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1. Do fertility drugs cause cysts? Do fertility drugs cause cysts?

   Occasionally, depending on the previous type and dosage of medication used in the previous month. Sometimes a follicle that did not mature in one cycle may evolve into a cyst which appears the following cycle. Additionally, an hCG injection can sometimes facilitate cyst formation. Cysts do not necessarily mean that you cannot begin another cycle.

2. I have heard that Femara is a cancer drug. Why do you prescribe it to treat infertility? I have heard that Femara is a cancer drug. Why do you prescribe it to treat infertility?

   Both clomiphene citrate (Clomid), and letrozole (Femora) are oral medications used to stimulate ovulation. Letrozole is emerging as a viable alternative to clomiphene citrate for women undergoing ovulation induction and ovarian stimulation, although no broad scientific studies have established the drug's efficacy as the first course standard treatment. Several preliminary studies have shown letrozole to be useful, producing few side effects, especially for women whose uterine lining may be thinned out by clomiphene citrate. As to its exact mechanism, letrozole falls in the category of drugs known as nonsteroidal aromatase inhibitors, meaning it is highly specific in suppressing estrogen synthesis. Aromatase is an important enzyme prompting the creation of estrogen. If the body makes less estrogen, FSH level increases, follicular development increases, and ovulation is stimulated. Letrozole was originally developed for breast cancer treatment, as certain types of breast cancer cells slow their growth in response to decreasing estrogen levels. Some time ago, one journal published an article about a study in Canada in which a very limited number of patients showed an increase of neural tube defects in the fetuses of women who had taken letrozole. However, there have been several subsequent larger studies which did not substantiate these findings. Since letrozole does not block the estrogen receptors, it is less effective than clomiphene citrate in preventing LH from surging. Therefore, on rare occasions, premature ovulation can occur, which is why we monitor our patients taking letrozole more frequently. We have also observed that clomiphene citrate works better for our younger patients, but we do not have conclusive data to support this yet. Generally, clomiphene citrate is used for women who are freezing embryos, whereas letrozole is used for older women who are doing fresh embryo transfers. At New Hope Fertility Center, we evaluate each patient's individual needs and circumstances and choose medications accordingly. Letrozole has shown to be particularly helpful for a subset of women whose endometrial lining may become thin while taking clomiphene citrate. As an anti-estrogen, clomiphene citrate can limit the development of the endometrial lining, which we believe makes it more difficult for an embryo to implant. For reasons that aren't quite yet clear, letrozole appears less likely to affect the uterine lining. Furthermore, letrozole has a short life span in the body, whereas clomiphene citrate can last for 4-6 weeks following an oral dose. At New Hope Fertility Cener, we are pleased with the results seen so far with letrozole and we look forward to seeing the outcome of studies that are underway to further assess its efficacy as standard treatment.

3. I have heard that Clomid is bad for older women. Why do you use it for older women? I have heard that Clomid is bad for older women. Why do you use it for older women?

   The fertility care specilaists at New Hope Fertility Center do not believe that Clomid is bad for older women. Older women do even better with natural and low stimulation cycles with the use of Clomid. Bear in mind that Gonal-F and Follistim are man-made FSH themselves. Repronex contains natural FSH, extracted from menopausal women because their FSH is very high. Clomid works by tricking the pituitary gland, causing a woman's body to produce additional FSH. In older women or "poor responders," we usually find high baseline FSH or "day 3" FSH due to lower ovarian reserve. These women generally produce higher FSH in response to Clomid, as demonstrated by responses to so-called "Clomid challenge tests." Clomid also provides gentler stimulation than injectables, and therefore does not recruit follicles that are not ready for the antral stage. This results in higher quality of the eggs retrieved and allows eggs which are not ready to have additional time in the ovaries. Clomid allows the woman's body to select the best eggs instead of just more eggs, letting the embryologists and lab incubator select the best specimens through in vitro embryo development.

4. I have heard that freezing embryos causes damage. Why do you do so many frozen embryo transfers? I have heard that freezing embryos causes damage. Why do you do so many frozen embryo transfers?

   Freezing embryos using a traditional "slow-dunk" method can damage them, and the thaw-survival rate is only around 50%. Our lab at New Hope Fertility Center is one of a handful in the U.S. to use a flash-freezing technique called vitrification. The use of vitrification for human embryos was pioneered by the Kato Clinic in Japan, with which we are proud to be affiliated. With this technique, ice crystals do not form during the freezing process, leaving no damage to the embryos when they are thawed. Our frozen embryo survival rate is 98%.

5. How do you know I won't ovulate before my retrieval? If I don't take Lupron, how can this be controlled? How do you know I won't ovulate before my retrieval? If I don't take Lupron, how can this be controlled?

   During the middle of a woman's menstrual cycle, when the lead follicle reaches 16-18 mm in diameter, the estrogen level reaches its peak. This estrogen peak triggers the estrogen sensor - the receptors in the brain - through so-called "positive feedback," and tells the highest hormone-producing command center (the hypothalamus) to produce gonadotropin releasing hormone (GnRH), which in turn tells the intermediate command center (the anterior pituitary) to produce leutenizing hormone (LH). The surge of LH triggers the final maturation of the egg. In conventional IVF, lupron (GnRH analogue) is used to down regulate (disable) the hypothalamus from producing GnRH in order to prevent a sharp increase in LH. Clomid, an estrogen antagonist, blocks the estrogen sensor, which then blocks the positive feedback loop so the hypothalamus does not receive the signal to release a larger amount of GnRH. Clomid works as efficiently as Lupron in preventing premature LH surge.