• What is infertility?

    Infertility means not being able to get pregnant after one year of trying, or six months, if a woman is 35 or older. Women who can get pregnant but are unable to stay pregnant may also be infertile.

    However, to fully understand the problem of infertility, it is important to know the steps towards getting pregnant

    • Every month an egg releases from a woman's ovaries
    • The egg then travels though the fallopian tube toward the uterus (womb) where it awaits fertilization by a sperm
    • Once a sperm fertilizes the egg , an embryo is created which then signals the beginning of a new life
    • Finally, the fertilized egg makes its way to the uterus where it attaches itself to the lining.(This process is called implantation).

    Infertility can occur when there is a problem with any of these steps. It can also be caused due a host of other factors as well.

  • When should you start looking for help to conceive?

    It's advisable to consult for help at an experienced fertility unit, when you face the following concerns:

    • If your wife is under 35 years of age and you have been trying to get pregnant for more than 1 year.
    • If the age of your wife is between 35 and 39 years and you are trying to conceive with adequately timed intercourse for a period of 6 months or more without success
    • If the age of your wife is more than 40 years or more and you are trying to conceive for 3 months or more.

    The female age is the most recognizable factor for prediction of the probability of successful conception. Thereby, when this factor is highlighted as the concern, then the plan for evaluation and treatment should be considered as soon as possible.

  • Is infertility just a woman's problem?

    Contrary to the common perception, infertility is not only a woman related issue. In fact men account for at least one third of the fertility problems

  • What causes infertility in men?

    Infertility in men is most often caused by:

    • Varicocele- it is a problem that affects at least 20% of men. It is caused due to the veins in the scrotum swelling and hence affecting male fertility since they can increase the temperature of the testicles adversely affecting sperm production.
    • Factors like Infections, Tumours, Hormonal Imbalances etc can cause a man to make minimal few sperm or none at all
    • Sometimes, the movement of sperm can be hampered due to injuries or any other damage to the reproductive system.
    • Genetic conditions such as cystic fibrosis can also affect the sperm quality and production.
  • What increases a man's risk of infertility?

    There are many other social and lifestyle factors which can increase the risk of a man's infertility.

    • Heavy alcohol use - In men excessive alcohol use can reduce the body's production of testosterone and reduce the quality of sperm
    • Drugs – intake of some type of drugs are known to cause infertility
    • Smoking cigarettes – Smoking is known to cause reduction in the production of testosterone in males
    • Advancing Age- with the increase in age, the male sperm's volume, motility ( ability to move) as well as the structure of sperm will reduce which will case infertility
    • Environmental toxins, including pesticides and lead
    • Health problems such as mumps, serious conditions like kidney disease, or hormone problems
    • Radiation treatment and chemotherapy for cancer can increase the risk of infertility
  • What causes infertility in women?

    Majority of the cases of female infertility are caused due to disorders in ovulation. Ovulatory disorders can be many types; a few of the common ones have been described as follows.

    • The most common cause of ovulation problem is polycystic ovarian syndrome which is a disorder that causes production of the male hormones in women which can impair ovulation.
    • Another common issue of ovulation is POI (Primary Ovarian Insufficiency) which is basically when a woman's ovaries do not produce optimal amounts of the hormone estrogen that impairs the process of egg release which leads to infertility.

    There is other less commonly occurring conditions which can cause infertility are:

    • Fallopian tubes being blocked because of pelvic inflammatory disease, surgery after an ectopic pregnancy or even endometriosis.
    • Uterine malformations – a small percentage of women have a uterus the shape of which differs from the normal. Although uncommon, this can be a cause of infertility
    • Uterine benign tumors such as fibroids which are non-cancerous growths that can cause blockage of the fallopian tubes leading to infertility
  • What factors increase the risk of infertility?

    There can be a number of factors which increase the risk of infertility. A few of them are as follows

    • Advancing Age - Advancing age is a concern for the following reasons:
      • The ability of the ovaries to produce more eggs is decreased.
      • Due to age, other health conditions have a higher probability of occurring which can affect fertility.
      • Chances of miscarriage increase with advancing age
    • Stress – studies have shown that the increased stress can adversely affect infertility
    • Smoking – the risk of infertility in smokers can be two times more than compared to non-smokers. Menopause also occurs earlier in smokers compared to non-smokers
    • Excessive Alcohol intake – regular consumption of alcohol in large quantities can adversely affect fertility in women. In women, it is known to cause early menopause as well as create hormonal imbalances
    • Athletic training – hard exercise or intense athletic training can be a cause for infertility
    • Condition of being overweight or underweight
    • Sexually transmitted diseases
  • Can certain foods cause infertility?

    Infertility is not caused by any food, but obesity due to a high calorie diet is a significant contributor for ovulatory problems.

    A body mass index of 26-30 and above 30 is a cause for concern and in such cases, part of the management plan is to control and lose the excess weight.

    Can pain and irregular periods lead to infertility?

    Having pain during periods does not mean infertility. They are a sign of your body's ovulatory cycles. If you are overweight with irregular menses then it should be investigated. Intermittent spotting is not considered as a period, the first day is when you experience a red flow.

    Are long gaps in periods a cause of infertility?

    Getting regular periods is a sign of ovulation, and for some women the menstrual cycle length can be as long as 40 days. This means that the fertility period for such a woman is on a reduced scale and they need to be monitored for pregnancy planning.

  • How to boost Fertility?

    How to improve fertility treatment outcome, some useful tips?

    Women egg health is one of the cornerstones of healthy fertility and is the foundation for any fertility treatment. The health of eggs can affect whether or not fertilization and implantation will occur as well as the viability of a pregnancy. Women are born with all of the eggs cells which she will have for the rest of her life, hence the reason her age can have such an impact on egg health.

    Egg cells are some of the only cells in the body that do not regenerate. Therefore, age of the women have a strong impact on the eggs since the ovaries continues to age, causing the eggs to become less than optimal. Therefore to encourage ovarian health through diet, herbs, supplements and increased circulation to the reproductive system is of the utmost importance.

    The cycle of an egg reaching maturation and in preparation for ovulation in the ovary, each month, is 90 days. But what most women don't know, is that there are things they can do to help support the health of the ovaries and eggs, but it must be done for at least 90 days continuously to have an impact.

    Some of the following tips will be helpful to boost the quality of eggs.

    Water

    Drink plenty of clear water as dehydration and lack of fluid intake can cause the blood to become thick and reduce circulation in the body, as well as many other issues. Drink at least 2 litres of clear water daily.

    Exercise

    Find something to do physical exercise that includes movement, such as walking, running, dancing, or even yoga. Exercise increases the blood flow in the body, brings fresh blood to all of the cells and helps to oxygenate the blood.

    Vegetables

    • Green Leafy Vegetables – The best example is spinach which is loaded with iron, folic acid and antioxidants. All these are required to maintain good health of your reproductive organs. This will also prevent defects in the newborn.
    • Orange and Yellow Vegetables – Orange and yellow vegetables are rich source of beta carotene and antioxidants. Beta carotene helps in correcting hormonal imbalance and also reduces probability of miscarriage.
    • Sweet Potatoes, Carrots and Peas –These vegetables also contain beta carotene that helps increasing your fertility.
    • Cruciferous Vegetables – These vegetables includes cabbage and broccoli contains phyto-nutrients and these help regulate estrogen metabolism.
    • Butternut squash- This is one of the most nutritious and healthy vegetables you can eat, with a rich array of vitamins, minerals and antioxidants - as well as significant amounts of digestible fibre. It's rich in beta-carotene, which is known to help boost production of the hormone progesterone. According to study and research published butternut squash can also help increase both sperm quality and count.
    • Beet root- A fantastic source of the antioxidant resveratrol, which is thought to help combat against age- related infertility. Beetroots are also rich in nitrates to improve blood flow. Beetroot juice particularly recommended for women undergoing IVF treatment. This way it will improve blood flow to the uterus to help with embryo implantation.
    • Asparagus- It is high in the potent antioxidant vitamin C and folic acid amongst other health giving nutrients.

    Fruit

    • Avocados- they are nutritional powerhouses packed with minerals, vitamins, essential fats, protein, carbohydrate and fibre. Its also an excellent source of folate that can help prevent spina bifida. They are a fantastic source of vitamin E, which studies have shown can be beneficial in improving lining of the womb (uterus).They can also help with embryo implantation, which is how a fertilised egg becomes a pregnancy.
    • Pomegranates- In ancient Persia, pomegranates were seen as a symbol of fertility and this still exists today in some countries. Pomegranates are also rich in many nutrients, including vitamin C, vitamin K, folic acid and several other vitamins and minerals. And they are known to have anti-ageing properties, anti-cancer properties, can be helpful for cardiovascular health and bone health and have anti-inflammatory properties as well as helping boost blood flow.
    • Berries - Blueberries and raspberries are loaded with natural antioxidants including vitamin C ,which help boost both female and male fertility. Antioxidants can protect sperm and its DNA from damage. 'Berries are a great source of health promoting antioxidants,
    • Citrus fruits- Not only are oranges, grapefruits and other citrus fruits one of the best sources for vitamin C, they're also packed with potassium, calcium and folate—a B vitamin that can help you get pregnant by regulating ovulation and creating a healthy environment for eggs. You should aim for at least one serving of citrus fruit each day (try a medium-size grapefruit, a large orange, three clementines or one kiwi) in addition to another serving of fruits.

    Fish

    • Salmon- Salmon is a great protein source, rich in many nutrients but particularly anti-inflammatory omega 3. Research has shown that optimal levels of omega 3 are important in the management of female infertility. Ideally it should be wild or organic in order to avoid unnecessary pesticides, fungicides and excessive omega 6 consumption found in conventionally farmed fish.

    Eggs

    Eggs are among the most nutritious foods you can eat — after all, they contain the nutrients to turn a single cell into a baby chicken.

    They are rich in choline, which studies have shown can have significant positive effects on foetal development that may have a lasting influence into adult life.

    Eggs are also rich in many different vitamins and minerals, as well as essential fats, and of course are an excellent source of protein.

    Nuts & seeds

    • Walnuts- are beneficial for sperm quality, are excellent sources of omega 3, fats and vitamin E, which is great for endometrial health, as well as B vitamins and protein. According to research a handful of walnuts daily increases sperm vitality, motility and shape.
    • Pumpkin seeds- are a good source of zinc, which is one of the most widely studied nutrients for both men and women in relation to fertility. It is crucial for the proper development of sperm and plays a vital role in cell division.

    Greek yogurt

    The natural yoghurt will provide calcium and protein, important for a healthy pregnancy.

    You probably thought sticking to low-fat dairy is the healthier choice, but that's not the case when you're trying to boost your fertility. Luckily, it only takes one daily serving of full-fat dairy to improve fertility odds, so grab a container of Greek yogurt for breakfast or an afternoon snack. Not only does it contain more calcium than milk, but it's packed full of probiotics and two to three times more protein than a cup of regular yogurt. It's also a good source of vitamin D, which helps the follicles in your ovaries mature, and it strengthens bones and boosts immunity.

    Abstain from Caffeine, Alcohol and Nicotine Intake

    Summary

    Supporting egg health is important for every woman who is preparing for conception, especially as we get older. There are many things you can do to help support and protect your egg health, but they must done consistently on a daily basis for at least 90 days to have the best effect. Here is a quick summary of the above points that will support and protect egg health:

    • 1. Increase circulation to the reproductive system with massage, exercise and drinking water.
    • 2. Eat a nutrient dense diet including vegetables, fruit and protein and use supporting supplements such as antioxidants.
    • 3. Create a 'stress support system' to help you reduce stress

    Your doctor will prescribe you different multivitamins, antioxidants and other nutrients that you should take for at least 3 months before starting fertility treatment.

  • PRE IMPLANTATION GENETIC TESTING

    What is pre-implantation genetic testing?

    Pre-implantation genetic testing involves removing one or more cells from an in IVF created embryo to test for the presence of normal chromosomal. This procedure analyses the genetic constitution of an egg or embryo to determine whether the genetic material is normal or abnormal. It does this by comparing the DNA of the test specimen with a defined normal profile.

    What are the different types of pre-implantation genetic testing?

    They are two types, called as PGD (Pre-implantation Genetic Diagnosis) and PGS (Pre-implantation Genetic Screening).

    What is PGD?

    PGD (Pre-implantation Genetic Diagnosis) involves removing a cell from an IVF created embryo to test it for a specific genetic condition (for example cystic fibrosis, thalassemia or heamophilia etc.) before transferring the embryo to the uterus. It is available to couples that are at risk of having a child with a specific genetic or chromosome disorder. It prevents the birth of an affected child by testing an embryo before it is implanted in the uterus (womb).

    What is PGS ?

    PGS (pre-implantation genetic screening), is the proper term for testing for overall chromosomal normalcy in embryos. PGS is not looking for a specific disease diagnosis - it is screening the embryo for all normal chromosome copy number. A normal embryo should have 46 chromosomes (23 pairs) and PGS looks for all these.

    What are the different approaches used for the testing?

    There are 2 main approaches to testing. The first method involves removing cells from a day 3 embryo, and testing the DNA of these cells. This reflects the status of the whole embryo. The other method involves testing the polar body (which is a waste product) of the egg and this reflects the status of the egg. In theory, by excluding abnormal eggs and embryos, the procedure should increase the chances of a successful pregnancy. Of course, it also increases the chances of having no embryos to transfer in that cycle if all the eggs/embryos are chromosomally abnormal.

    What is the technique called?

    The technique to do this is called Micro-Array Pre-implantation Genetic Diagnosis (MA PGD) which is one of the latest technologies for testing embryos for genetic abnormalities. The latest evidence from several clinics has been very encouraging.

    Who might benefit from PGS?

    Pre-implantation Genetic Screening can benefit couples with a greater likelihood of a chromosome problem in the embryo. Those people who are most likely to benefit are:

    • Any couple at risk for passing on a genetic disease or condition because they have a family history or have a child with serious genetic condition
    • Older women (over 37 years old) who are predicted to produce good numbers of eggs but don't conceive. This is because the rate of abnormal chromosome numbers in eggs increases with advancing female age.
    • Women who have had repeated IVF/ICSI attempts, but implantation has repeatedly failed or they have miscarried at an early stage of pregnancy.
    • Women who have conceived naturally but have had repeated miscarriages.
    • Women who wish to reduce their chance of having a child with abnormal chromosomes.

    What are chromosomes?

    Chromosomes are thread like structures that carry DNA molecules which have the genetic material defining the individual, and they also provide the instructions that tell the embryo how to develop into a baby. Chromosome exist in every cell of the body. Apart from sperm and eggs, each cell should have exactly 46 chromosomes but sperm and eggs, each have 23 chromosomes so that when fertilization occurs, the resulting single cell (which goes on to form the embryo) has 46 chromosomes.

    Why look at chromosomes in eggs and embryos?

    Research has suggested that IVF/ICSI success rates might be improved if embryos are screened for chromosome abnormalities, with only embryos that have the correct chromosome constitution being transferred to the womb.

    What happens if an embryo has an incorrect number of chromosomes?

    If a chromosome is lost, or if one of them is duplicated, the genetic instructions no longer make sense and the embryo will be unable to form a healthy baby. With very few exceptions, an embryo with the wrong number of chromosomes will not produce a baby. Most chromosomally- abnormal embryos either fail to implant in the womb or miscarry during pregnancy.

    How common are chromosome abnormalities in embryos?

    Research has shown that chromosome abnormalities are very common in eggs and embryos. Furthermore, the risk of having an embryo with the wrong number of chromosomes is greatly affected by the age of the mother. For women in their early 30's, about 25-50% of the eggs and embryos have an abnormal number of chromosomes. However, for women over 40 years old, the proportion is even higher, such that around 75-85% of the embryos produced are likely to be abnormal.

    Are chromosomes routinely tested during IVF/ICSI procedures?

    No, its not routine practise. In the lab, the embryologists look at the embryos down a microscope and grade them based on their physical appearance ("morphology") at that moment in time. The assumption is that the better the appearance, the better the quality of the embryo and hence the more likely it is to implant. In these circumstances the embryologists cannot look at the number of chromosomes (as the assessment is different) in each embryo and we know that just because an embryo looks good, it doesn't mean that it is good – i.e. it can still have an abnormal number of chromosomes. Conversely, an embryo that doesn't look very good, by traditional (morphological) assessment, might have the normal number of chromosomes, and hence be more likely to implant.

    How is the PGS/PGD test done?

    To have PGS or PGD, the woman must go through IVF with ovarian stimulation process and preferably have more eggs retrieved.

    PGS can be performed on fewer eggs but there is a higher risk of having no embryos to transfer due to failure of the PGS process or because all the embryos are chromosomally abnormal.

    Why is assisted conception (IVF) needed for PGD/PGS?

    It is important that we start by obtaining a good number of eggs from a woman and create many embryos, which will only be possible with IVF. Therefore, we need to create a large number of embryos for the best chances of success for PGD/PGS.

    The genetic lab examines the 3-day-old embryo for the chromosomes and then the doctor transfers one or more normal embryos back into the woman's uterus.

    Does PGS have any risks to me or the embryos?

    For the woman, the risks of an IVF/ICSI cycle and performing PGS on the embryos are exactly the same as those in a standard IVF/ICSI cycle. Performing PGS does not add to the risks to the woman.

    For the embryos, there are theoretical risks of excessive damage caused by the removal of cells prior to testing. This damage depends on the skills of the embryologists. All the embryologists who perform the biopsies at our centre have been fully trained to perform the biopsies.

    Success rate of PGD

    There are several factors that can affect the success rate. The most important is a woman's age. The chances of success decrease after the age of 38-39 years.

    Starting a treatment cycle is no guarantee that there will be suitable embryos to transfer. Sometimes we may be left with no embryos to transfer for one or more of several reasons:

    • there may not be many eggs to collect;
    • some eggs may not have fertilised;
    • all embryos may have been affected;
    • some may not have survived the biopsy procedure.

    Would it help me to choose the gender of my child?

    Yes, PGD can help couples select the gender of their child with 99.8% accuracy.

    Is PGD my only option for gender selection?

    At the current time, PGD is the only option for gender selection that is available to the larger population.

    How accurate is gender selection with PGD?

    PGD has a 99.8% accuracy in predicting an embryo's gender. The reason that IVF-PGD is not 100% effective in gender selection is that in minority of cases, when the single cell is removed from an embryo and screened, the embryologist may find no signal, but this is very rare.

    Who is eligible to use gender selection with PGD?

    Patients who are already undergoing fertility treatment may consider family balancing because they are already undergoing IVF and want to take advantage of the option of choosing gender with PGD. However, a couple may choose gender selection for their own reasons; for example, perhaps they are an older couple who wants to have one child of each sex.

    Is gender selection legal?

    Yes, gender selection is legal in UAE, United States and some other countries; however, it is not legal in United Kingdom and few other countries.

    Are there any risks to the mother with PGD/PGS?

    There are no additional risks to the mother with PGD/PGS. She experiences the same risks as a woman undergoing IVF without PGD/PGS. Talk to your doctor about the risks of IVF.

    Are there any risks to the baby with gender selection?

    PGD is still a relatively new technique. Several studies looking at children born following the procedure have concluded that there, do not appear to be any major side-effects to the treatment. The incidence of abnormality is similar to that seen in other forms of assisted reproduction (4-5%).

    Are there any prerequisites to doing gender selection?

    You should receive full preconception gender selection counseling by your doctor about the following:

    • 1.Full information of the risks of failure
    • 2.Confirmation, that you will fully accept children of the opposite sex, if the preconception gender selection fails
    • 3.Counseled about having unrealistic expectations about the behavior of children of the preferred gender
    • 4.Keep in mind that pre-implantation genetic diagnosis does not replace the recommendation for prenatal testing after you achieve successful pregnancy.
  • INFORMATION ABOUT INTRAUTERINE INSEMINATION

    FAQ's INTRAUTERINE INSEMINATION (IUI)

    What is IUI?

    Intrauterine Insemination (IUI) is a process where sperm is specially prepared in the lab to concentrate those with the best quality and then directly placed into the woman's uterus around the time of ovulation.

    Could IUI help me get pregnant?

    IUI is usually straightforward and painless, but it's no longer recommended as a first-line fertility treatment. It may help you as a couple if:

    • You and your partner find it very difficult or are unable to have sex because of disability, injury, or a psychosexual problem.
    • You need extra help to conceive, for example, if your partner has a sexually transmitted viral and needs sperm washing to protect you and your potential child from the disease.

    Some fertility problems, such as mild endometriosis, a low sperm count or poor-quality sperm, and unexplained infertility used to be treated with IUI. However, it's no longer recommended for these problems, as research found that success rates using IUI were no better than just carrying on trying to get pregnant naturally.

    If you and your husband haven't conceived after two years of trying, your doctor is likely to recommend IVF. If you have any cultural or religious objections to IVF then you may still be offered IUI.

    Can IUI be done if there are problems with my fallopian tubes?

    For IUI to work, your fallopian tubes must be open and healthy. If your doctor suspects you have tubal damage or if you don't become pregnant within few cycles of IUI, she/he may recommend that you have tubal patency test. The doctor will discuss different ways of checking the tubal patency and advise the best procedure that would be suitable for you.

    Is IUI done at a specific time during the menstrual cycle?

    If you are not using fertility drugs, IUI will be performed between day 10 and 12 of your monthly cycle – with day one being the first day of your period. You will be given blood tests or urine tests to identify when you are about to ovulate.

    or:

    If you use fertility drugs to stimulate ovulation, vaginal ultrasound scans are used to track the development of your eggs. As soon as an egg is mature, you are given a hormone injection to stimulate its release.

    How is IUI carried out?

    This procedure is performed using a simple, minimally invasive (similar to having a pap/cervical smear) fine catheter and takes only a few minutes. As you lie down on your back the doctor will insert a speculum into your vagina to keep your vaginal walls apart. Using a catheter (soft flexible tube) through your cervix, your doctor will then put the sperm directly into your womb near a fallopian tube. This is the passage the egg travels along from an ovary to your womb. The whole process only takes a few minutes and is usually painless. Some women may experience a temporary, menstrual-like cramping. You may want to rest for a short time before going home.

    Your doctor will probably ask you to lie still for about 10 to 15 minutes after IUI, as this improves your chances of conception. Then you're free to carry on life as normal. You'll be able to take a pregnancy test in about two weeks.

    For men

    You will be asked to produce a sperm sample on the day the treatment takes place. The sperm will be washed to remove the fluid surrounding them and the rapidly moving sperm will be separated out from the slower sperm. The rapidly moving sperm will be placed in a small catheter to be inserted into the womb.

    If you are using frozen sperm, it will be removed from frozen storage, thawed and prepared in the same way.

    What are the different types of IUI?

    • Natural IUI - Insemination takes place after monitoring a natural cycle
    • Stimulated IUI - The chances of success may be increased if the insemination is combined with small doses of fertility drugs to stimulate ovulation.

    In both options the development of the ovarian follicles is monitored using ultrasound and the insemination is timed to take place around ovulation (either 24-36 hours after a natural surge is seen using urinary ovulation kits or 24-36 hours after administration of the hormone injection hCG, which triggers ovulation).The male partner is scheduled to produce a semen sample a few hours before the insemination to allow time to prepare it appropriately.

    Who benefits from IUI?

    Although IUI may improve your chances over natural "timed intercourse", it is much less successful than IVF. Different research and guidelines increasingly recommend proceeding straight to IVF after a period of trying to conceive with unexplained subfertility, mild male problems or mild endometriosis where IUI might have previously been initially suggested.

    What is the success rate of IUI?

    It is difficult to assess success rates for Intrauterine Insemination (IUI) because success depends upon the cause of infertility and whether fertility drugs are used to stimulate egg production. It also depends on the women's age and her ovarian reserve.

    Discuss with your clinician whether fertility drugs are suitable for you.

    Are there any risks to IUI?

    Intrauterine insemination itself is normally quite straightforward – it is usually fairly painless, although you may experience mild cramps similar to period pains. However, the risks associated with the fertility drugs that are often used with this treatment can include reactions to the drugs and certain pregnancy problems.

    Although less invasive than IVF, it may be uncomfortable if it proves difficult to insert the catheter. And the procedure may cause cramps similar to period pains.

    With stimulated IUI, you also run the risk of multiple pregnancy.

    The use of ultrasound scanning before ovulation means that if there are more than two mature egg follicles present, the cycle can be abandoned. Your fertility specialist should discuss all risks with you before beginning your treatment.

    With stimulated cycles there is a very small risk of developing ovarian hyperstimulation (OHSS). This serious condition happens when your ovaries respond too well to the fertility drugs that cause you to ovulate. The fertility drugs used for IUI are unlikely to cause a severe case of OHSS. However, a mild case may give you a bloated and uncomfortable tummy or make you feel sick.

    It's vital that you seek medical help if you think you are experiencing OHSS. Your doctor will probably advise cancelling your IUI treatment for this cycle. That's because the risks of conceiving a multiple pregnancy will be too great, and OHSS can sometimes worsen in response to natural pregnancy hormones.