Lets ask Dr. Quaas
Dr. Alexander Quaas earned his M.D. from the University of Manchester in Manchester, England and his Ph.D. from the Albert Ludwig University in Freiburg, Germany. He completed his residency in Obstetrics and Gynecology at Harvard University and his fellowship in Reproductive Endocrinology and Infertility at the University of Southern California. Prior to joining Reproductive Partners Fertility Center – San Diego, Dr. Quaas was a physician and faculty member at Oklahoma University Health Science Center and at the University Hospital of Basel, Switzerland. He is a board certified in Reproductive Endocrinology (RE) and Infertility.
Dr. Quaas is constantly researching and is very involved in the teaching field of infertility as well. He always has a way of explaining everything to me until I completely understand it. And sometimes, if he doesn't quite know what to tell me, he will do more research before giving me an answer. This is a quality I really appreciate.
So I sat down with Dr. Q, my current RE, and wanted to ask him some questions that I thought would be helpful for anyone going through, or just starting, IVF to have at their fingertips. Its so overwhelming to try and think of all the questions we have in one sitting alone so why not get the ball rolling. And actually I learned a few new things myself! Enjoy!
Questionnaire (with answers by Alex Quaas, MD, PhD)
1. Please give us a little bit of your background in relation to becoming an infertility Dr. How many years have you been practicing?
I originally wanted to become a cardiologist, then an orthopedic surgeon, but chose to pursue a career in reproductive endocrinology and infertility because I liked the mix of patient care, procedures, and cutting edge translational research involved.
2. What are some of the most common questions you get asked during a consultation?
The most common questions I get asked are:
Why can’t we get pregnant even though all our tests are seemingly normal?
What can we do to improve our chances of conceiving naturally?
What is the optimal intercourse timing? Should we have intercourse every day around ovulation or every other day?
Are children born from IVF different from naturally conceived children?
How long is it still possible for me to have children?
What is the risk of miscarriage? What is the risk of genetic abnormalities for our baby based on my age?
3. What are the most common reasons for infertility?
Based on the normal process of reproduction (sperm swimming through the uterus and meeting the egg in the tube after it gets released from the ovary, then forming an embryo together that implants in the cavity of the uterus after ovulation) the most common causes of infertility can be derived:
Male factor / sperm issues
Ovulatory factor / problems with ovulation = the release of a healthy mature egg
Anatomic factors of the female reproductive organs (specifically the uterus and the tubes)
Ovarian reserve issues – age-related decrease in the quantity and quality of the eggs
4. What kind of diet should women be (and men) when trying to conceive and also go through IVF?
A healthy balanced diet is recommended, similar to a “Mediterranean diet” that is beneficial for general health as well. Avoid excessive amounts of sugar, trans fats, carbs and alcohol. Stick to healthier options such as fruit / vegetables / lean protein-rich foods and foods high in antioxidants. At the same time I believe it is important not to be too strict with yourself, and to not change too many variables at the same exact time, because the process of going through infertility is stressful in and of itself. I believe that regular exercise is a good complement to a healthy diet, and can help relieve tension and reduce stress levels.
5. Why do AMH levels drop? Is there anything we can do to keep those high?
Anti-mullerian hormone (AMH) is produced by the “granulosa cells” of the small follicles harboring eggs in the ovaries. Therefore, the AMH concentration is a marker for the overall quantity of eggs left, and gives us an idea how someone will respond to ovarian stimulation. The levels go down with age as part of the general decrease in egg quantity and quality. This is a natural process, and it is faster in some and slower in others. Bad lifestyle choices can accelerate the process of ovarian aging, however a particularly good lifestyle cannot completely prevent ovarian aging.
Therefore, it is recommended to be proactive about your individual fertility and family planning, while maintaining a healthy lifestyle.
6. What is your advice on PGS testing?
There is a great debate in our field regarding the use of pre-implantation genetic testing (PGT). While it is generally accepted that PGT to prevent specific genetic disease-causing mutations (PGT-M) is beneficial, there is some controversy around the use of PGT to screen for aneuploidy / chromosomal errors of the embryos (PGT-A). PGT-A appears to be useful for women over the age of 35 who have multiple embryos to choose from, to assist with the selection of the best embryo. It is also useful in convincing couples in their decision to proceed with “elective single embryo transfer”, given that the chance of success with single embryo transfer of a euploid embryo is very high.
7. What are the top things women should get checked before starting an IVF cycle? (thyroid, estrogen, hyrsteroscopy, etc.)
The most important tests include ovarian reserve testing (cycle day 3 FSH/ estradiol/AMH levels) and thyroid testing (TSH level). I also find it useful to check a Vitamin D level and replete Vitamin D if indicated. Other tests are specific to each individual couple, such as testing for diabetes in overweight and obese women. We also offer genetic carrier screening for recessive diseases to each couple.
8. What gender do you see predominantly after PGS is complete?
On average it is 50-50 female to male.
9. How do you feel in regards to transferring one vs. two embryos?
As a field we have moved more and more in the direction of transferring less and less embryos. This has to do with improved implantation rates through improvements in stimulation protocols, lab techniques etc., but also with the increased awareness of the risk of multiple pregnancy for the mother and the children.
With improved freezing technology, increased use of culture of the embryo to the (more advanced) blastocyst stage, and increased use of PGT-A, single embryo transfer has really become the standard of care in the year 2019. I rarely ever transfer more than one embryo, and our success rates (measured as the rate of singleton term healthy normal weight babies per number of transfers), are very high.
10. What can women do to increase their egg production and quality?
(See above) Women are born with all the eggs they are going to have, no new eggs are being produced in the reproductive lifespan of a woman. Ovarian aging is a natural process, and it is faster in some and slower in others. Bad lifestyle choices can accelerate the process of ovarian aging, however a particularly good lifestyle cannot completely prevent ovarian aging. Therefore, it is recommended to be proactive about your individual fertility and family planning, while maintaining a healthy lifestyle.
11. Why do they say that most people are not successful on their first round of IVF? Why does it usually take more than one transfer? (or is this a myth)
Success rates in IVF depend in large part on the age of the female partner, and egg / embryo quality. In women under the age of 35, and in women who have a genetically normal high quality embryo available for transfer, the success rate from the first transfer is around 60%. So it is a myth that it usually takes more than one transfer. In the patients where the first transfer does not work, couples can be reassured that the chance of success for a potential second transfer is around the same as it is for the first transfer.
12. What is the average number of follicles that are extracted from a woman?
We aim to stimulate the ovaries in a way that generates a decent number of healthy mature eggs, while minimizing the risk of ovarian hyperstimulation syndrome (OHSS). Therefore we usually aim for a total number of growing follicles of around 10-20, with the goal of retrieving around 15 eggs. Obviously goals are individualized based on age and ovarian reserve, and in some women it is not possible to aim for a double-digit number of eggs retrieved. In general, quality is more important than quantity, and it is better to create a smaller number of top-quality embryos than a large number of poor quality ones.
13. What are your thoughts on rest post transfer during the 2 WW?
There is no evidence to suggest that bedrest after a transfer improves the chance of pregnancy. However I do recommend that women take it easy for 48 hours after the transfer, avoiding strenuous activities and stress. In general, I recommend avoiding doing anything after the transfer that could be a source of regret if things do not work out. That actually applies for pregnancy in general. As an example, (hot) yoga is unlikely to harm the pregnancy in the first trimester. However it may be best to avoid it because if the pregnancy unfortunately results in a miscarriage, most patients will second guess every action that could have contributed to the outcome, and feel guilty even though it is not their fault. So my recommendation is to avoid anything that could lead to feelings of guilt and second-guessing if things do not work out as desired.
14. At what point do you recommend for a couple to seek donor eggs or even surrogacy?
We recommend treatment with donor eggs if a woman’s ovarian reserve is so low that the prospect of achieving pregnancy using her own eggs is unrealistic. Often we get to this recommendation after a couple has had disappointing outcomes with one or more IVF cycle attempt using the woman’s own eggs.
Surrogacy is generally recommended when either a woman’s uterus is deemed incapable of carrying a pregnancy, or if a pregnancy is judged too risky for a particular patient because of significant medical conditions (“comorbidities”). Accordingly, indications for surrogacy include scarring or complete absence of the uterus, or serious diseases of the heart, kidney or lungs.
15. What is the ideal lining size for implantation?
In general, we prefer an endometrial thickness of at least 7 mm after attempts to build up the lining with estrogen exposure. However, the appearance of the lining is also important, and pregnancies commonly occur with lining thicknesses of less than 7 mm. Every patient has a unique and individual situation, and deciding when the lining is ready for transfer represents a balance between optimizing the endometrium for implantation, and proceeding with the transfer in a reasonable timeframe, given that time is precious in the face of declining ovarian reserve.
16. What tips would you give someone who is just starting their fertility treatment journey?
Infertility and its treatment are stressful and can take a toll on relationships. While having a baby is ultimately the goal, another important focus for the couple is to maintain a healthy relationship with each other. Tips for this include
Do not blame each other for the delay in getting pregnant, a couple is a unit of two people sharing the same goal(s)
Try to not let efforts to conceive become a chore (this is difficult, but it is not impossible to maintain some amount of spontaneity in this process)
Try to see the process with a sense of humor at times- over the years I have witnessed that couples who can see humorous aspects in this journey can get through this emotional rollercoaster more easily
There are lots of ups and downs in the process of fertility treatments- it can truly be a rollercoaster. I tell all my patients to not get too high with the highs (seemingly good news or promising developments) and to not get too low with the lows (temporary setbacks in the journey such as a seemingly negative embryo update or even a failed embryo transfer)
Never give up- even when things look bleak there are always viable options to eventually build a family.