Vitamin D is a fat soluble vitamin that is present in a variety of forms but has recently been recognized as playing a critical role in reproduction.  It is essential in the production of sex hormones in the body.  It is thought that a deficiency of Vitamin D may lead among other things to ovulation disorders.

It has been demonstrated that Vitamin D deficient rats had a 75% reduced fertility and a 50% smaller litter size that was corrected with Vitamin D treatment.  In addition, sperm motility in males was reduced in the presence of a Vitamin D deficiency.

A recent study at the Yale University School of Medicine revealed that only 7% of 67 infertile women studied had normal Vitamin D levels and not a single woman with an ovulatory disorder had normal levels.  Nearly 40% of women with ovulatory dysfunction had a clinical deficiency of Vitamin D.

At the American Society of Reproductive Medicine conference this year, a study presented by Dr. Briana Rudick from USC showed that a deficiency of Vitamin D can also have a detrimental effect on pregnancy rates after IVF, possibly through an effect on the[O1] endometrial lining of the uterus.   In her study only 42% of the infertile women going through IVF had normal Vitamin D levels.  Vitamin D levels did not impact the number of ampules of gonadotropin utilized nor the number of eggs stimulated, embryos created nor embro quality.  However, Vitamin D levels did significantly effect pregnancy rates even when controlled for number of embryos transferred and embryo quality.  In this study the pregnancy rate dropped from 51% in Caucasian women undergoing IVF who had normal Vitamin D levels to 44% in those with insufficient levels and 19% in those that were deficient.

Vitamin D deficiency has also been associated with poor pregnancy outcomes including preeclampsia and gestational diabetes

Vitamin D can be obtained for free by sitting out in the sun and getting sun exposure on the arms and legs for 15-20 minutes per day during peak sunlight hours.  The sunlight helps the skin to create Vitamin D3 that is then transformed into the active form of Vitamin D by the kidneys and liver.   An oral supplement is available also in the form of Vitamin D3, with a minimum recommended amount of 1000 IU a day for women planning on becoming pregnant.  For those with clinical insufficiencies a higher dose may be administered by injection.

IVF’s Early Years

Practicing reproductive medicine during the ’80s was like having a new love or beginning a new romance — all of it seemed liked a miracle, and everything was about helping patients get pregnant using this new technology and educating the world about what was now possible. This was an exciting time, and the 15 percent pregnancy rate was achieved by transferring six embryos at a time.

But our excitement was often tempered by the consequence we experienced with many high order multiple pregnancies. Unfortunately, these were often complicated and did not always end well. Aside from pregnancy and neonatal complications, many of the marriages also suffered. It was hard to balance a new family’s anticipation and heartfelt joy with the sometimes painful and unforeseen consequences — babies who suffered and families that fell apart.

Sometimes beginnings are like that. They start off so bright, and then they get tempered.

The Middle Years—Safer and Not So Sexy

Thankfully, I am now in the “middle years,” of IVF which is so much more successful and no less a miracle. We can attain pregnancies in greater than 60 percent of retrievals for women under 40. These rates are accomplished while transferring one, two or, at most, three embryos at a time. Cryopreservation, or freezing embryos, has also improved our pregnancy rates per retrieval, giving us multiple opportunities to get a patient to conceive from a single IVF stimulation and retrieval.

The middle years of IVF are not like the beginnings of a romance — this is the wood chopping time. The freshness of the technology has worn off, and the focus on making the treatment affordable, accessible and safe may not seem as sexy. But it is the middle years of any pursuit — whether it is marriage, raising a child or practicing medicine — in which the gold is often mined.

A Time for Reason, Not Headlines

The middle years of my practice mean we are making an effort to encourage safer single-embryo transfer and avoid risky multiple pregnancies. We introduced a program in 2007 at East Coast Fertility for patients who transferred one embryo at a time, offering free cryopreservation, storage and frozen embryo transfers until a live baby was born.

Still, patients don’t commonly choose single-embryo transfer. They haven’t seen what I have seen — they still believe that the technology will some how fail them, that IVF won’t work. But from our experience, similar to others’, there was no significant difference in pregnancy rates between patients who chose to transfer one embryo vs. those who chose to transfer two embryos.

While there was a trend toward higher rates for the two-embryo transfer group, it was practically eliminated when frozen embryo transfers were added. These groups were age-matched with no difference except for a 40 percent twin rate and one triplet in the two-embryo transfer group, compared to the single-embryo transfer group in which no twins were created.

It is hoped that these results will encourage a higher percentage of patients with a good prognosis to transfer a single embryo, which is the safer option.

The middle years of practicing reproductive endocrinology captivate my heart. It is a time for reason — not headlines. And for me that is just perfect.

Many husbands pride themselves in their new found skill with mixing medications and administering injections for their wives. It helps many men who are used to caring for their wives to be in control of administering the medication for them. Successful IVF then becomes something he’s has played a very active role in and related better to the experience, his wife and the resulting baby.

Despite a lack of prior experience, most people can learn to prepare and administer the medication. Whether it is the feeling of “playing doctor” or the knowledge that he is contributing significantly in the process and supporting his wife, most men relate that giving their wives the injections was a positive experience for them and for their relationship.

Along the same line of thinking, accompanying your wife at the time of embryo transfer can be most rewarding. This can be a highly emotional procedure. Your embryo/s is being placed in the womb and at least in that moment many women feel as if they are pregnant. Life may be starting here and it is wonderful to share this moment with your wife. Perhaps you may keep the Petri dish as a keepsake as the “baby’s first crib”. It is an experience a husband and wife are not likely to forget as their first time together as a family. I strongly recommend that men don those scrubs, hats and booties and join their wines and partners as the physician transfers the embryos from the dish into her womb. Nine months later do the same at delivery for memories that last a lifetime.

Among the guests was a family friend, Conrad, who talked about the old neighborhood. He grew up in Kew Gardens and I was from Queens Village and Floral Park. Conrad asked me if I remembered playing handball and what would happen when the ball hit a crack on the floor and took an awkward bounce away from its original path, preventing a player from returning the ball cleanly. “It was called a Hindu and you got to do the point over.” Yes, I remembered “Hindus” and “do overs” and thought to myself that it would be an ingenious concept if we could extend the “do over” beyond the game to life in general.

Who hasn’t come across some crack in their path that causes an unexpected detour? My patients grow up expecting that they, like everyone else, can create their own family when they reach a stage in their lives, perhaps married and financially and emotionally secure. When a woman does not get pregnant as expected, it’s as if she hits that crack in her path — just like the handball — and her life gets thrown off track. If only she could get that “do over” and set her life back on its rightful path.

We also see these “Hindus” in our IVF cycles especially when a patient develops an LH surge and her ovulation is accelerated so that her eggs and ovulation are affected prior to retrieval.

Perhaps we need to consider the “do over” rule. IVF is a great way to give a couple a second chance to replay their errant family building when a “crack” in their fertility prevents successful procreation.

Fortunately, Rebeka’s parents got a “do over” and now, 22 years later, are celebrating their baby’s college graduation.

Life can throw a lot of cracks in our path that will detour us along our way. We should help each other by offering “do overs” whenever we have the opportunity.

I was feeling depressed the other day.  It seemed that we had insurmountable computer issues, staff morale was down and my family was acting rebellious.  My kids were arguing with each other, with me and I found myself mindlessly walking out of my office down Old Country Road.

I came to a busy intersection and just stood there as cars sped by me.  Honestly, at that moment in time I was thinking, why am I here?  Why put up with all the hard work at the office trying to make the practice viable despite the pressures of the recession?  Insurance companies were denying claims and when they were paying claims, it was at lower reimbursements that threatened to not compensate for our expenses.  The government was planning to lower reimbursements even more.  Patients, also experiencing financial difficulties were either asking for more breaks in the fees or not paying.  I have to admit I gave thought to giving it all up as the pain and aggravations were not worth the efforts.

Suddenly, a white Audi convertible came to a screeching stop right next to me.  It was one of my patients in the passenger seat sporting a very pregnant belly and apparently blowing through what I assumed was a labor pain.  Her husband spoke.  “Dr. Kreiner, Lara went into labor early this morning and we are on our way to the hospital to have the baby…can you come with us?”  Speechless and shocked, I let myself into the cramped backseat and tried to comprehend what was happening as Lara’s husband took off.

We pulled into the emergency room five minutes later.  Lara and I were taken to the labor floor while her husband dealt with the paperwork at the desk.  Nurse’s barked orders, the doctor was called, and Lara started screaming during her pains and in this laboring frenzy I was awakened from my funk.  It has been awhile since I was involved in a delivery but this baby was not waiting for the doctor and I got back into obstetrical mode, checking the baby’s position and heart rate and getting the anesthesiologist to administer the epidural.  Lara’s husband was now at her side assisting her with her breathing.

“Push Lara, push”, I yelled as I saw the baby’s head crowning.  She and her husband acted as if they had trained all pregnancy for this moment, working together as a team, his arm around her shoulders, breathing with her and supporting her back as she pushed.

Well, the doctor got there just before the baby was delivering.  I stood on the side watching this miraculous event…Lara and her husband together pushing the baby out of the same womb that I had implanted nine months earlier.  I remembered the image of showing Lara and her husband the photograph of the embryo and then watching on ultrasound as I injected the drop of media and air bubble containing the microscopic embryo into her uterus.  I thought how sweet life was and I smiled.

Moments later, Lara put baby Adam to breast, her husband a proud new father was beaming as he gave out chocolate cigars to the doctor and nurses and then came to me with tears in his eyes and said, “thank you, so much Dr. Kreiner.  We could never have done this without you.  This will be my first Father’s Day and I couldn’t be happier.”

What can I say?  It was as if my problems never existed.  I thought the only thing missing for me was to be with my family and appreciate what I have.  And what my wife and I have is truly amazing.  We have my two lovely daughters and two sons, one with a fantastic girlfriend who he just moved in with and another son who has the best wife and most gorgeous three children one can ever wish for.  Playing with them, having brunch and dinner with the family I love, I enjoyed a very Happy Father’s Day.

I grew up on baseball in the 1960’s with the likes of Mickey Mantle and Roger Maris.  A few years later Tom Seaver and the Miracle Mets held my fancy.  Over the years I have been intrigued by many baseball spectaculars such as Mark McGwire and his run to break Roger Maris’s homerun record and Barry Bonds’s overcoming Mark McGwire’s record.  Roger Clemens winning his 300^th game and pitching his 3000^th strikeout was unforgettable.  I was enchanted with these baseball heroes when they achieved their record breaking accomplishments.

Then the story about how modern day athletes were using steroids became public and the glory of those heroes from the past 20 years disappeared.  Many of us lost our youthful innocence with the discovery that steroids had intruded into the daily routines of professional baseball.  But as my bubby (my Russian grandma) used to say; c’est la vie.  At least that was the French translation.

This week someone’s little boy who was pitching in the big leagues for the first year had a perfect game, meaning no batter reached first base the entire game with only one out to go.  This is a rarity in baseball having previously occurred only 20 times in major league history.   The final out was weakly hit, a ground ball to the infield, the pitcher covering first base beat the batter, and the throw was caught before the batter reached the bag.  Replays documented the batter was out but unfortunately, the umpire mistakenly shot his arms out signifying a safe sign thus preventing the last out which would have made this a rare perfect game.

So why should I blog about a botched call ruining a perfect game?  This arbitrary wrong turn of events which prevented a perfect game crushed me emotionally the same day my patient who I wanted so much to have her baby, miscarried after 3 years of trying to conceive.  She, like the rookie, Galarraga, deserved to have their day, the perfect game, the perfect baby.  Randomly, both were denied.  How is an individual who has such hopes, dreams and aspirations focused on the denied event to deal with this catastrophic disappointment?

As an observer of both, I was feeling distraught, angry, pushing me to cry out for justice for some supernatural power to make things right again.

Forty five minutes after the game after umpire, Jim Joyce, had the opportunity to review the play he went to the dugout to speak with pitcher, Armando Galarraga.  He apologized to the pitcher for spoiling his slice of fame. … There were few words, just a deep apology, as tears welled in Joyce’s eyes. “He feels really bad, probably worse than me,” said Galaragga, who began the season in the minors in Toledo. “I give a lot of credit to that guy, to say he’s sorry. I gave him a hug. His body English said more than the words. Nobody’s perfect, everybody’s human.”

We, in the field of infertility face disappointments as regularly and the menstrual cycle.  When a pregnancy is conceived, in our minds, the “perfect baby” is essentially created.  Miscarriage, the loss of one’s “perfect baby” seems to be a life crushing blow.  Perhaps, we can gain strength from the story about these two men, Armando Galarraga and Jim Joyce, who were able to reconcile this catastrophic schism in their path to obtaining their “perfect” goal and move forward to the next game.

Thank you, Armando and Jim for helping us to see the way.  After all, if you can get this close once only to miss because of a random mistake, then why can’t we expect that we have a good shot that it will work next time?

In the mean time, again as my Bubby would say, “Play ball”.

My son is starting his second year residency in obstetrics and gynecology. He, like I was 30 years ago, is turned on by reproductive medicine and enjoys performing gynecologic surgery. When I decided then to specialize in reproductive endocrinology and infertility (REI) I was looking forward to being on the frontier of fertility medicine. The details of Reproductive physiology were being unraveled in real time and IVF had just reported its first successful pregnancies. In those days, microsurgery of the fallopian tubes was commonly performed by REIs as well as endometriosis and fibroid surgery.

During my fellowship, surgery was a huge part of my training. I travelled to Nashville to train with one of the world’s experts in laser laparoscopy. I practiced my tubal microsurgery skills weekly on anesthetized rats in a plastic surgical lab. I assisted on reproductive surgery several cases every week throughout my fellowship.

Myself and other fellows performed research on basic reproductive physiology questions that had yet to be worked out. Personally, my interest was polycystic ovarian disease and its relationship to weight gain. I studied male hormone production in the ovary and the adrenal gland before and after significant weight loss. I discovered that there was an inverse relationship between weight loss and male hormone production and that this was mediated through insulin. These were exciting times. If only we had metformin back then, I would have proven that in addition to weight loss, we could decrease insulin levels and therefore male hormone levels with metformin.

Today, discoveries in reproductive physiology are much more esoteric than it was when I was a fellow. Reproductive surgery, in particular tubal microsurgery and laser laparoscopy for endometriosis and adhesions is usually replaced with in vitro fertilization (IVF) which has become so much more successful, less invasive and therefore a preferable option. Most causes of infertility, if they are not successfully treated with ovulation induction and intrauterine insemination (IUI) can be overcome with IVF.

In the 1980’s when I was a fellow, IVF was grossly inefficient and we had to transfer multiple embryos to achieve a pregnancy. Consequently, triplets and quadruplets were not rare occurrences. In many programs, they constituted over 10% of all pregnancies. Today, we can often transfer one embryo at a time minimizing the risk of multiple pregnancies. We can freeze excess embryos so many patients need go through only one stimulation and retrieval and still have multiple transfers providing them with an excellent chance of conceiving a baby from their efforts.

Today, we get excited about advances in preembryo genetic screening and diagnosis and contemplate the current and future potential of eliminating hereditary medical disorders. This involves highly trained laboratory personnel who perform the latest technologic advances. In 2010, the REI, in general is removed from a hands on involvement with the frontiers of Reproductive Medicine and instead works like a film producer gathering his team including these lab personnel, nurses, etc and directing them as to how to approach his patients’ fertility problems. It used to be that he used the microscope and laser laparoscope to perform the tubal and endometriosis surgery. The IVF retrieval and transfer were new procedures that were still being perfected.

Today, they are the routine cases performed daily by the REI.

My son looks at the REI of today as a doctor who starts his day with 1-2 hours of ultrasound that is part of the daily ovulation monitoring for IUI and IVF. Many REIs no longer perform more surgery than hysteroscopy and occasional laparoscopy or myomectomy in addition to their retrievals. These are all considered routine procedures now. The current frontier in infertility is limited pretty much to the laboratory. Though many of us consider ourselves expert in stimulations, retrievals and transfers and while we know we make a significant difference in our patients’ outcomes our work does not appear or feel as glamorous as it once did. Perhaps, he will decide, as I did, that the pleasure in helping women build their families is sufficient reward. Or perhaps, this Nintendo generation, will seek a more apparently exciting lifestyle. How about that Robotic surgery?

It was fifteen years ago that I sat listening to a lecture about the hazards of multiple pregnancy and how IVF had increased multiples so drastically in the preceding ten years. What a depressing thought. I loved helping women conceive. I was living my dream, practicing the infertility and IVF I had learned ten years earlier at the Jones Institute with Howard and Georgeanna Jones themselves as well as Zev Rosenwaks and other masters of the IVF craft.
I had seen quadruplets created first hand as a result of our IVF efforts. But, that was a necessary side effect of transferring a sufficient number of embryos to offer a patient a reasonable chance for a successful transfer. IVF was very inefficient back then and our pregnancy rate even in 1995 with transferring 3-4 embryos was at best 40%.
The sobering truth is that multiple pregnancies — even with ‘just’ twins — are sometimes dangerous to the health and well-being of mother and babies let alone the triplets that were still occurring in 7-10% of the pregnancies at the time.
Since then, thanks to dedicated research to fine-tune IVF, much has been learned about both clinical practice and laboratory technique. IVF is no longer experimental and is currently much more efficient so that the live birth rate for women under 35 years of age at East Coast Fertility is greater than 60% per retrieval.
One of the most important recent developments — single embryo transfer, or SET — is being consistently backed up by study after study as the optimal IVF method for patients with a good prognosis.
The SET Program
The safest pregnancy with the greatest chances for an optimal outcome — a healthy baby — is a singleton pregnancy. In 2007, East Coast Fertility started leading the field of reproductive medicine by establishing our own SET Program.
Confidence in our high quality embryology laboratory and immensely successful embryo cryopreservation program has afforded ECF the ability to limit the number of embryos transferred, essentially eliminating the risk of triplets or more.
We analyzed our success with elective single embryo transfer and compared it to our success with elective double embryo transfer since the opening of our lab in 2005.
Fresh eSET was less likely to result in pregnancy than eDET 39/75=52% vs. 342/561=61% though this difference was not significant statistically. When frozen embryo transfer pregnancies were added this difference was 64% vs. 68.3%. There were no multiples in the eSET group but a 27.8% twin rate in the eDET group with 2 cases of triplets. So to encourage patients with good prognosis to utilize SET, we offer the following incentive:
For the cost of an IVF cycle, SET Program patients will receive free cryopreservation of their embryos, free storage and free frozen embryo transfers until they have a baby. This represents a savings of up to over $12,000. It also ensures a much better chance of a healthy baby.
Is SET for you?
Each patient’s case is considered individually. Each factor impacting conception and pregnancy is taken into account, such as; the age of a patient, embryo quality, the number of prior failed IVF cycles and embryo quality. Single embryo transfer is appropriate in certain situations where the likelihood of a multiple pregnancy is high, including; women younger than 35 years, women who conceived with first IVF cycle, women with concerns about multiple gestation and donor egg recipients.
Single Embryo Transfer is revolutionizing the practice of reproductive medicine, and the team at East Coast Fertility is committed to their collective pledge to lead the way in creating safe, healthy pregnancies.

The case of a mix-up of frozen embryos in a Michigan IVF program in Feb. 2009 yet again became a media splash with the affected couple appearing on ABC News to promote their new book, “Misconceptions”.  The couple who already had a set of twins as a result of a successful IVF recounts a story about their experience including the fact that the frozen embryos were mistakenly transferred into the wrong woman.  This woman carried the pregnancy and after delivery handed the baby back to his biological parents.  Reports of the mix-up have triggered calls from a few to make IVF illegal.

Mixing up gametes and embryos is tragic and society must do everything humanly possible to prevent such a mix up except disallow the practice of IVF.  As with other societal advances, accidents have rarely and unfortunately happened in the field of IVF but, weighed against the benefit of all the babies who otherwise would never have been born, we should strive to improve the safety of IVF, not eliminate it.

Many of the greatest advances have had tragic results, unintended accidents that should have been avoided. Usually, they are the result of human error often preventable with the institution of carefully designed safeguards with a system of checks and balances.

Significant risk, including that of injury or death, is part of nearly everything we do in life today. The construction industry has always been plagued with accidental deaths. Not a bridge or a great high rise has been completed without misfortune. Do we stop construction? No, we ensure that all possible regulations that could protect those involved are in place and followed as strictly as possible to prevent further accidents.

Nuclear power is controversial because of the fear of accidents. Despite past accidents at Chernobyl and Three Mile Island, nuclear power plants continue to be constructed throughout the world because it is perceived that the possible benefits of this alternate source of energy outweighs the concerns for the risks.

Cardiac bypass surgery and other surgeries save lives and relieve suffering but, occasionally, patients intended to benefit are hurt or even killed accidentally. Rules and regulations are instituted to avoid problems such as performing the wrong operation on the wrong patient, using the wrong medication, operating on the wrong limb. Yet situations rarely occur, usually because of a human slip. Rules are broken and mistakes result.  When they do hospitals review the procedures and protocols and insure a sufficient system is in place to catch errors before they have an effect on patient care.

Just as we have safeguards in the operating room, we have them in place for identifying gametes and embryos with checks and balances that should prevent a mix-up such as the one in this case.

In the operating room, patients are identified while they are awake by the embryologist, nurse, physician and anesthesiologist by full name and birth date. As soon as the ovaries are aspirated, the eggs are identified and put in dishes with the patient’s full name and birth date on them. When the dishes are changed to replace the media, again matching names are put on the new dishes with a unique case number. A partner’s sperm specimen is labeled by him and processed in tubes labeled to match the partner’s name and the corresponding patient’s name and the case number. This is doubly checked with the patient’s record which will also reflect the unique case number. It is reviewed by two embryologists for accuracy prior to fertilization. Finally, when the embryo is loaded in a catheter for transfer, the identity of the dish from the embryo is checked by the physician, embryologist, nurse and the patient herself prior to the transfer being performed.

Every attempt is made to confirm the identity of the gametes and embryos throughout the IVF process prior to transfer. In 25 years of practicing IVF, my program has not mixed up gametes or embryos.

There are approximately 1 million babies born through IVF and only a few rare mix ups reported.

Perhaps we don’t hear about every mix up. I’d estimate that between 1/50,000 and 1/100,000 pregnancies from IVF have occurred with some mix up in the embryo or gamete. When it occurs, it is tragic and requires the attention of our field and a refocus on those checks and balances we have in place to prevent such mishaps.

I work hard and I pray that we do everything possible so that this never happens again. The FDA regulates gamete donation. The New York State Department of Health regulates our labs and our operating rooms. These checks and balances are in place and are included in the monitoring performed by these agencies.

Perhaps, if the other states required as strict a monitoring to ensure their clinics and doctors are adhering to the necessary safeguards as well then the mix-ups would not occur.

Happy New Year! If you are like my patients, this traditional holiday wish/greeting is a heartfelt hope, a wish that 2010 will bring you the family of your dreams. In the very least, your most important resolution for the new year is to build the foundation for that family you always assumed you would have.

But, how do you get started when it isn’t happening on its own?

First, if you are thinking about getting pregnant get a check up! Get your pap done – go to the dentist – have your blood pressure and lipids checked. I’m not an expert on the art of motorcycle maintenance, but our bodies, like machines, go through wear and tear and, as a result, occasionally are not operating at optimum capacity.

Here’s what needs to happen for a life to be created. Millions of sperm need to traverse the cervix (which needs to have adequate watery mucus for the sperm to swim through to get to the uterus) and, from there, to the fallopian tubes where, enmasse, the sperm gang release digestive enzymes that help bore a hole through the egg membrane. Your egg needs to be healthy and mature, picked up by the finmbria, the fingerlike projections of the fallopian tube and swept along the length of the tube by microscopic hairs within the tube. The environment of the tube needs to allow for fertilization with penetration by only one of the sperm, followed by division of the fertilized egg into a multicellular embryo. While the embryo continues to grow and cleave and develop ultimately into a blastocyst containing the future fetus (inner cell mass) and placenta (trophoblast) the tubal microhairs continue to sweep the embryo ultimately into the uterine cavity.

The lining of the uterus, the endometrium, must be prepared with adequate glandular development to allow the now hatched embryo to implant. Yes, there is a shell surrounding the embryo that must break in order for the embryo to implant into the uterine lining. Inflammatory fluid, polyps, fibroids or scar tissue may all play a role in preventing implantation.

Oy, it’s amazing this ever works!

In fertile bodies of good working order, this all works an average of 20% of the time!

So . . . how do we get our bodies in optimal shape to maximize our chance of conception?

Check on medications that you may be on. Can you stay on them while trying to conceive? Guys need to do this too! Some medications may affect ovulation or implantation. Prostaglandin inhibitors found in common pain relievers can affect both ovulation and implantation. Calcium channel blockers commonly used to control high blood pressure may affect your partner’s sperm’s ability to penetrate and fertilize an egg.

How is your diet? Is your weight affecting ovulation and preparation of your uterine lining either because it is too high or too low? Do you have glucose intolerance that is leading to high levels of insulin in the blood that affects your hormones and ovarian follicular and egg development? Perhaps you would benefit from a regimen including a carbohydrate restricted diet, exercise and medication to improve glucose metabolism.

Make love. Sex is critical to reproduction, obviously but I am often asked how often and how to time as if it need be a schedule chore. This is a bit tricky as it is vital that while we reproductive endocrinologists are assisting our patients to conceive we want to preserve the relationship that provides the foundation on which we want to build their family. I try not to give patients a schedule until they are in an insemination cycle where we actually identify the precise day of ovulation. I recommend spontaneous lovemaking that in cases of normal sperm counts (which should be analyzed as part of that check up) should average at least every other day in the middle of a woman’s menstrual cycle. Ovulation, typically occurs 14 days prior to the onset of her menses. Sperm survive anywhere from 1 day to 7 days in a woman’s cervical mucus varying both on the sperm and the quality of her mucus which for some women is optimal for only hours if at all. Eggs survive 6-8 hours. Therefore, when we perform insemination it is better if we inseminate prior to ovulation rather than after as we the sperm have more time to sit around and wait for the egg than visa versa.

See an RE. When all else fails, it is recommended that you consult with a reproductive endocrinologist if you have not conceived after one year before age 35 and six months if you are 35 or older. The treatments available to the specialist are extraordinarily successful today and should ensure that for the great majority of you, 2010 will be a very happy new year.