Alexandra Peyser, Sara L. Bristow and Avner Hershlag

BMC Cancer 2018 18:544 | ©  The Author(s). 2018

Received: 27 February 2018 | Accepted: 1 May 2018 | Published: 9 May 2018


Astrocytomas are the most common malignant glial tumors. With improved prognosis, it is possible for patients to pursue pregnancy post-treatment. However, with potential gonadotoxicity of oncology treatments, fertility preservation prior to chemotherapy and/or radiation therapy should be considered. This requires close collaboration between the oncologist and reproductive endocrinologist. To our knowledge this is the first report of successful pregnancies following fertility preservation for AA.

Case presentation
33-year-old nulligravid woman with newly diagnosed anaplastic astrocytoma (AA; WHO grade III, IDH1-negative) sought fertility preservation. Prior to chemotherapy and radiation for AA, the patient underwent in vitro fertilization (IVF) for fertility preservation, resulting in 8 vitrified embryos. Following chemo-radiation, the patient underwent two rounds of frozen embryo transfers (FET), each resulting in a successful singleton pregnancy.

This case illustrates the realistic possibility, in carefully selected patients with brain tumors, of oocyte or embryo cryo-preservation prior to chemo-radiation and subsequent pregnancies.

Fertility preservation – Anaplastic astrocytoma – Glioma – Brain cancer

Astrocytomas are the most common malignant glial tumors originating from small star- shaped glial cells (astrocytes) within the central nervous system. Anaplastic astrocytomas (AA) are defined as grade III glial tumors according to the WHO 2000 classification [1]. The incidence of AA is approximately 0.48 per 100,000 person/years. They occur more often in younger adults ages 30–50 and account for 17% of primary malignant brain tumors [2]. Prognosis in historical studies, which include both IDH (Isocitrate dehydrogenase)-mutant and IDH-wild type AAs, ranges from 3 to 5 five-year-survival. Prognosis is better for a genetically-defined subset of IDH-mutant tumors, with a median survival closer to 10 years [3]. The mainstay of therapy is surgery followed by radiotherapy. Multiple protocols, including various combinations of high dose radiotherapy, chemotherapy, alternative fraction regimens, heavy particle treatment, interstitial brachytherapy and radiosurgery have been proposed to extend survival [3].

Determining the safety of fertility preservation and subsequent pregnancy after treatment of gliomas is difficult due to the lack of data in the literature. Most studies have been done in patients where the glioma was diagnosed during pregnancy; in these cases there have been reports of changes in the growth of the tumors throughout the pregnancy [45678]. Significantly, it seems that the same hormones and growth factors required for fetal development may also enhance tumor growth [9]. Currently, no guidelines exist for the medical management and treatment of gliomas diagnosed prior to or during pregnancy. Therefore, it is recommended that women with treated gliomas who want to pursue pregnancy should be followed by a high-risk obstetrician as well as a neuro-oncologist and monitored throughout pregnancy.

Case presentation
A 33-year-old nulligravid woman with newly diagnosed AA (WHO grade III, IDH1 negative) presented to our office for fertility preservation. The patient had undergone a craniotomy with complete resection of her right parietal lobe tumor one month prior, and was scheduled to start chemotherapy and radiation in the next month. Her neuro-oncologist recommended that she undergo fertility preservation prior to chemo-radiation. The fertility preservation did not delay the anticipated start of her chemo-radiation treatment.

The patient had no significant medical or gynecological history. On physical exam, the patient was a healthy-appearing woman. She had left lower extremity weakness and instability. Transvaginal ultrasound demonstrated a normal-appearing uterus and ovaries bilaterally. A dominant follicle was noted on her right ovary; therefore, it was decided to administer HCG 10,000 IU at the time of her presentation to trigger ovulation, thus enabling the initiation of gonadotropins two weeks later. The patient had a high antral follicle count (6 on right, 7 on left).

The patient received low dose gonadotropins: 1 ampule of Human Menopausal Gonadotropin (Menopur®, Ferring Pharmaceuticals, Parsippany, NJ, USA), 75–187.5 IU of FSH (Gonal F®, EMD Serono, Rockland, MA, USA) for 10 days and cetrorelix acetate (Ganirelex®, GnRH antagonist, EMD Serono, Rockland, MA, USA) for the last 6 days. Final oocyte maturation was triggered with Lupron Luprolide Acetate (Lupron®, GnRH agonist, SANDOZ Pharmaceuticals, Princeton, NJ, USA) 40u. Twelve oocytes were retrieved transvaginally under ultrasound guidance. Eight embryos developed and were vitrified in liquid nitrogen (6 on day 3 and 2 on day 5 post-retrieval).

The patient returned to our Center one year later after she was cleared by her neuro-oncologist following the completion of chemotherapy and radiation. The patient had 6 weeks of radiation therapy with Temozolomide (Temodar®, Merck&Co, Inc., Whitehouse Station, NJ, USA) followed by 6 months of maintenance dose. Her last dose of chemotherapy was one month prior to returning to the office. The patient had maintained regular cycles post chemotherapy. The patient underwent a frozen-thaw natural cycle embryo transfer of a single day-3 embryo with vaginal progesterone (Crinone®, Actavis, Parsippany, NJ, USA) luteal phase support. The patient remained on Keppra® 500 TID (levetiracetam, UCB Pharmacueticals, Brussels, Belgium) and Lactulose throughout the pregnancy. A viable singleton pregnancy was seen on ultrasound 1 month later. The patient delivered a healthy female baby weighing 7lbs 5 oz. at term.

The patient returned two years later desirous of another pregnancy. Her neurological status had been stable, was tumor free and was cleared by her oncologist to conceive again. This time the patient was treated with Estrace® (estradiol, Warner Chilcott, Rockaway, NJ, USA) 6 mg a day and underwent a frozen-thaw cycle with a single day-5 blastocyst transferred. The patient conceived with a viable singleton pregnancy and delivered a healthy male at term weighing 6lbs.

Throughout the patient’s treatment regimen for fertility preservation and frozen embryo transfers, no adverse or unanticipated events were encountered.

Discussion and conclusions
Women diagnosed with gliomas during child-bearing years may undergo fertility preservation prior to receiving chemotherapy and radiation to harvest oocytes and freeze them or freeze embryos if they have a partner, since their postoperative treatment, especially chemotherapy, is potentially gonadotoxic and may render them sterile. Studies have shown that the risk of ovarian failure as a result of chemotherapy varies based on both the drugs used as well as the patient’s age [1011]. Temozolomide (Temodar®, Merck&Co, Inc., Whitehouse Station, NJ, USA) is an alkylating agent, and while the effects of other alkylating agents used for chemotherapy on fertility have been studied, little is published about the gonadotoxicity of temozolomide in females. A handful of small studies have shown that fertility potential is affected in males [1213], with one case resulting in fathering a healthy child after treatment with temozolomide [13]. A study from France followed fertility outcomes in two groups of glioma survivors who had received temozolomide categorized based on whether the patient pursued fertility preservation [14]. They observed one spontaneous pregnancy in a woman who did not undergo fertility preservation and three pregnancies – one delivery, one spontaneous miscarriage, and one ongoing pregnancy – in women that underwent fertility preservation (four out of 24 women followed for one to five years). In the absence of more data, we recommend to assume high gonadotoxicity level of temozolomide, and pursuing fertility preservation in such patients following clearance by the neuro-oncologist.

A remaining concern for oncologists and oncologic surgeons is whether fertility preservation delays critical treatment. In cases when the patient receives adjuvant therapy, such as the one presented here, there is typically a sufficient interval between surgery and planned adjuvant therapy (chemotherapy and/or radiation) to allow for a short window of opportunity to freeze eggs or embryos without affecting the cancer treatment timeline at all. In addition, if neoadjuvant therapy is recommended in other cases, recent advances in reproductive technologies allows for fertility preservation to be initiated any time during the menstrual cycle (“random start”). This allows patient to start an ovulation induction cycle on the day she presents to the oncofertility specialist, and it is expected that the cycle will be no more than 2 weeks. Thus, fertility preservation should not delay or alter treatment regimens for cancer patients.

The literature is scarce regarding the possible interactions between gliomas and pregnancy. Changes of the biological behavior of some tumor subtypes may occur during pregnancy, such as an accelerated tumor growth and/or malignant transformation. Several reports have discussed interactions between pregnancy and the growth of gliomas. One study analyzed velocity of diametric expansion (VDE) of WHO grade II gliomas in 11 pregnant women and demonstrated an increase in VDE during pregnancy [4]. Multiple case series have demonstrated cases where woman with WHO grade II gliomas developed de-differentiation of the tumor during pregnancy which became apparent either clinically, radiologically or confirmed histologically by post-delivery surgeries [567]. A recent case report revealed a malignant transformation from diffuse astrocytoma (WHO grade II) to glioblastoma (WHO grade IV) in a post-partum patient 1 month following the patient’s delivery [8].

The mechanism by which tumor growth is enhanced during pregnancy stems from the idea that the large amount of hormones and growth factors excreted during pregnancy simultaneously increase tumor growth. Placental growth factor for example, is an angiogenic element necessary for both fetal development and the growth of gliomas [9]. Due to the relative paucity of cases reported, the majority of cases focus on gliomas diagnosed during pregnancy. There are no guidelines for the management of gliomas diagnosed either during or prior to pregnancy. If a woman with a treated glioma desires a pregnancy it is advised to perform very close neurological follow-up with repeat MRI’s in addition to obstetrical monitoring.

The use of antiepileptic drugs (AEDs) during the course of pregnancy may be teratogenic and increase the risk of congenital malformations. Levetiracetam (Keppra®) is considered a safe medication for use during pregnancy. The North American AED pregnancy registry published data collected from pregnant women taking Levetiracetam monotheraphy from 1997 to 2011. The relative risk of major malformations was not increased in comparison to women with epilepsy who did not take AEDs while pregnant [15].

To our knowledge this is the first report of successful pregnancies following fertility preservation for AA. This case illustrates the realistic possibility of oocyte or embryo cryo-preservation prior to chemotherapy and radiation with subsequent embryo transfers. A recent article published in Neuro-Oncology [16], describes a study reviewing primary brain tumor patients age 18–45, referred for fertility preservation. Seventy-three percent accepted referral to a sperm bank (87% men) or a reproductive endocrinologist (56% women). The study concludes that there is significant interest in fertility preservation among these patients, particularly if they had no children [16]. Patients should be informed at the time of tumor diagnosis about the option of preserving their fertility. Proper referral to a reproductive endocrinologist as well as a mental health professional is recommended to help make informed decisions [17].

It is incumbent upon physicians to engage in discussion of the ethical perspectives of fertility preservation in patients with brain tumors. For childless women, the option of post-treatment pregnancy opens a window of hope that may elevate their mood, helping them cope with a potentially fatal diagnosis and difficult treatment. However, the possibility that pregnancy may negatively affect prognosis remains a major concern.

AA: Anaplastic Astrocytoma
AED: Antiepileptic Drug
FET: Frozen Embryo Transfer
IDH: Isocitrate Dehydrogenase
IVF: In Vitro Fertilization
VDE: Velocity of Diametric Expansion

Availability of data and materials
All data generated or analyzed during this study are included in this published article.

Authors’ contributions
AP and SLB reviewed the entire case and was a major contributor in writing the manuscript. AH was the primary physician on the case and was a major contributor in writing the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate
Research reported in the study was performed in accordance with the Declaration of Helsinki and was exempt by the Northwell Health Institutional Review Board under Policy and Procedure Section 25.0.

Consent for publication
Documented written consent from the patient was obtained to report the details of the case.

Competing interests
The authors declare that they have no competing interests.

Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open Access

This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( applies to the data made available in this article, unless otherwise stated.


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© The Author(s). 2018

Dr. Avner Hershlag recently spoke with Refinery29 to inform their article on endometriosis, egg freezing, and the singer Halsey’s decision to freeze her eggs. Halsey revealed in a recent interview that she’s struggled with endometriosis and has taken steps to preserve her fertility through egg freezing.

“I’m 23 years old, and I’m going to freeze my eggs,” she said when interviewed on the talk show program The Doctors. “And when I tell people that, they’re like, ‘You’re 23, why do you need to do that? Why do you need to freeze your eggs?’ Doing an ovarian reserve is important to me, because I’m fortunate enough to have that as an option, but I need to be aggressive about protecting my fertility, about protecting myself.”

Endometriosis is a common condition that affects over 200,000 women each year. If you have endometriosis, the tissue that normally develops inside the uterus during your cycle also develops on the outside of the uterus and/or surrounding organs. This can cause symptoms including discomfort, heavy periods, and infertility. Endometriosis can be managed with medications and surgery, but because it is a chronic condition, you should consider proactively protecting your fertility through egg freezing.

“Endometriosis is a chronic condition and tends to come back even after surgery,” said Dr. Hershlag. “The disease itself, as well as surgeries, threatens to diminish ovarian reserve, and therefore freezing eggs early on is a smart, proactive strategy.”

Egg freezing involves the monitoring and retrieval of mature eggs, which are then frozen and stored until the woman is ready to use them. Because egg quality deteriorates as we age, freezing eggs when you are young can give you a more viable option if you have trouble conceiving later in life. To learn more about egg freezing, endometriosis, and other steps you can take to enhance your fertility, contact us.

A miscarriage is one of the most difficult situations a couple can experience. Both parents are left in unimaginable pain and grief. In addition, it can lead to many questions and wondering what went wrong and why the pregnancy didn’t take. However, it can be even worse if there is a situation of several miscarriages.

What Causes a Miscarriage?

Miscarriages are described as the loss of a pregnancy prior to the 20th week. In many instances, the woman might not even realize she is pregnant because she might miscarry before she has even missed her menstrual period. Generally, however, around 15 to 25 percent of known pregnancies end in a miscarriage. Over 80 percent of those occur within the first trimester. A miscarriage can occur after the 20th week of pregnancy, but those are rare.

The majority of miscarriages occur because of chromosomal abnormalities that are not inherited by either parent but that abruptly develop in the unborn baby. Most often, the miscarriage occurs because the baby would not be able to survive. Miscarriages can occur for other reasons as well. They are as follows:

• Hormonal problems
• Uterine abnormalities
• Immune system responses
• Infection
• Diabetes or thyroid conditions in the mother
• Physical problems in the mother
• Being over 35
• Problems with the cervix
• Recurrent miscarriages (three or more)

Are Multiple Miscarriages a Sign of Infertility?

Sadly, approximately four percent of couples end up experiencing recurrent miscarriages. At this point, miscarriage and fertility become a worrisome issue. However, there is hope because there are options for these couples that can help them to conceive and go on to enjoy a healthy pregnancy.

Anyone who has experienced multiple miscarriages will want to get support and answers to their numerous questions. Medicine has advanced considerably over the years and there is the option of infertility and genetic testing that can help couples to regain control over their fertility.

Testing Available for Couples Who Experience Miscarriage

There are certain tests available for couples who have experienced miscarriage. These are as follows:

Genetic Karyotype: Couples who have experienced several miscarriages, generally three or more, who are considering trying to conceive naturally or through in-vitro fertilization (IVF), should consider this type of test. Genetic karyotype testing checks for chromosomal abnormalities that can present the risk of miscarriage and a baby being born with a genetic issue.
PGS (Preimplantation Genetic Screening): This type of test is recommended for people who have a high risk due to a family history of genetic problems like cystic fibrosis or fertility issues and have a history of recurrent miscarriages. It can check for healthy embryos for couples who plan on using IVF so that the embryos can implant and develop in a normal and healthy manner.
Fetal Tissue Testing: This type of testing is done on the fetal tissue after a miscarriage. It is done to determine why the pregnancy didn’t develop and progress normally and can bring couples some answers. It is recommended for couples who have no known risks for miscarriage. Unfortunately, it doesn’t always result in a conclusive answer.

Solutions for Infertility

When it is discovered that you have a correlation with miscarriage and infertility, you can seek help from your doctor to conceive and have a normal, healthy pregnancy. Couples have the following options:

Artificial Insemination: The sperm is inserted into the woman through a tube, which helps with conception when there are issues like low sperm count or problems with cervical mucus. It is frequently used with a medication known as Clomid.
Assisted Reproductive Technology (ART): ART is done by removing the woman’s eggs and directly fertilizing them with her partner’s sperm. After fertilization, one or more embryos are inserted into the woman.
In-Vitro Fertilization (IVF): IVF is a type of ART, but multiple embryos are placed inside the woman.

Remember, if you have experienced miscarriage and infertility, it’s important to not lose hope. There are options that can help you to have the family of which you’ve always dreamed.

mother's day infertility

Mother’s Day is bittersweet when you are struggling with infertility. On one hand, you want to celebrate all of the mothers in your life. Yet, you also find that this day dredges up some difficult emotions. As this special day draws near, use these coping strategies to shower the women in your life with love while also taking care of yourself.

Start The Day With Self-Care
Waking up on Mother’s Day is difficult when you long for a family of your own. Begin your morning by doing what makes you feel best. Perform a few yoga stretches, treat yourself to breakfast in bed or go for a walk. Investing a few minutes of your morning on taking care of yourself will give you a better perspective before you start celebrating the mothers in your world.

Reach Out For Support
One of the hardest things about dealing with infertility is that your struggles are often invisible to the rest of the world. Consider talking to your mother today about what you are really going through, or you could reach out to someone else who is also struggling with infertility. Finding a listening ear allows you to vent your painful emotions while benefiting from knowing that someone out there understands.

Choose How You Spend The Day
There is no rule that says that you have to be a smiling participant at every Mother’s Day event. If you know that the day will be difficult, consider taking your mom out for lunch the day before or after. Alternatively, you can recruit your partner or support person to attend your family’s Mother’s Day event so that they can soothe your emotions if you become overwhelmed. It is also okay to cut your attendance at these events short or just stay home if you are dealing with raw emotions.

Find Ways To Laugh
Laughter truly is the best medicine, and you can find ways to distract yourself with a little humor. Head to your local comedy club for brunch, or find a hilarious comedy on a movie channel that you know will make you laugh. Alternatively, you could invite a group of your single girlfriends over for a silly makeover session. Whatever you choose, make sure that it is lighthearted and fun so that they day flies by with humor.

Indulge In Some Pampering
Who says that mothers should get all the love on this day? Everyone woman deserves to be celebrated for their caring nature, and spending a little extra time on yourself reminds you that you are also important. Run a luxurious bubble bath, schedule a massage or go for that new hairstyle. You’ll feel better both inside and out.

This year, don’t let Mother’s Day leave you feeling burdened by the pain of infertility. Surround yourself with family and friends who understand what you are going through, and remember that reaching out to others is better than wallowing in self-pity. By being willing to practice a little self-care, you can make it through this day while emerging stronger and with a better support system in place.

questions to ask your fertility doctor

National Infertility Awareness Week was just last week. This purpose of this campaign was to encourage people who have been battling infertility to seek help from a doctor. It also encourages them to seek the support of their family members and friends. Additionally, people are encouraged to ask their insurance company if they will cover infertility treatments. It is important to note that infertility is a common problem. It is estimated that 15 percent of couples are battling infertility.

Questions to Ask Your Fertility Doctor

When you’re ready to take the leap, consider these important questions to ask your fertility doctor during a consultation.

  1. What are some of the reasons we have been unable to conceive?
  2. What treatments should we try first?
  3. What is the success rate of these treatments?
  4. How many times do people have to try this treatment before it works?
  5. What medical tests do I need to get before I get this treatment?
  6. What are the short-term side effects of this treatment? Are there any long-term complications?
  7. Will we provided with a psychologist if we choose a sperm or egg donor?
  8. Do we have access to egg donors, sperm donors, or surrogates through this fertility clinic?

If you are in an LGBT relationship, then there are additional questions to ask your fertility doctor.

  1. Can you recommend an attorney to me who has experience in family law in the LGBT community?
  2. Will you work with the donor agency and reproductive attorney that I already have?
  3. How many gay patients do you have?
  4. What options do I have that will allow both partners to be physically-involved in the process? Is there a way to make sure that both parents are biologically-related to the child?

You should not hesitate to ask your doctor any of these questions about infertility and the potential treatments. The more you know about infertility, the easier it will be for you to get it treated.

national infertility awareness week

Did you know that 1 in 8 couples struggle with infertility? Even though it’s a common issue affecting many people throughout the world, infertility doesn’t get the awareness it deserves. An astounding 15 percent of all couples in the country struggle with creating a family. Some consider infertility unimportant, but infertility needs to be considered a subject of compassion and education. With National Infertility Awareness Week fast approaching, those struggling with infertility and those who support them have created a movement aimed at removing all barriers that stand in the way of building families.

What is infertility?

Infertility is defined as the inability to naturally conceive a child. It does not discriminate on sexuality, economic status, religion, or race. If after 12 months of unprotected sex one cannot conceive, you are considered infertile. On average, a third of all cases can be traced back to the woman, a third of all cases can be traced back to the man, and the other third of all cases are because of both partners or a cause cannot be found.

Medical technology has come a long way, especially in recent decades. Those who specialize in infertility can now help determine the root of the cause and help those who suffer with infertility in tremendous ways. Treatments for infertility are available to both men and women, including various surgeries, drugs, and assisted reproductive technology.

What is National Infertility Awareness Week (NIAW)?

National Infertility Awareness Week was founded by Resolve, The National Infertility Association. Resolve is a non-profit organization whose goal is to help improve the lives of the many men and women affected by infertility. They provide free support programs in areas all over the country, assist in raising awareness on the issue, and works hard to protect the rights and legal access of every family they work with.

NIAW is April 23-29, 2017. This year, Resolve’s theme is “Listen Up!”. Their campaign was created for anyone who cares about the infertility community can feel endowed to make a difference. NIAW wants people to understand how infertility affects people and their families. By joining the movement, people can help create a community in which infertility is supported with compassion and help.

Resolve urges people to join their movement during NIAW to help in any way they can; getting involved in their communities, supporting friends and families who suffer with infertility, and supporting policies and legislations that stop anti-family laws.

What can you do to help?

This National Infertility Awareness Week, there are many ways to get involved. Resolve hosts many events at local and national levels in which they urge people to get involved with. They ask that you show compassion and support to anyone you know or don’t know who suffers with infertility. Addressing an issue is the first step in finding acceptance and help among others. Start the conversation and donate your time to help even one person deal with their infertility.

National Infertility Awareness Week is a necessary step in finding more tolerance and help among the infertility community and beyond. While infertility has come a long way in recent decades, it’s still a subject most people are uncomfortable with. But with so many people around the world suffering with this issue, what are we so afraid to talk about? It’s time to broach the subject and offer help to the many people trying to build a family.

improve fertility

National Infertility Awareness Week is April 23 to April 29. It is estimated that 10 percent of couples struggle with infertility. Not being able to conceive can be frustrating for the couple. Fortunately, many couples have been able to improve fertility after making a few changes in their lifestyle.

Maintain a Healthy Weight

Your weight can have a positive or negative affect on your ability to conceive. Studies have shown that underweight women take four times as long to conceive. Women who are underweight can take twice as long to conceive. Weight problems can lead to irregular ovulation, which makes it harder to conceive. If you are underweight, then you can increase your chances of conceiving by gaining five pounds. Likewise, you can improve fertility if you lose five to 10 pounds if you are overweight.

Stop Smoking

Women who smoke are less likely to get pregnant. Women are also less likely to conceive if they have a partner who smokes. Tobacco use can damage sperm and egg. It can also increase the risk of miscarriage.

Supplement Use

There are a number of vitamins that can boost your fertility. The B vitamins can help stimulate ovulation. Folic acid, which is a type of B vitamin, is not only important for conceiving, but it also helps prevent defects in women who are already pregnant. Vitamin D is another supplement that can boost your chances of conceiving. Studies have shown that women who are infertile have lower vitamin D levels.

Vitamin D helps promote regular ovulation. It also helps the body produce sex hormones. Additionally, you can take vitamin C. This nutrient helps prevent progesterone production. Progesterone helps regulate the menstrual cycle.

Stay Calm

Stress can make it more difficult to conceive by increasing cortisol production. Cortisol can cause hormonal imbalances. Stress can also make it harder for you to be intimate with your partner.

infertility emotionalExperiencing infertility can be like riding a roller coaster that you can’t get off. The ups and downs keep coming on a regular (or not-so-regular) basis as couples plan for ovulation, endure the two-week wait, experience the sadness and frustration of a negative pregnancy test result, then pick themselves back up to try again. For couples in fertility treatment, there is the added stress of new procedures, hormone treatments, doctor visits, endless scans, and significant financial speculation. (read more…)