Infertility management

Women may have problems having a pregnancy for a variety of reasons.  These include:

Body weight far above or below the ideal level

Women who are very thin or very overweight may observe irregularity of their menstrual cycle.  This has an effect on the success of pregnancy, since differences in weight may affect hormone production.  Women who exercise a lot may have similar symptoms.  Some women who are overweight have polycystic ovarian syndrome, a condition that affects egg production and influences body weight.

Changes in hormones that are needed to regulate the monthly cycle

Some women with infertility may have problems making hormones necessary for pregnancy, such as prolactin, FSH or LH.  These hormones can be measured by blood tests, and treatments to replace or influence these hormones levels may be helpful.

Changes in the structures of the fallopian tubes or uterus

A variety of factors can affect the structure of the uterus or the fallopian tubes.  The fallopian tubes are necessary to deliver eggs from the ovary to the uterus, where fertilization and implantation occur.  Fallopian tubes can be affected by conditions like endometriosis or pelvic inflammatory disease.  The uterus can be affected by these causes as well as fibroids, the uterus structure, or other factors.

Treatments for infertility depend on the cause.  Sometimes specialized treatments are helpful for infertility.  These may be stimulation of egg production with a medicine like clomid, in vitro fertilization, or selection of eggs and sperm with normal genetic material to facilitate a healthy pregnancy.


HCG is a hormone.  It stands for human chorionic gonadotropin.  It’s biological role is to promote the corpus luteum during early phases of pregnancy and to promote the production of progesterone to prepare the uterus for a fetus.

Pregnancy tests detect levels of this hormone.  The level of this hormone is lower at early stages of pregnancy, 5-50 mIU/mL.  These increase with each week of pregnancy, from levels of 1000 to up to 200000.

HCG is similar to LH, a hormone that affects ovulation.  HCG is often used to help women with infertility.  The injection of HCG is used to promote maturation of eggs and ovulation.  Ovulation normally occurs about 36-40 hours after injection.  During IVF procedures, egg retrieval is normally done about 36 hours after HCG, before natural ovulation.

HCG is sometimes used in men to stimulate testosterone production.  It has also been linked to performance enhancement scandals in professional sports.

Gonal F

Gonal F is a hormone medicine.  It is injected under the skin to stimulate egg production.  It is similar to the hormone FSH (follicle stimulating hormone).

Gonal F is often used to treat infertility, in particular for IVF procedures.

Common side effects of Gonal F include abdominal pain, bloating, pain where the injection is given, or a headache.  Serious side effects are rare but they may be trouble breathing, dizziness, bleeding or swelling.

What is Clomid?

Clomid, clomiphene, or serophene, is a medication that interferes with estrogen receptors in the hypothalamus, a hormone regulator in the brain.  The result of clomid treatment is the release of GnRH, or gonadotropin releasing hormone, and resulting increases in FSH and LH release from the pituitary gland.  The causes growth of ovarian follicles, and often clomid is used to stimulate ovulation.

What is infertility?

Infertility is the inability to have a pregnancy within 12 months of trying.  Some of the causes of this condition are related to males, some are related to females.

Common causes of infertility are:

Problems with ovulation / eggs

Problems with the uterus / endometriosis

Blockage of the fallopian tubes

Changes in hormones / prolactin

Male factors / sperm quality

Evaluation of the causes of infertility require a careful evaluation of medicines and medical history, genetic family history, and testing for sperm count, appearance, uterus and fallopian tube anatomy, hormone testing, and sometimes genetic testing of the blood, sperm or the eggs.

How long does the flu shot last?

Answer: forever, but….you should repeat the shot once per year

The flu shot is a mixture of particles from recent common flu viruses from around the world.  This helps the body form an immune response to flu infections- the flu vaccine is known to prevent flu.

There are different formulas for the flu shot.  The formula changes every year, in order to act against the most common viruses.  The flu shot does not protect against all flu viruses- normally just two or three.  Sometimes the vaccine does not cover an unexpected outbreak of a new type of flu virus.  This is why clinical outbreaks occur despite widespread use of the flu shot.

Each year the flu viruses that affect people change, so it is important to have a new flu shot once per year.  The effects of the immune response after one vaccine also decline during the year after treatment.

Is the flu shot ok for MS?

The inactivated flu shot is appropriate and helpful for people who have a history of Multiple Sclerosis. 

There is a potential interaction between interferons (Avonex, Beta Seron, Rebif) and the flu shot.  Both of these can cause flu like symptoms.

The FluMist nasal spray, which contains a live virus, is not recommended.

How long does the flu last?

The seasonal flu is caused by an outbreak of the influenza virus.  This tends to occur during the winter.  The flu normally causes symptoms of fever, muscle pain, fatigue, weakness, and sometimes, coughing, sneezing, or sore throat.  The flu is normally transmitted from person to person via sneezing or coughing.

The time between onset of the illness and exposure is normally 2-4 days.  People with simple flu infections recover in 2-5 days, although durations as long as one week are not uncommon.  In some people, the symptoms may last longer.  These are people who are children or older adults, people with chronic illnesses or immune suppression.

A complicated course of the flu may include associated viral pneumonia, bacterial pneumonia, changes in heart rhythm, confusion and meningitis, or other serious infections.  These conditions are more serious, and they tend to have a longer duration.

Does Prevagen Work?

Prevagen has been touted as a dietary supplement that helps to improve memory.  Does Prevagen work?

Prevagen is a dietary supplement made by Quincy Bioscience, a company based in Wisconsin.  It contains apoaequorin, a protein derived from a jellyfish.  Evidence cited by Quincy Bioscience that Prevagen is effective is reported in a study in 2016.  This study was not published in any journal.

The goal of the study was to determine whether the active ingredient of Prevagen, apoaequorin, improves cognitive function in older adults who have normal or near normal memory function.  In this study, healthy adults ages 40-91 with memory concerns were examined by cognitive tests over a period of 90 days.  People with neurological diseases and other conditions were excluded from the study population.

The authors reported that there were significant improvements in cognitive function in people treated with the study chemical compared to those who were not.

Limitations of this study include:

The study duration was 90 days.

Only participants with minimal or no cognitive impairment were studied.   Results for people with mild or greater memory impairment were not reported.

This study examined a small number of study participants.  Of the 211 people enrolled in the trial, only 100 were included in the final analysis.  Only 37-60 received the test chemical.

With respect to the majority of cognitive tests, the study reports there is a trend to significance.  This is the same as saying there was no change.

They authors state there are significant improvements in the control group compared to the placebo group in three tests.  These are the Groton Maze recall, the Detection test, and the One Card Learning test.  The statistical analysis shows a lack of significant results.  Examining the numbers reported in Tables 3 and 4, there was no significant improvement in either the control group or the placebo group over the time of the study.

The background evidence for the in vitro efficacy of the active ingredient of Prevagen was published.  These include two meeting abstracts and one article in PLoS One.

It would be wonderful if Prevagen improved memory in normal people or people with memory problems.  Although the evidence presented in this study was limited, we are hopeful that better evidence will be reported soon.

Note that The Federal Trade Commission and the State of New York have accused the manufacturer of Prevagen of false advertising.

Thoracic Outlet Syndrome

The thoracic outlet is a part of the body between the neck and the arm.  Three major structures pass through this – the nerves of the arm (the brachial plexus), the subclavian vein, and the subclavian artery.  Compression of the thoracic outlet structures often occurs by a muscle, muscular band or a cervical rib.  When any of these structures is compressed or squeezed, a person may develop symptoms of pain, color change, or numbness.  Sometimes these symptoms occur with specific arm positions.  This condition is known as thoracic outlet syndrome (or TOS).

Vascular thoracic outlet syndrome is a rare condition caused by compression of the subclavian artery or subclavian vein.  Sometimes these are referred to as arterial or venous TOS.  They may cause symptoms of swelling or bluish color change, pain in the fingers, coldness or pale coloration in the fingers, or poor oxygen supply to the fingers.  When compression of the vein or artery is confirmed, vascular surgery treatment is recommended.

Neurogenic thoracic outlet syndrome is a more common condition.  It may be related to a history of trauma or repetitive movement.  Symptoms of neurogenic TOS may include pain and weakness in the hand, pain in the neck or the back of the head, and tingling.  Coldness and color change may also occur, but this can be caused by nerve irritation rather than vascular changes.  No arm swelling or pulse changes are present with neurogenic TOS.

The symptoms of neurogenic thoracic outlet syndrome can sometimes be triggered by movement of the head or arms.  Rotating and tilting the head is one way to trigger the symptoms.  Another way is to raise the arms to the level of the shoulders , extend the wrists and tilt the head towards one side.  Sometimes this is a useful test during an office evaluation.  Congestion of veins on the chest or absence of a radial artery pulse with positioning of the arm is a helpful clue for vascular TOS.

Because TOS is affected by positioning of the arm, diagnostic testing for this can be misleading.  A chest xray will evaluate for the presence of an extra rib at the bottom of the neck.  The cervical rib is sometimes present at birth and it may influence symptoms of TOS.  In many patients, EMG or nerve conduction tests are normal.  The EMG is most helpful because it can assess for other conditions that mimic TOS.  MRI or MRA testing results can be variable, and often they are not helpful.

Treatment of TOS may benefit from physical therapy, medications, injection of anesthetic into a muscle that causes TOS, or sometimes surgery.  Surgery is rarely necessary for neurogenic TOS.

The following is a link to a thorough discussion of TOS, its diagnosis, and treatment at a TOS treatment center.