

 

  • Expectant management, or “wait and see”
  • D&C
  • Medical management (e.g. mifegymiso)

 

There are pros and cons to each option.  D&C comes with a 95% success rate of clearing the uterus, but involves surgery and the (small) risk of infection, uterine perforation and bleeding.  Mifegymiso is more painful and the success rate of clearing the uterus that is is lower at about 85%.  Expectant management is even less successful.

 

A recent publication in Fertility & Sterility reassures us that there is no wrong choice of treatment, with respect to furture fertility.  This study examined pregnancy rates at 6 months after medical or surgical (D&C) management of miscarriage and found similar rates: 68% of women who underwent medical management and 65% of those who had surgical management were pregnant again.


Most of our patients are Olive who miscarry opt for medical management for the advantages of privacy, low intervention, self-scheduling, and the avoidance of the (small) surgical risks of D&C.   For many reasons, including further pregnancy rates, this is a good choice.

 

While a miscarriage is a devastating outcome of a desperately wanted pregnant, the small bit of good news we can share is that there is a good chance of a pregnancy in the following months, no matter what treatment is chosen,.

 

Reference: Tzur Y, Samueloff O, Raz Y, Bar-On S, Laskov I, Tzur T. Conception rates after medical versus surgical evacuation of early miscarriage. Fertil Steril. 2021 Jan;115(1):118-124.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

2020

Good bye 2020! The year started with great optimism. At Olive our pregnancy rates were stable or higher than the months before, we were getting started with a few new research projects, we were teaching ob/gyn residents and had a great REI fellow who was working well. We were helping lots of people and the clinic was humming.   On a person level, I had a couple of fun vacations planned and the year was shaping up well.

 

We heard about a virus in wet markets in China in February and (speaking for myself!), thought it would be contained quickly.  Then March came in like a lion as cases started to climb around the world.  Governments, hospitals and other institutions started to get worried.  We cancelled vacations, stopped socializing and started to get worried too.  I actually caught COVID and was ill in mid-March.

 

Doctors switched to Telehealth and meetings became Zoom sessions and school children stayed home.  Some people panic bought staples - yeast and toilet paper were hard to find.  We tuned in every day to hear our pubic health leaders try to guide us with less data but more wisdom than we thought was available.

 

Though we weren’t told to close, we did in late April for about 6 weeks.  We stayed open only to help a couple of women who had been diagnosed with cancer in mid-April and needed to freeze their eggs.

 

During those 6 weeks doctors, many nurses and other staff continued to work to keep the clinic running remotely - answering patient’s worries and sorting out what would happen when we opened.  We had meeting after meeting to come up with a framework to safely open in a pandemic.  Standard Operating Procedures were developed, the waiting room was rearranged to rid us of fabric that could not be wiped clean, we hired COVID screeners and extra cleaning staff.  Olive staff rose, banded together and surprised even themselves in managing a crisis like COVID.  Some patients were stressed, angry, and scared. Many were deeply grateful that we kept working, stayed available and opened again, safely.  Some were sad to learn we could no longer allow partners in the clinic unless necessary.   What a rollercoaster ride patients were on, in the midst of the already challenging ride of infertility.

 

When we re-opened there was enormous uncertainty at Olive and in the larger community. What are we supposed to do it we are exposed to someone who had COVID?  When are we supposed to isolate? What is the difference between isolating and quarantining?  So many questions that only time and more data could answer.

 

In the fall people wondered about the impact of COVID on pregnancy (seems to be much like a severe flu - not a cause to delay conceiving) and now as winter settles we wonder about the vaccine (still not entirely clear but if you get it wait 2 months to conceive; Likely safe in pregnancy but no data so unless you are high risk to catch COVID (e.g. a health care worker) not necessarily recommended for you to be vaccinated in pregnancy - stay tuned as this will change as data emerges!).

 

Certainly there were many heavy, hard things about COVID.  There were many good things too: fewer infectious illnesses overall, a change to focus on the essentials of life, fewer hours spent commuting, lower carbon emissions, better appreciation of our essential workers…..

 

Thank you.  Thank you to our patients for their patience as we navigated 2020.  Thank you to our staff for finding a way to say “yes” during uncertain times, working overtime, bringing your best selves on days when it was scary to even show up at all.

 

Best wishes for 2021.

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

COVID and egg freezing

I love stories. Podcasts like Serial, S-Town, Dying for Sex, and The Shrink Next Door keep me parked in my car listening outside my house, when I should have gone inside long ago.   When I was in my 20s I watched Dateline, read autobiographies and start searching for the stories of my family.  Not all stories are good ones or well told, but they all still have value.

 

The stories that will come out of 2020 will be sad, amazing, boring, scary, and surprising.

 

How a vaccine, when unhindered by bureaucracy and funding limitations, could be brought to people in months.

 

How people expressed gratitude to the often ignored workers in our community like the delivery person or hospital cleaner.

 

How so many elderly in long term care died alone from COVID.

 

How parents and teachers pivoted on short notice to home school children.

 

How science was questioned and common sense ignored in some countries resulted in unnecessary loss of life.

 

The stories from the fertility world are just starting to become known.  As people were locked down and contraception became harder to access (like all health care), a baby boom became likely in many countries.  Early reports from the US, however suggest couples in affluent demographic groups were less like to want to conceive - many reporting a desire to delay childbearing until the health and societal significance of the pandemic becomes more clear.

 

In the world of fertility care, we saw a marked increase in demand for egg freezing.  As COVID put dating largely on hold, single women got worried.  Most women in their 30s know the harm the passage of time has on their fertility and they know that with each year the chance of having a child with their own eggs drops.  Single women in their 30s, unable to date, unable to plan a pregnancy (unless they wished to do it as single women), took control and frozen their eggs in record numbers.

 

We weren’t the only clinic noticing this increase in requests for egg freezing. An article in The Lily (a women’s newspaper out of the US) discusses the phenomena of pandemic egg freezing and it most certainly could be about our clinic.

 

It’s a smart move in many ways, especially for those in their 30s who know that having children in a few years away - storing eggs for the future is wise.

 

What else will we look back and consider having been a smart move, nudged on by the pandemic?  Probably not spending hours making sour dough bread, in my opinion.  Perhaps it will be our new devotion to home. Perhaps better hygiene.

 

I’m going to enjoy slowing down over the holidays and read stories about how this pandemic has shifted our world for the better.

 

If you have questions about egg freezing, email me (btaylor@olivefertility.com) or get a referral to us from a family physician to have a consult with one of our fertility doctors.

 

 

 

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

Clinic rules

These COVID times are hard times.  They are.  We are trying our very best to stay open to keep helping people. A condition of staying open is that we do not permit non-essential visitors to the clinic. We cannot allow partners, children or other support people in the clinic, sadly.  Everyone must wear a mask.  No one can come into the clinic (staff or patient) who does not pass the COVID screening questions.

 

Every day people are still asking us to make exceptions to these rules.  I get it – this is a hard process made harder if you cannot have the people you need around you.   Ultimately, though, we are choosing between staying open and breaking the rules.

 

Everyone at Olive hates saying “no” to these daily requests, but we must.  So, please, please respect our guidelines.  These guidelines help keep people safe and are not meant to be punitive or unreasonable.  We just want to stay open and help people grow their families!

 

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

Chrissy Teigen

I like social media. I love flipping through seeing my great aunts share recipes, see where old friends from high school are vacationing, reading celebrities post about political events, etc.  One celebrity I follow is Chrissy Teigen. I like her a lot.  I like her cookbooks and I like her style.

 

Two nights ago I was scrolling through instagram and saw her post about losing her son Jack in the second trimester.  The photos are incredible and her words deeply moving. I cried. I also felt blown away by her honesty and openness.  She has been criticized for sharing this loss and I can’t figure out why.  Why is there anger or hate when another human tells their story?  Maybe I wouldn’t tell it the same way, or at all, but to criticize another person is mean.  I wonder if it’s sexism, too.

 

Fortunately most people have been praising her. After all, she is not alone.  Many of us have experienced pregnancy loss. I have. About 30% of pregnancies are lost in the first trimester and about 1% are lost in the second trimester.

 

I diagnosed a patient yesterday with a miscarriage and she mentioned Chrissy’s story. Another woman I told she wasn’t pregnant this month and she said “it’s ok, I read Chrissy Teigen’s story and things could be worse.”  That, that is the value of sharing our sad, crushing, heartbreaking losses. It helps.

 

 

Social media has plenty of shortcomings.  I tell my teenage daughters to ignore the perfect images portrayed by filtered influencers and remember that many of those portrayal are inaccurate.  I’ve shown them my photo on our website and they saw my nearly perfect skin.  Anyone who has seen me in person knows I have terrible acne with scarring.  That imperfect side of us needs to be shared.  From small things like imperfect skin to the enormous things like the loss of a child.

 

There are support groups in most large communities for pregnancy loss. I want to highlight this organization: The ButterFly Run.  It is a run for charity to support pregnancy loss programs at BC Women's Hospital.  I like their website's resources page.  The run is virtual this year and happens this weekend. Last year a group of Olive staff ran and we plan to run every year - this is what we live and support.

 

Thanks to women like Chrissy and those countless others who work to help women and men who experience such enormous heart break.

 

Dr. Beth Taylor

 

 

 

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility

Be kind, be calm, be safe

I had my eyebrows waxed this morning.  They were overdue but people really can’t see that sort of facial detail on a Zoom call, so I had let it slide.  On the drive to the brow studio my daughter asked me if I know any “Karens” and, after sorting out how a 10 year old knows this reference, explained that I did not know any “Karens.” I also said that I didn’t like much of this whole “Karen” insult to women.  Anyway, I left the car and went to have my brows done. While I was in the chair an actual, real life “Karen” came in behind me.  She was very rude to the poor receptionist asking why she needed to do another COVID questionnaire when she had been to this salon in the past.  The receptionist tried her best to help her complete the COVID questionnaire and absorb the terrible snarkiness she was being dealt. I felt terrible for the receptionist.

 

The world is a stressful place. We are all feeling it and it is really understandable that we let our frustrations out on the people around us.

 

Our staff at Olive are feeling the stress too.  While the vast majority of people coming to the clinic are lovely, as always, we are seeing more and more aggressive, angry patients. We have staff in tears, staff considering quitting, and staff on stress leave.  We even had a senior IVF nurse with over a decade of experience in this field go to the Emergency Room with a panic attack recently.  This level of stress is new for us since the COVID pandemic began.

 

What is upsetting people?

 

We cannot have partners or patient support people in the clinic as we have to limit the number of people per square feet in the clinic to comply with Work Safe BC and the Ministry Of Health.  This is very sad; we know how hard the information is to process, and procedures are to experience, alone. It adds a new level of stress to patients.

 

We are limiting the number of in-person visits and have moved some of our IVF education to an on-line format. This is less personal than we’d like, but it does allow us to stay open and continue to help people.

 

Our international patients have to isolate for 2 weeks in Canada before they can come to the clinic. This adds a huge barrier to care for them and drives up the cost of an already expensive endeavour.

 

This is not ideal. We have always been proud of our patient-centred model of care.  COVID is making it hard to meet that standard, I have to admit.

 

We are truly doing our best to “be kind, be calm and be safe” as Dr. Bonnie Henry would want. We ask for your understanding.

 

Let’s hope our COVID restrictions will do be a thing of the past soon.

 

Dr. Beth Taylor

Dr. Beth Taylor MD, FRCSC
Reproductive Endocrinology & Infertility