[WEBINAR] Fertility 101 Recording Transcript
Originally aired on July 13, 2026

Ligia Popescu   0:06
Hello, everyone. Welcome to Fertility 101, the first of seven fertility awareness and education live webinars presented by Pozitivf Fertility. I’m Ligia Popescu, your host today. Our guest is Dr. Marianela Gile, who’s here from Pozitivf Fertility. She’s A physician there.

Thank you all so much for joining today and sharing a part of your evening with us. So before we get started, I’d like to take a quick look at the agenda on the next slide.

After the speaker intro we’re going to do the feature presentation, followed by some closing remarks and a live Q&A. Just some audience tips. All your audience reactions are welcome anytime using the React button on the top of your screen there. You can use the Q&A button at the top of your screen there, just to the left to ask questions anytime. Please unmute yourself if you feel like you want to ask a question live. We will definitely be providing a recording of this event to everyone who registered. And I want to assure all audience members that your privacy is guaranteed. Your face, your name,

Your profile will not be visible to anyone but the speakers here. So please feel free to ask your anonymous questions anonymously.

So, if you have any questions, my e-mail there is at the bottom, ligia.popescu@pozitvf.com.

Please reach out to me if you have any questions or, you know, send me a reply back to any of the emails if you got them for this event.

Now, I’m going to turn it over to our guest, Doctor Gille. Do you mind sharing a bit about yourself before you start?

Marianela Gille   1:55
Of course. Hi, everybody. Nice to see you all. Thank you for making the time to join us this evening. I know you’ve had long days today, but hopefully this session will be very helpful to understand a little bit more about fertility and more than anything, when it’s important to start testing or when we need to start looking into things.

I’m Marianela Gille. I am originally from the border town of Matamoros, Mexico, and I’ve been in the United States pretty much since I was 18. I am an OB-GYN by training, and I’ve been here at Pozitivf Fertility for about a year and a half. I’m currently working out of the San Antonio location, and I go visit the Houston location about once a month, and I will soon be in the Austin, Texas location, which should hopefully be opening soon.

And I’ll go ahead and kick it off. So a lot of this is meant to be basics as far as just when to start looking into fertility workups, when is waiting too long, when should you keep trying on your own? So hopefully I can give you some tools today so that you can feel comfortable knowing like, am I okay to keep trying on my own? Or Do I need to start being more proactive?

So the traditional one year rule, if any of you have been to your OB-TYN and said, I’ve been trying to get pregnant, this is usually the criteria that they will use before they can determine if you should be getting any additional testing at that time or not. Now, this rule does not apply to everybody.

But in general, if you are under the age of 35 years young, you want to seek a fertility consult after 12 months of having intercourse. And it’s not having intercourse every day. If you’re having intercourse at least two to three times a week, you’re very likely covering the ovulation window.

Okay. So if it’s been a year and you still have not gotten pregnant, that’s a good time to start looking into additional workup. If you’re above the age of 35, then at that point, it is important to take action once you get to about the six month mark.

And why is that? It’s because we know that with age, the egg count, not only the quantity, but the quality will drop. And we’ll talk about that a little bit further shortly. So in general, that’s your general timeline, right? Less than 35 years young, you want it to be for a year of trying.

Over 35 years young, you want to go ahead and start looking into it if it’s been six months of trying.

Now, there are exceptions. If you have a history of endometriosis, of polycystic ovarian syndrome, of any other condition that could affect fertility, thyroid issues that are uncontrolled, you may want to look into it earlier.

So this again applies to patients that don’t have any significant medical history and are trying to get pregnant. But if there’s anything in your history that potentially could impact your fertility, it may be important to start looking into it sooner rather than later.

Unfortunately, like with many things in life, women don’t have, men have things a little bit easier. So their sperm can be good for a very long time. But as women, our quality and quantity of eggs does start dropping. So that is why we do need to be a little more proactive. Okay.

Now, why waiting isn’t always winning? At the end of the day, it can also take an emotional toll. Tracking your cycles, checking your temperatures, using the apps, negative tests month after month can be really exhausting and it could just overall be very overwhelming. In general, if you don’t necessarily need to wait the entire year before you even start getting a little bit of a workup, you can always start with something as simple as an AMH, which I’ll talk about in a little bit more detail right now. And at the end of the day, having information, right, knowledge is power. So that’ll help you to make a guided decision, like, okay, should we keep trying on our own, or do we need to be more proactive at this point?

Now, let’s talk about AMH first. AMH is a blood test that checks for a hormone called the anti-Mulverian hormone. Okay? It’s a blood test you could get done with your gynecologist. You can get it done here with us. And essentially, the AMH does not tell me if you’re going to get pregnant or you’re not going to get pregnant.

What it tells me is, or it gives me an idea of where your current egg account stands, okay?

At the end of the day, we know that for us women, our ovaries are like a little bank that holds all of the little eggs that we will have in our lifetime. And the AMH gives us an idea, are we at the average? Are we above the average we should be our age? Or are well below the average, okay? And then the AMH also does not tell me anything about the quality of the eggs. It’ll tell me a lot about the quantity, but that’s where age becomes a really important factor. And I’ll show you all a little graph right now that’ll help to depict this better, okay? So essentially the AMH is a way of getting a little bit of a baseline to get an idea of where we’re starting from.

Now, what happens during the standard workup? In a standard fertility workup, generally we do the AMH blood test, an ultrasound, which will usually check your ovaries, your tubes, and your uterus, and then also a semen analysis is really important.

OK, this can all be done within a day.
Now, I’m going to make fertility really simple. If any of you have been to one of our consults here, this is usually what we start with. It’s really important for our patients to understand what is going on with their body and to understand fertility. And the reality is a lot of people want to make fertility really complex, but fertility can be very straightforward. We need three things to get pregnant.

We need sperm, we need eggs, and we need a place for them to get together, which is the uterus. Now, in order to evaluate these three components, for the sperm, we do the semen analysis. For the eggs, we do the AMH that we just mentioned, that anti-Mullerian hormone, and the AFC, which is the follicle count.

And for the uterus and tubes, we do imaging, and I’ll go into each one of these in details.

So these are the general parameters of a normal semen analysis. When you send your partners in to get this done, we’ll go ahead and run through all of the results and see if there’s anything that would cause any issues. Different things that we check for, like the total volume, the concentration of the sperm, the motility, which is how the sperm moves.

The morphology, which is how the sperm looks. The sperm needs to have a very specific shape so that it could penetrate the egg. And then the total motile sperm combines all of these numbers and it gives us a general range. And this is again to get pregnant by nature. Even if your semen analysis results are not great, there’s also treatment options that can help with this.

Now, when we talk about eggs, this is a little depiction that shows that when we are born, we’ll look right here, we know that most women are born with anywhere between 1 to 2 million eggs on their day of birth. And then over their lifetime, that number will start to decrease. And by the time we hit menopause, that’s when we’re running out of eggs.

Now, if we’re born with about 1 to 2 million, by the time we get to our first period, we’re already at 400,000. We’ve lost more than half of our eggs without even having a period. After that, the number will continue to drop, and we start to see a faster decline after the age of 37.

So most of our patients that come and see us are anywhere from 35 to 42. There’s some younger, there’s some older, but let’s use 35 as a general reference. A woman that comes in at 35 years young, we know that she should have about 50,000 eggs. 50,000 sounds like a lot of eggs.

But it’s not like we can just use all of the eggs, right? Every month, the ovary gives us a batch of eggs to use, and our brain’s hormones and the ovarian hormones will coordinate to see if anything starts to develop, which would be like a little follicle growing and a little egg inside of it. When we start doing treatments like
IUI or IVF, the medicine that we give helps to get more of those follicles to develop at the same time.

Now. When you come in for an ultrasound, the other thing that we check for is the follicle count. So we’ll take a look at both ovaries and we’ll count all of the little circles that are on the ovary, which are the little follicles that the ovary has given your body that month to work with. Again, by nature, your body will usually pick one little follicle to grow so that it can release an egg. But there is a certain amount of follicles that we should see at any given time at a specific age range. So for example, at the age of 35 years young, we should see about 20 follicles, so about 10 on each ovary. If that number is lower, if we’re looking at 10 to 15, then we know that maybe you’re not at the 100,000 eggs. You might be lower than that, right? And at that point, sometimes it’s important to be more proactive about our fertility because we know that your egg count may be dropping faster than another woman at the age of 35. Now, the other thing we look at is that AMH, what we had discussed, right?

And that is also very age-based. At the age of 35 years young, the AMH should be somewhere between a 2 to a 3.5.

I can tell you when I used to practice general gynecology, we were always taught anything between a one to a four is normal. So if we had a 25 year old that had an AMH of 1.5, we were taught to say that is normal. But the reality is that the age of 25, an AMH of 1.5 can be very low.

Because if that woman were to wait another 5 to 10 years to have a baby, and that AMH drops below 1, that can make it a lot more difficult to get pregnant, especially if she’s trying to plan for a family of two or three kids. So it is very important to interpret AMH based off the age as well, okay?

Now, here’s the other component, right? One thing we said was the quantity of eggs. The quality of the eggs we know changes over time.

So as we age as women, these eggs have been in our body since we were in our mother’s womb. Okay? So for that 35-year young women, those eggs were created 36 years ago by her mother, which means that over time, there can be more genetic defects in the eggs that are there. So that’s why we know that as we increase with age, we see that the amount of abnormal eggs goes up. So about 35, we have about 20% of eggs that are normal, sorry, 20% of eggs that are abnormal.

80% will still be normal. Look at the big jump by the time we get to the age of 40. 50% of the eggs will be abnormal and 50% will be normal. And by the time you get to 42, we’re looking at about 70% abnormal. 45, we’re looking at about 90% abnormal.

So that’s why it is important to take action, especially if you’re considering a family of 10, two or three kids, because we can’t just think about that first pregnancy. We have to be thinking about second and third pregnancy as well when we’re doing our overall assessment and treatment plan.

Now, another component too that we see with direct correlation with age is that as women age, we know that the amount of miscarriages goes up. And that makes sense, right? If these eggs have been in her body for a longer period of time and start developing more genetic or chromosomal errors, then at that point, there’s a higher risk of miscarriage as we become older.

The third component that we mentioned was the uterus and the tubes, right? So generally the eggs are stored here in the ovary. And if we have normal menstrual cycles about once a month and we’re ovulating, that egg will get released from the ovary into the tube and it will try to make its way into the uterine cavity.

Sperm will be deposited in the vagina so that it could try to make its well into the cavity and the tube. And that’s where we generally create an embryo so that it could try to implant itself back inside of the uterus. So that’s why all of these components here are very important, okay?

Here at Pozitivf, we can do both tests within 10 to 20 minutes. It’s a simple procedure called a saline infusion sonogram and HyFoSy (hysterosalpingo-foam sonography). The saline infusion sonogram, basically what we do is that we put a little catheter right through the cervix. It’s a tiny little straw like the size of a spaghetti noodle. And we go ahead and fill the uterus up with water so that we can see the cavity and make sure that there isn’t any growths or abnormalities.

You’ll be able to see this in real time as it’s happening. And ideally, we want to make sure that the cavity is super smooth, kind of like this, so that there isn’t anything unusual.

What does it look like when there’s something unusual? I’ll show you out here. This is an example of a cavity that has either polyps or fibroids that are little growths inside of the uterus. And these can become problematic because if a little embryo is hanging around in the uterus and it tries to implant itself, and accidentally sticks onto a polyp or a fibroid, it may not get the nutrients or the blood that it needs in order to develop into a healthy baby, and those can end up in a miscarriage.

Generally, once we diagnose one of these, either a polyp or a fibroid, we recommend what’s called a hysteroscopy, which is a procedure to clean out the uterine cavities so that we can leave a really nice smooth surface, kind of like the one here on the left, so that the embryo can have a better chance of sticking right where it needs to.

Now, the high flow C is a different solution. So first we’ll put water in, or saline, just so that we can see inside the cavity. Then that saline will come out. And then we put another liquid that has a little bit of a foamy texture so that it can go into the tubes and determine if the fallopian tubes are open or not.

So it looks something like this. Again, you would be able to see this in real time as we’re doing it, so we get answers right away. And at the end of the day, there’s many patients that get to this point. We’ve done all the testing. The cavity looks normal. The tubes look normal. The ovarian count is normal and yet they’re still not able to get pregnant.

So that diagnosis is called unexplained infertility. And while it can be the most difficult diagnosis to process because you don’t have an explanation, it is also the most treatable diagnosis.

Why? Because there’s healthy eggs, there’s healthy sperm, and there’s a good uterus. The reality is that all of the testing that we do  sees everything from a really big picture. We don’t know what’s going on at the microscopic level, right? We can have a healthy egg and a healthy sperm, but for some reason, maybe it just cannot penetrate the shell. We can have a healthy looking tube, but we don’t know what’s going on at the microscopic level inside of the tube, so that if the sperm and the egg aren’t able to find each other, that becomes a problem.

Ligia Popescu   17:51
We have a question, yes. Are both tests required?

Marianela Gille   17:51
Generally, you want to get an assessment of both, because if you don’t get both the tubes and the uterine cavity checked, you’re essentially getting only a piece of the puzzle. And when you’re trying to determine, like, do I need additional treatment, you want to make sure to have all of the answers before you start going down the path of something like an IUI or an IVF. I’ll give you an example.

If the tubes are blocked or closed and you did the saline and the cavity looks beautiful and everything looks great, and you try something like an IUI or conceding naturally, if those tubes are blocked, that sperm and egg are never going to find each other. So yes, I would say we definitely recommend both the saline and the HyFoSy.

More questions coming in.

Is unexplained infertility diagnosed before a laparoscopy? So yes, unexplained infertility can be diagnosed before a laparoscopy. There is some providers, because everybody has different ways of managing medicine, that believe that doing a laparoscopy to take a look inside the cavity to see if there’s any signs of conditions like endometriosis or something more complex.

But the reality is that while that can sometimes be the case, if all the components look normal and there’s no signs and symptoms of something like an endometriosis, you do not need a laparoscopy to make a diagnosis of unexplained infertility.

If anyone else has questions, please feel free to put them on the chat, send them through TikTok. We’re here to answer anything you all want to know.
Okay.

Very often when we have patients come in for their very first new patient appointment, we call it, they are nervous, of course. They’ve never been into a fertility practice. They don’t know what to expect. So just to give you a general reference, when patients come here to Pozitivf, we generally already have their blood work and their semen analysis results in.

So by the time you show up, we schedule you first for an ultrasound, and we’ll come in and do an ultrasound that takes about anywhere between 10 to 20 minutes, where we’ll do both the full follicle count, the saline, the HyFoSy.

And with that, we’re able to get all the components that we need to make an assessment and determine
what the cause is of infertility and what the best treatment outcome is. I can tell you most patients by the time we’re done with the ultrasound, tell me like, oh, that wasn’t as scary as I thought it was going to be.

Or patients that have previously had something called an HSG, which also looks at the tubes, will generally say like, wow, this was way less uncomfortable than I was expecting because HSGs can be a lot more uncomfortable. So if you’re normal or you’re scared, that’s very common. And don’t worry, we will always have somebody here to guide you through all of the steps so that you feel really comfortable through the process.

Okay, next question is, if all initial tests come back normal, does that mean that there is nothing wrong? So going back to the testing that we do, looks at everything very big picture. It’s really hard to see what’s going on at a microscopic level.

So it’s always very reassuring when we see that things look normal. And again, that is the best prognosis going forward because we know that we have good components so that we can work with the sperm, the eggs, and the uterus to help get to a healthy pregnancy. And again, I think it still is the hardest diagnosis because it’s usually easier when you have an explanation as to why something isn’t working out. It’s a lot harder when you’re like, well, I don’t know why it’s breaking out. You’re telling me everything is normal and now I need to get treatment.

Any other questions? Yeah. I have an endometioma and kissing ovaries, but can get pregnant. Can get pregnant with laparoscopy be next.
The question was, I have endometriosis and kissing ovaries. Would A laparoscopy be the next best step? The answer is it depends. If you can get pregnant and you’ve never tried to get pregnant before, there is a lot of women with endometriosis that carry completely healthy pregnancies.

One thing that patients with endometriosis will learn through their process and notice even before or after surgery is that sometimes the surgery can help to get rid of some of the endometrial tissue that’s stuck inside of the pelvis, or in the case of an endometrioma, it can remove the endometrioma.

But the surgery itself can also damage the ovaries and damage the egg reserve. So you generally A, want to get operated by somebody who’s really well versed with endometriosis, just so that they can make sure to guide your or to take care of your ovarian tissue as much as possible.

And additionally,I would say you don’t always necessarily need to get a surgery done before pregnancy. If you’re having difficulty getting pregnant, or if you’re having miscarriages, then at that point, a laparoscopy may be the best next step. Right?

Ligia Popescu   24:09
What would it mean if you came, if you had a sperm analysis and it was abnormal? What could you do about it?

Marianela Gille   24:17
Great. So, and that’s a great question. Thank you. And I’ll clarify. Men’s sperm does start to suffer a little bit with age. They just don’t run out of it, right? So a man could be 80 years old and still produce sperm. The quality is probably not going to be as great, or it’s definitely not going to be as great as somebody that’s 40 or somebody that’s 30.

So again, their quality will suffer a little bit, but the quantity maybe not as much. Now, let’s say that there is a sperm issue. It depends what type of a sperm issue it is. If the concentration is low or if there’s an issue with the motility, sometimes doing a treatment like IUI, intrauterine insemination, could be an option because maybe the sperm is just having difficulty getting all the way from the vagina into the tube. For us, it doesn’t look that far, right? For us, it’s like, oh, that’s like maybe 6, 7 centimeters. But for the sperm, it’s like running a full marathon. And the idea is that when you do an IUI, you take the sperm, first they do a wash so that they can get the best swimmers. And then they put those all the way inside of the uterus, close to where the egg is going to drop, it’s essentially like putting it right at the last mile before the end of the marathon, right? So that could be an option.

Now, if we start looking into other sperm issues like the morphology, which is how the sperm looks, right? If the sperm isn’t perfectly shaped to try to penetrate the egg, or if the concentration is really, really low to the point where it’s not going to be a good option to do an IUI, then sometimes the best next step is to do an IVF. Because with IVF, you don’t need the millions of sperm. You just need a few good swimmers. And essentially with IVF, what they’ll do is that they’ll also pick the best swimmers and they will put the sperm directly inside of the egg in a process called ICSI.

So that bypasses the morphology issue, right? It doesn’t need to be perfectly shaped to penetrate the egg because we’re forcing it directly inside of the egg. So those are two options of treatments that we can do.

Ligia Popescu   26:18
Wonderful. We do, yes. And we do have another question. When as an when an individual has endometriosis, is suppression before IVFFET recommended?

Marianela Gille   26:18
Great question. So the question is, if when patients have an endometriosis diagnosis, do they always need to be on suppression before the embryo transfer? And the answer is not necessarily. In fact, most patients with endometriosis will still get pregnant and carry a perfectly healthy pregnancy, without being on any suppression. And suppression is no joke, right?

For any of you that have ever been on suppression or heard of friends that have been on suppression, those hormones can really impact you, right? Essentially, you’re putting your body into a medical menopause, some people call it, or it’s even like medical puberty because your hormones are just not being produced.

You’re going to start feeling hot flashes, mood changes. And all in all, it is sometimes recommended, but not always. I would say if you have a stage 3, stage 4 endometriosis diagnosis, or you’re having really severe symptoms, it could be a strong consideration. If it’s a mild endometriosis or a stage one, stage two,..
Sometimes it’s better to go forward with the transfer.

Here’s the other thing, especially if you have multiple embryos. If you have only one embryo left and this is the only embryo you’re going to get a chance to do it with, then that can be another consideration for suppression. So I do think it’s very based off the patient and the full picture, not just one component.

But to answer your question, no, we don’t necessarily always need to put somebody on suppression before the transfer.

Ligia Popescu   28:02
Wonderful.

Marianela Gille   28:03
Question from TikTok. How did, how I, hello, I did my time intercourse procedure. How many days after the shot can I do a pregnancy test?
So we have somebody that’s been doing timed intercourse and she’s asking how many days after the shot to do the pregnancy test. I’m assuming that this is an HCG shot, which is an injection that tells your body to ovulate. And if that is the question, we would recommend doing a pregnancy test.

Maybe about, I would say 11 days afterwards, you may start to see some positives. Generally, whenever you would expect your next period is a good time to start testing.

I lost my left tube due to an ectopic and the right tube has a distal Tubal blockage – do I need IVF?
Yes, the question is, this patient lost her left tube due to a ectopic pregnancy, and the other tube has a blockage. Essentially, these tubes are damaged, right? One of them is not present. The other one that’s there has a damage to it. It’s going to be very difficult for that sperm and egg to find each other, if not almost impossible.

So yes, at that point, an IVF cycle is definitely the next best step.

Will I need meds if I already ovulate?
Well, the question is, will you need medication if you already ovulate? If you’re already ovulating and you’re trying to do timed intercourse, you don’t necessarily need to take medication. If you’re doing something like an IUI, we generally recommend medication. Why? Because you’re putting a lot of time and effort into something.

To have this be a month that you end up not ovulating. And it happens. Even if you have perfectly regular periods once a month, you may not necessarily ovulate every single time. So the medication sometimes helps to ensure that the ovulation is more likely to happen if you’ve already gone through the process of preparing for a procedure like this.

IUI. And for IVF, you definitely need medications. There is some ways to do it where you may not need them, but the reality is that it’s a really complex process. And without medication, at most, you’ll get one egg. And with one egg, that’s a really, really low guarantee that you would end up with a healthy baby.

Marianela Gille   30:32
Next question from the chat. I’m 39, not ready to have a baby and interested in freezing my eggs. What does the testing process look like for this? Would it make more sense to freeze egg now or try IVF in a few years if I have issues getting pregnant? This is a wonderful question.

Marianela Gille   30:52
At the age of 39 years young, I would strongly encourage you to consider freezing the eggs now.

Why is that? Let’s say you’re ready to have a baby in the next year, two years, three years. The difference from 39 to 42, even to 41, is pretty significant as far as quality. I can tell you patients that end up with eggs from 39 years young versus 41 years young have a way higher possibility of creating a healthy embryo.

Once you start getting past the 40s, it makes it a little bit more difficult. So if you have the time and you can, this is the best moment to do it.

In fact, we say the best time to freeze eggs is anywhere between 32 to 37. Of course, 39 is still a good time. You don’t want to wait too, too, too long. The faster you could do it, the better.

Marianela Gille   31:47
For egg freezing, because you’re not trying to do the full embryo transfer and the whole process, you don’t need to go through all of the testing that we discussed.
In fact, I would just recommend at that point doing an ultrasound to take a look here. Let me pull it up here to make it easier.

An ultrasound to take a look at the general uterus, ovaries, do a follicle count, and to also do your blood work, the AMH. With that, it’s enough for us to get an idea of at least how many eggs we’re going to get.

And we can start making puns like, do you need one round? Do you need 2 rounds? And the reality is that we never know until we actually go through the process itself.

For egg freezing, because you’re not trying to do the full embryo transfer and the whole process, you don’t need to go through all of the testing that we discussed.

In fact, I would just recommend at that point doing an ultrasound to take a look here. Let me pull it up here to make it easier. An ultrasound to take a look at the general uterus, ovaries, do a follicle count, and to also do your blood work, the AMH.

With that, it’s enough for us to get an idea of at least how many eggs we’re going to get.

And we can start making puns like, do you need one round? Do you need 2 rounds? And the reality is that we never know until we actually go through the process itself.

Another question. Can you tell me what the live birth rate success in your clinic for women over 40?

Live birth rate for women over 40. I don’t know the exact number over 40, but our live birth rate is about a 55%, which is considered to be even above the national average .So overall we do have really good pregnancy rates and really good like birth rates as well.

Marianela Gille   33:08
Next question, I’ve had most of the work up along with my husband. Age is 39 for me. I guess my question is, would IVF be the go plan as opposed to IUI due to age and quality? Sorry, long question. No apologies. This is a great question.
And I’m sure a lot of other women are in similar situations.

So it depends how long you’ve been trying. If you’ve been trying to get pregnant for three months and all of your workup looks generally good, your AMH is okay, and you’re thinking about having one to two babies, you could still consider IUI.

However, let’s suppose that all of your workup looks great. Your hormone level looks great. We assume you have a normal egg count, and we decide to go with IUI. If you get pregnant, what a blessing, right? That’s incredible, but it might take one, two, 3 rounds to get there. And then if you do get pregnant, you spend the whole next
nine months pregnant, a year and a few months recovering. So let’s say two years later at 41, you’re considering baby #2, especially if you’re considering baby #3 later on.

At that point, it may be a lot more difficult to get pregnant. So I would not encourage waiting too long to try or taking action with one route or another.
And I think your biggest question that you need to ask yourself is, do we want one child or do we want the possibility of creating two or three? If your answer is two or three, you’re probably leaning more towards IVF.

Next question I have here. I have an AMH level of 0.16 40 years old and my partner has low semen volume. What procedure would be the best for our situation and what are the chances of having a successful pregnancy? So with an AMH level of 0.16, that does put us in a little bit of a difficult situation.

Why? Because we know that there’s eggs there, but there’s not as many as we want to have. And then being at 40, we know that the quality may also not be great. So let’s say 50% of the eggs are of good quality, 50% may not be good quality. The next best step is definitely IVF, and it’s doing it sooner rather than later. And
also with the low semen analysis, right, the volume. If you start going through a cycles of IUI, your pregnancy rate is honestly going to be pretty low. In fact, I have a really good graph here I can pull up.

Marianela Gille   35:48
So, here’s a really good graph that shows the IUI success rates based on age.
We know that at the age of 40 years young, that’s the yellow line, with one round of IUI, the pregnancy rate is a 10%. Two rounds of IUI, that’s a 17%. Three rounds or more, it’s a 20%. With a low AMH, these numbers may actually be lower, maybe even half of that or lower than that.

So I would say your next best option is probably going to be IVF at this point.

Next question I have here. I have an AMH of 6.25. Are there challenges with high AMH? I’m not sure if ovulation is happening each month. Is IVF the best option for me? Great question. An AMH of 6.25 is considered to be really high. The age is also a factor, but even if you’re as young as 25 or 30 and you have an AMH of 6.25, there is a good chance that there is some component or a possibility of something called Polycystic Ovarian Syndrome, which has actually recently been renamed to Polys or Poly, I’m blanking on the word, but it’s PMOS and essentially it encompasses a lot more conditions that we know are associated with PCOS.

However, PCOS is a term that’s been used for a very long time, and polymetabolic endocrine.

So all in all, AMH of 6.25 can be an indicator of that. And if that’s the case, you may not be ovulating every month. And if you do end up going through an IUI or an IVF round…We know that in a patient with this high of an AMH or this many follicles, you actually may end up with a lot of the follicles being of bad quality.

I’ll give you a really good example. I have a patient with PCOS who recently had 50 follicles extracted and we ended up with 45 eggs. 45 eggs sounds incredible. Once you actually put the sperm, fertilize them and try to develop them, we only ended up with about 20 embryos, which 20 embryos is still a lot, don’t get me wrong, but you wouldn’t expect to have, or sorry, 20% of them that were of good quality to fertilize.

If I take another patient that has 20 follicles, which is a normal amount at that age,
and we do the same process, we’ll probably end up with the same amount of embryos. Why is that? Because even though there was a bunch of eggs, a lot of them may not have been of the best quality because there were so many.

So generally with PCOS, it has become more common now to recommend IVF as first line so that you don’t spend too much time going through multiple rounds of IUI.
and not being able to get to the goal of a healthy embryo that could create a healthy baby. Now, if you’re not sure if you’re ovulating, another option is to try taking medicine to help you ovulate and see if you’re able to get pregnant on your own. That usually can be done through your OB-GYN. They’ll give you a medication such as Clomid or letrozole that can help the body ovulate to see if you can try it naturally.

Next question? Yes. I had an ovarian drilling. What are success rates after that procedure? So we had a patient ask about ovarian drilling and what success rates are after that. The reality is it depends where you started from.

If your ovarian count was very low, if the age is above 40 and especially above 45, ovarian drilling may not necessarily make that big of a difference. There is a theory that the drilling itself will kind of stimulate the ovary to start producing more follicles or release more eggs.

But it’s really dependent on the whole history of a picture. I can’t say just in general.
Next question we have here. Male 40-year-old partner with AZFC deletion and female 35 years old, two children from a previous marriage. Unable to conceive after five years. Currently seeking fertility care and we would like three to four children, God willing. Partner also shows blood varicocele blockage. Is it okay to push the repair to repair the blockage with or after before M testing? Should egg retrieval be timed? Do you see more success? Also, I have an AMH of 0.9. Children are 16 and 9. Do you recommend twin transfer? Okay, let’s take this by parts because there’s a lot of really good questions here.

Anytime we have a male that has this specific deletion and we need to do a testing, I would say the goal is to try to get, and I’ll leave this to the urologist to make the call, because usually we’ll send you to a urologist to decide if they want to repair the varicoceal before or not.

Generally, they like to go forward with the testing, but if there’s a big degree of damage, or if they don’t think that they’re going to find a lot of sperm because of the miracle seal, they may repair it first.

Now, when should the egg retrieval be timed? We will work with timing the egg retrieval and the testing on the same day, ideally. There are some practices that will do the testing ahead of time and freeze the sperm. If possible, we generally try to get it done on the same day, just so that we have fresh egg and fresh sperm that same day.

Now, with an AMH of 0.9, do we recommend, or AMH of 0.9, do we recommend twin transfer? That is a great question. The answer is we do not recommend twin transfer. Why is that? I have a great slide here to show that.

While twins can sound really fun, the reality is that they can be very dangerous pregnancies, okay? And I can tell you that most women, by the time they get to our office and have never had children before, and they’ve been trying for three, five, or 10 years, they just want to grow their family.

And I can’t tell you how many requests we get for twin transfers or to try to create twins. And this is what I generally tell them. If nature gives us twins, we roll with it, but we shouldn’t be trying to go against nature and trying to create two babies at the same time.

There’s also the possibility when you transfer one embryo that it can split into two and give you twins. And again, if that happens, we go with it.

But if you transfer 2 and theoretically one of them splits or both of them splits, you can end up with triplets or with quadruplets. Let’s not even go to the extreme. Let’s focus on twins. This way here shows the increases of risk to the baby, to the mother, and to the family unit with twin pregnancies.

Risk to the baby. Mortality is five times higher in twins. Cerebral palsy, five times higher. Severe handicap, two times higher, and congenital anomalies, two times higher. Risk to the mom. Hypertension, preeclampsia, diabetes, anemia, bleeding, surgery risks. And family unit.

This one, a lot of people giggle, but it’s real, increased rates of divorce due to the strain on the relationship. One child is a lot of strain. You put two in there, and at the end of the day, it can cause a lot more issues. So again, if nature gives it to us, what a blessing, and we roll with it. But we shouldn’t be actively trying to create twins.

Next question: I’ve had two C-sections. Two C-sections makes it even riskier to put two babies in there, because at the end of the day, the uterus is going to have to expand more. If you do start having early contractions or going into preterm labor, that is very common with twins. That can make that previous C-section scar weaker and that can increase the risk of what’s called a uterine rupture, which can be very dangerous. So all in all, you definitely don’t want to be trying to create two at the same time.

Question from TikTok. Trying to conceive for four months, I’m overweight, otherwise normal cycles. DBT rises 4 DPO spot, 12 DPO progesterone didn’t help.

Marianela Gille   44:17
Okay, so there’s a question about being overweight and trying to conceive.
Being overweight, it depends how overweight we’re talking. If you’re just a few pounds above what’s considered to be a healthy weight for that age or for that BMI or for that body frame, it shouldn’t make a big difference if you’re having regular periods approximately once a month and if you’re checking for ovulation.

But if you start getting into a BMI range above…30, 35, and especially 40, that can make it a lot more difficult to conceive, like a lot more. Not to mention that it can, if you do get to the point of conception, then that can make it a very dangerous pregnancy as well. So we generally do recommend getting to a healthy weight before conception happens.

I’ve had three C-sections and my youngest is 15. Is pregnancy still risky?
Patient that had three previous D-sections and it’s been 15 years from the last one, they’re asking if it is still safe to get pregnant.

With every C-section, risks start going up. That’s the reality, right? So once you get to three C-sections, yes, it does become riskier no matter how much time has passed. Because at the end of the day, the uterus itself, yes, it’s healed itself, but there’s still scar tissue and there’s still an area where there may be some weakness
from the previous incisions.

If the question is, is it possible to get pregnant? Yes, absolutely. Is it risky? Depends. What you can always do is reach out to the last person who did your surgery and see if they can go through the operative report and note if there was any severe adhesions or scar tissue in the belly.

If there was a lot of adhesions when they did the third C-section, then that means that very likely there was more adhesions that formed and that can make it riskier for an additional pregnancy. If they tell you that everything looked really clear and healthy and there wasn’t a lot of scar tissue, then that already puts you in a better place. So all in all, it’s definitely worth having that conversation or trying to get the records from the doctor that last operated on you.

What are your thoughts on metformin to support weight loss during IVF? There’s a question about metformin use during IVF to support weight loss. Metformin itself actually has a lot of research that shows that when you have PCOS, we can actually end up with a better quality and quantity of eggs if we are on metformin. So all in all, I’m very much in favor. In fact, any of our patients that come in here that are diagnosed with PCOS or diabetes, we like to put them on metformin because we know we see good results. So I do encourage.

I have a question here. For egg freezing, do I need to remove my next one on birth control? My periods are semi-irregular about every 30 to 45 days. So not necessarily. It is still possible to do an egg freeze while keeping their birth control. If you’re not currently sexually active or you’re already coming up to the end of your next one on or you want a little break from the hormones, its not a bad idea to remove it, do the egg freeze, and then get a new one.

But if you’re a year into your next one on, you really like it, you’re sexually active, you’re at risk of pregnancy, and you’re not ready for it right now, it’s better to not remove it.

Question? I have one here. I had weight loss surgery in September. I’m still above the recommended BMI. Do I need to wait to be post-op one year to begin IVF? And what BMI do you all require here? I know you mentioned recommended, but what is the highest you will work with? Okay, so regarding BMI, we generally like to wait a year after the surgery just to make sure that you’re not actively losing weight rapidly when you’re doing the process of the transfer itself.

Why is that? Because if you’re losing weight as our little embryo is trying to get nutrients, then that can cause some risk to the embryo itself.
Now, our BMI cutoff here to do IVF is a BMI of 45. That does not mean that we do not see you until, oh, sorry, of 40. That does not mean that we don’t see you if your BMI is above 40. We absolutely will see you. And we actually have a program here that’s called Fertility Fit. And for our patients that come in and are eager to get started and have a BMI above 40 and want to lose weight, we help them with trizepatide to see if we could try to get them down to the goal BMI so that we can get started with the IVF treatment as soon as possible.

And if we’re not ready necessarily to do the transfer at that point, It’s still a good option to start creating the embryos again, because younger eggs are going to form better embryos. And then in the future, once they’re ready to do the transfer, then we can go ahead and get them placed.

Well, question is, what is your opinion about DNA fragmentation? Opinion about DNA fragmentation. So DNA fragmentation is a test done on the semen, so it can determine if there is a lot of issues with the sperm itself. And it used to be really common because with the DNA fragmentation, they were trying to determine more than anything, does this patient need a process called ICSI or not? Okay. And at the end of the day, we do ICSI on all of our patients.

Why is that? Because if we didn’t do the ICSI, and the eggs didn’t fertilize, then that’s a lot of a process to go through for you to not end up with what you’re hoping to get to. So if in general in medicine, this is not just for DNA frag, but any test that you’re going to do needs to give you some guidance of what is the best next step.

If that test is not going to change the outcome, we do not recommend doing that test. And in general, the DNA fragmentation isn’t going to change the way that we practice medicine. We’re still going to take the sperm. We’re still going to put them through a filter to make sure that we get the best swimmers. And we’re still going to only transfer the sperm into the egg that we look, that looks healthy and that looks like it’s going to be viable.

The DNA frag test is not really going to change the outcome. So we wouldn’t want you to do a test that you’re going to spend time, money, energy, and paying for. That’s not going to really change the outcome.

Next question I see here. Can you be on tirzepatide GLP-1 during egg freezing or IVF? So generally we like to stop the tirzepatide 2 weeks before the egg retrieval. Why is that? Because we need your bodies to kind of wear it off a little bit before we’re putting you through some of the anesthesia medications.

If you’re not ready to transfer right away, then you can go ahead and get back on the tirzepatide the following week until you’re ready to do the transfer. If you’re trying to do that embryo transfer right away, it’s better to stay off the tirzepatide because we want you off the medication two months before you’re doing the embryo transfer.
Why is that? Same concept as the one that we talked about with the weight loss surgery. You don’t want to actively be losing weight when you’re starting a pregnancy, okay?

We’ll usually guide you until you when to stop it because we do have a lot of our patients that are on tirzepatide and we’ll tell them exactly when to stop it so we could start the stimulation medication and then bring them in for the procedure.
Yeah.

Do you recommend the Full Well Women’s Fertility Trio Vitamins while preparing for IVF?
Someone’s asking if I recommend the Full Well Women’s Trio vitamins. I don’t know that specific vitamin itself, but the general vitamin combo that we recommend is a prenatal vitamin. A question I do get a lot is, Dr. Gille, tell me exactly which one to buy. What is the best brand? There’s no best brand of vitamins.

The reality is that a lot of companies have put really nice marketing into some of the prenatal vitamins and driven up the cost and charge you twice as much for the same thing that you’re going to get from an HEB brand vitamin. So I generally recommend get a normal store-bought regular brand or Ritual is one of the fancier ones, but that’s if you really want to try something a little more natural. Nature Made is generally my go-to. Simple and straightforward, it has everything that you need, and it’s not going to break the bank.

I think we’re almost on time. We have time for maybe another two to three questions.

I cut my tubes 2 years ago and I want another baby next year. What is my best option? This is someone who had her tubes tied two years ago and she wants another baby and is asking what’s the best next step.

So if you think you’re going to want to have another baby anytime, whether it be now, a year or three years from now, the best thing to do is to start the IVF process so that you can create the embryos. Once you create the embryos, those are going to be in storage. And whether you choose to transfer them in six months, a year, or three years, you’re going to have a way better outcome than if you wait an entire year and then try to start creating embryos at that point. It’s also very age-based. If you’re 25 and you’re thinking about waiting until the age of 26, maybe not that big of a difference.

But if you’re 36 and thinking about waiting until the age of 37, one year, one year in your mid to upper 30s can start making a much bigger difference. So I definitely recommend start first with the egg freezing process. Leave them frozen, give yourself peace of mind, and when you’re ready, you just transfer the embryo.

Ligia Popescu   54:17
Nice.

Marianela Gille   54:19
How come I went through IVF for my first, then got pregnant naturally for my second, and now I’m trying for my third with IVF? So someone’s asking how come the first time they got pregnant they had to go through IVF, second time spontaneously got pregnant, and now they’re trying again for a third and they’re needing IVF again.

The reality is that no one can tell you you’re completely infertile, right? There’s…
many reasons as to why the pregnancy didn’t happen on its own the first time. We don’t know what it was. And the reality is that if you continue to try and wait, maybe you would have gotten there on your own, but maybe you wouldn’t have.

And it would have been another three years or four years, and that would have gotten you further away from your big picture, which is creating your family of these three children.

So all in all, IVF is for the moment that you’re ready to move forward. It’s not happening on its own. And it feels like it’s the right next step. And that’s what you and your doctor come up with. Do couples conceive naturally after IVF? Yes. I don’t see it all the time, but I do see it quite frequently.

I used to actually deliver babies a few years ago and those IVF babies, the moms would be like, I don’t need birth control. I did IVF. And I was like, you do need birth control because even though you think it can happen, there is a possibility. And I don’t know, every six months I would get one that would come and be like, yep, pregnant again. And it was only three months later and that wasn’t the plan.

So it could be also that through pregnancy, there’s hormonal shifts, your body shifts, the uterus shifts. It’s hard to say exactly what helped it happen that second time. But if you’re now trying for a third and it’s been some time and you still haven’t gotten to your goal, then yes, IVF is probably going to be your next best step.

A question here, is the price of surrogacy the same as IVF or more pricey? So the price of surrogacy is actually a lot more than IVF. Why? Because logistically, it’s a lot harder to coordinate, right? You have to plan that another person is going to be carrying this child. So there’s a lot of additional screening and process that
goes into having one person carry the baby of another person.

In fact, it’s a process that is so complex that we actually don’t offer it here at Pozitivf. Part of our services here is providing lower costs or more affordable fertility services. And once you start getting surrogacy involved, that involves lawyers, a lot of paperwork, a lot of clearance, and that can actually drag out the process and start getting the cost close to about 100,000, if not more. Whereas IVF is something that costs about 15 to 20,000, depending what you’re going for. So yes, it’s a lot more pricing.

It’s definitely something worth looking into if you cannot carry the child or if it’s not an option for you to be pregnant.

Okay, next question is, AMH is 0.03. My vitamin D is 26. Would including a D supplement help if I am about to start the IVF process? Not necessarily. The AMH itself is produced by the follicles in your ovary. So no matter how many supplements, vitamins you take.

In reality, there’s only one supplement that maybe has a very small chance of helping, which is the CoQ10. Your vitamin D level is a little bit low, right? 26 is below the standard. We like to see it at about 30 or above, but you’re not alone. I would say most women are probably around that range.

So increasing your vitamin D level is going to be better for the process of conception. I don’t think it’s necessarily going to make a big difference when it comes to changing your AMH or the quantity or quality of the egg itself.

Quite another question similar in the similar ballpark is can you increase your AMH? AMH in theory cannot be increased. There’s A caveat though. There’s many patients that will do, let’s say an AMH every six months just to see where it’s at. And they’ll see it drop a little and then sometimes it goes up a little and then it drops again.

The reality is that it shouldn’t fluctuate greatly, and it’s not always going to be the same number or dropping perfectly. But in theory, you cannot necessarily create more eggs, right? The eggs that you have were given to you by your mother when you were in her womb. So no matter what supplements, treatments, or products are offered out there…There’s nothing that can create new eggs at this point.

Ligia Popescu   59:01
So I think we need to pull up the closing slides. And yeah, we’re almost there. It was an exciting presentation. I loved all the questions.

Marianela Gille   59:06
Oh, sorry, yes.
Sorry, yes, let me pull it up here. I love answering questions, so I can keep going, but…
Let me see where we have it.
Let me find the slide.

Ligia Popescu   59:22
Thank you.
What I’m going to do right now is invite this audience to please join us again next Monday for our second installment, where we will be on the topic of IVF versus other options with Dr. Jaye Adams, another REI from Pozitivf fertility. So I’m going to put that information here.

Ligia Popescu   59:47
And then I also want to just share the contact information for Pozitivf. If anybody is interested in, you know, scheduling an appointment, you can go to, I’ll put this website in the chat. This is the link: pozitivf.com

And yes, so they’ve got many, many locations. So please give us a call. We’d love to have you come in and schedule your first appointment or your new patient appointment, whatever it is, we are going to respond to your questions. I’ll get a recording out to everyone.

Thank you for joining us. It was a really great time. Thank you so much, Dr. Gille, for joining us. Appreciate it.

Marianela Gille   1:00:32
Thank you so much everybody for taking the time to join us tonight  

Ligia Popescu   1:00:33
Thank you.