“Unexplained infertility” explained: insights into one of the common diagnoses for couples trying to conceive

When couples are trying unsuccessfully to conceive and then present for evaluation—a variety of standardized tests are performed. If these tests all return with reassuring results, they are left with a diagnosis of “Unexplained Infertility” (ICD-10 Code 97.9). This is the treatment code used for about a third of patients diagnosed/treated in the USA. For many couples, this is very unsettling. In this episode of our Clinical Conversation series we try to provide details on what this means. Our hope is that this information is reassuring and helps more people move on from the diagnostic phase to the treatment phase with greater confidence.     

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Unexplained Infertility (17:20):  https://youtu.be/oTFw-3QV_hc

0:55 Unexplained Infertility—brief definition and use in coding

2:00 How if “infertility” defined

3:50 Creating a new definition: “Infertility, unspecified”

6:46 Sometimes greater clarification of diagnosis is revealed during treatment

                —(9:00) Example: Implantation Problems

9:45 When to stop testing—balancing risk vs benefit vs cost

11:30 Moving from Testing to Treatment

                –(12:15) Example: Male Factor—mild vs moderate

14:00 Each patient / couple has unique circumstanced making diagnosis more challenging

With kindness and optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

ENDOMETRIOSIS UPDATE; latest information on how it impacts fertility

We have been talking about endometriosis since I began my career as a fertility specialist in 1995. Yet it is really over the last several years that I feel we are finally beginning to understand the various ways it can impact fertility. Like most disorders, it is a condition on a spectrum that can manifest in various ways with varying implications.  Here is a link to an episode of our Clinical Conversation series where I am sharing some of the latest science.  This episode includes some questions submitted by some of our regular listeners. I hope you find it to be helpful.

Endometriosis: clinical conversations with Dr. Greene and fertility coach Lisa White

(~27 minutes):  https://youtu.be/znrz0IoRGv4

0:35 Definition: what is endometriosis?  

2:50 How common is endometriosis?

4:30 How can you rule out endometriosis as a contributing factor?

4:50 Submitted question: Do you approach IVF differently in women with endometriosis?


–Implications on egg quality

9:15 Submitted question: Is it safe to have endometriosis during a pregnancy?

                —some rare forms of endometriosis described

11:00 Submitted question: Are we seeing an increase in women with endometriosis?   

12:30 Some Diet/lifestyle tips to reduce the risk od developing endometriosis?

—BONUS: link to recent article from EndometriosisNews

14:30 What supplements do you recommend for endometriosis

                —Pycnogenol: link to previous blog post

                —BONUS: new research suggests curcumin may also be of benefit

19:40 Submitted question: Is it a good idea to treat endometriosis prior to IVF?

21:30 Endometriosis and Egg Quality

—BONUS:  One topic that I overlooked in this review is emerging data on how

                Endometriosis can cause hardening of the surface of the egg which can be overcome

                by using ICSI to fertilize the eggs. Here is a link to supporting research.

24:00 What about adenomyosis (endometriosis in the muscle of the uterus)?

—BONUS: There is a test for inflammation due to endometriosis as a factor in implantation failure. It is called a Receptiva-BCL6 test. Here is a link to additional information. 

As you can note, this is such a large topic with so much information we are still learning. Use this information to assist in guiding your treatment decisions.

With informed optimism,


Robert Greene, MD, FACOG Conceptions Reproductive Associates of Colorado

What’s New in Egg/Embryo Freezing: All About the TMRW Tank

Traditional Storage Tanks- Eggs/Embryos are frozen in a small vial with printed label in a designated cryotank and tracked manually or electronically through a separate system.
TMRW Tank- Eggs/Embryos are frozen in a small vial with their printed label and RFID chip in the TMRW tank, and are tracked through the integrated TMRW software system. Here is our All-star Conceptions Embryology Team with the TMRW Tank!

Egg and embryo freezing/banking have become extremely popular options over the last year. A major factor in this decision is Long Term Storage. Eggs and embryos can safely remain frozen for years until you are ready to use them. It is important to feel confident that your samples are stored at a reputable establishment in a safe, transparent, and accessible location. The TMRW tank is an evolution from our current equipment. The basic foundation is not brand new, since we have used cryotanks safely for years, but the software integration system is state of the art. It paves the way for a future where gamete and embryo data can be tracked remotely from our computers, or an app on your phone. Better still you have the assurance that your eggs and embryos are being monitored 24 hours a day every day of the year. Below is a summary of the TMRW Tank concept!

What is it?

  • TMRW Tank is the first and only automated egg/embryo storage platform
  • It links frozen egg/embryos to traceable RFID chips to completely prevent errors of identification
  • It facilitates labeling, tracking & locating samples
  • It gathers data to ensure cryogenic temperatures & egg/embryo wellness
  • It integrates all data into a software system monitored on our computers
  • It replaces old-fashioned liquid nitrogen storage tanks and manual labeling/monitoring

Why is it necessary?

  • Safer and more secure identification system- 100% digital chain of custody tracking
  • Easier monitoring in real-time with integrated software system on computer
  • Integrates embryology storage with the most up-to-date software technology

Who is using it?

  • The TMRW tank was rolled out to 30 leading fertility clinics in the US, including Conceptions
  • It was created by TMRW Life Sciences

When/where will it be in use?

  • Commercial launch was in December of 2020
  • The TMRW Tank is already at Conceptions Reproductive Associates of Colorado!

You can read more about this at https://www.tmrw.org/

DIET, LIFESTYLE AND FERTILITY: emerging science on steps to improve outcome

There is a growing body of research that explains how we can actively improve our own health, wellness and fertility. It involves paying attention to our food choices, our activities and the chemicals that we allow ourselves to be exposed to through our choices as consumers. Here is a link to Clinical Conversation episode where I am sharing some of the latest science. 

Fertile 2021: nutrition and lifestyle (29:53):  https://youtu.be/kkC1R4Orn8c

1:00 Moving beyond theories and popular recommendations

2:00 Creating evidence-based diet-lifestyle tips to boost health, wellness and fertility

2:50 Food—let’s define what we need it to do

5.25 Moving from surviving to thriving

6:10 Eating Mindfully

                —Seeking foods in their most natural state

                —9:00 Food preparation methods (i.e., microwave oven, air fryers, etc)

                —11:30 Organic—why it matters

                —12:15 Plant-based eating

                —13:00 Timing healthy changes to fertility treatment

                —15:50 SIRT foods

                —16:40 Intermittent Fasting; what it is and why it may help

                —19:30 Concerns of ketogenic diets during fertility treatment/pregnancy

                —20:15 Alcohol—total abstinence may not be needed

22:15 Emotional Stress and is management

                —Meditation and slow deep breathing

                —Studies on fertility and egg quality

24:50 Some Additional Tips to consider

—Sleep and the potential role of melatonin

—Exposure to cold temperatures may have health promoting benefits

—Forest-bathing; emerging science how trees can influence immune resonse

27:45 Follow the evidence and make your decisions consciously

With informed optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

COVID Vaccination Guideline for Fertility Patients and Pregnant Women: Phase 1

As we proceed with the first efforts to vaccinate against SARS-CoV-2; many patients are scrambling to decide how they feel about receiving a vaccination. The current efforts are complicated by opinions that are often driven by politics. The goal of this clinical conversation is provide you with the science—so that you can make your own evidence based decision.  It is also worth nothing that organizations that guide healthcare professions are supporting the use of the vaccine for women that are pregnant or breastfeeding. These organizations include The American College of OB/GYN (ACOG), The American Society for Reproductive Medicine (ASRM), The American Society for Maternal-Fetal Medicine (SMFM) as well as the US Center for Disease Prevention and Control (CDC). In case you don’t want to listen to the entire conversation, here’s the listening guide.

Fertility Treatment+COVID+Vaccine (26:09): https://youtu.be/WpQ0M_IreLQ

1:10  Become informed so you can make your own choice

1:45  Perspective on status (mid December 2020)

4:20 What makes these first vaccines unique ?

6:15 Why are these new vaccines considered so safe?

                ***Listener’s note; this recorded live and I correct myself a couple of times for

                                Mistakenly using the word “virus” instead of  “vaccine”

10:30 [UPDATE] This vaccine has now been approved and is in use

11:45 Why does these vaccines use two injections?  

14:00 Recommendations for women currently going through fertility treatment

17:00 What about women that are currently pregnant or breastfeeding?

20:00 What about vaccines for other preventable diseases like measles?

21:45 Importance of being informed so that you can make an educated decision

23:00 Experience of other democratic countries and how they’re dealing with this pandemic

25:00 Note of gratitude

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado


ACOG Statement on the Johnson & Johnson COVID-19 Vaccine

On April 13, 2021, ACOG released a statement following the CDC and FDA decision to put the Johnson & Johnson COVID-19 vaccination program on hold.

“At this time, there is no clear phenotype of women who are more or less likely to experience this rare complication. However, until there is a better understanding of the frequency and impact of this finding, it will be important to encourage pregnant and postpartum women who wish to be vaccinated to receive the mRNA vaccines: Pfizer or Moderna.

“Individuals who have been vaccinated with the Johnson & Johnson vaccine within the last 21 days who experience severe headache, abdominal pain, leg pain, or shortness of breath should seek immediate evaluation. They should be certain to communicate that they have received the Johnson & Johnson vaccine to prompt appropriate evaluation. Given the elevated risk for thrombosis experienced by women during pregnancy or the postpartum period and while using birth control pills, evaluation of acute thrombosis is commonly performed in our specialty. Rapid treatment with anticoagulation is the standard; however, this is not the same event and anticoagulation for treatment of CVST is dangerous.” Read the full statement.

Introduction to Egg Quality: optimizing pregnancy rates and minimizing miscarriage risk

Too many people rely upon their fertility center to create results. In reality, one of the most important aspects of fertility treatment in determining success is egg quality. I’ve been doing a deep dive on the latest research to try to determine what can be done to optimize egg quality. Attached is a link to a Clinical Conversation created to begin analyzing this topic. The goal is to provide women with data-driven practical tips. I hope that you find this helpful as well as motivating to help you begin making some healthy choices to insure your success:

Egg Quality Part 1 (23:10): https://youtu.be/QTr8M-Pij30

  • 1:20 natural pregnancy rate
  • 3:00 Comparison of Sperm Quality vs Egg Quality and how they impact natural rates
  • 5:00 Components for estimating Egg Quality
  • 7:00 Aspects of egg quality
  •                 —DNA
  •                 —Mitochondria
  •                 —Other physical components of the egg
  •                 —Metabolism of the egg
  • 9:00 A new perspective on fertility treatment
  • 10:45 Age and egg quality / egg number
  • 13:00 Emerging view of egg development
  •                 —wave theory vs. continuous recruitment
  •                 —DNA markers vs age (~15:00)
  •                 —Hottest topics—>new data on genetics of eggs
  •                 —Individual variation offers hope for intervention
  • 19:30 Egg quality if often a key component of “Unexplained Infertility”

With kindness and optimism,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

TWINdemic: fall 2020 update on COVID+Flu season for fertility patients

Unfortunately, the number of cases of SARS-CoV-2 is increasing—not just here in Colorado but in most of the country and other parts of the world as well. Additionally, we’re heading into flu season which further complicates our ability to keep our patients, our staff and our families healthy. Ironically-from the perspective of a fertility center-this combination is often being referred to as a Twin-demic.

Below is a link to our latest videoblog updating you on the current public health status. In the meantime, please take precautions:

Here’s a link:  https://youtu.be/nRtX6NVIQ_s  (about 20 minutes)

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

Embryo Grading Explained—this is what those numbers and letters mean

Previously, we discussed what the current means of embryo testing is and what insights it provides about the DNA. In this clinical conversation, we review the way embryos are described based upon their development and their description.

If you’ve completed an IVF cycle and are now getting ready to prepare for an embryo transfer, your embryologist will tell which embryo(s) they recommend for transfer. Although there is a lot that goes into this recommend, there is a shorthand description that they use to summarize each embryo. That is the “embryo grade.”

  • 0:45        How important is embryo grading?
  • 4:15        Summary of the current (most popular) grading system
  • 8:35        Correlation between embryo grade and implantation rate
  • 12:30     Lisa’s experience—a real life example shared
  • 14:00     Genetic testing vs grading
  • 15:30     Transferring more than one embryo of different grades

This video is about 20 minutes long. Here are a few key points if you don’t want to listen to the entire post:

Here’s a link:  https://youtu.be/xQFXCe-BVak  (about 20 minutes)

Stay informed,


Robert Greene, MD, FACOG

Conceptions Reproductive Associates of Colorado

What’s in a Prenatal Vitamin?


  • FOLATE aka FOLIC ACID (most important)
  • Iodine
  • +/- Iron (this can also be supplemented separately as needed, such as for anemia)


  • Folate reduces risk of neural tube defects (birth defects), such as spina bifida
  • Iodine optimizes thyroid health and fetal brain development


  • Optimal to start about 3 months prior to conception
  • Take 1 serving (number varies by vitamin) daily

How much?

  • At least 400 mcg folate per day, but individual needs may be higher
  • 150 mcg per day of iodine


  • Any pharmacy or grocery store, or available online

Other ingredients?

  • Limited evidence for other ingredients, but they are usually not harmful.
  • It is important to avoid excessive quantities, such as for Vitamin A or B vitamins.

Which are legitimate products?

  • Prenatal vitamins can be given as a prescription from your doctor
  • Prescription brands are FDA-regulated
  • Direct-to-consumer (aka over-the-counter, or OTC) brands are not as strictly regulated
  • If you buy it OTC, check for the following certification standards:
    • Look for NSF (National Sanitation Foundation) certified
    • Or look for USP (United States Pharmacopeia) verified

Introducing Dr. Chiang!

Greetings to the Enhancing Fertility Blog community! I am happy to be joining the Conceptions team and looking forward to connecting with everyone via this blog. I recently relocated from Alabama to my husband’s home state of Colorado. My areas of interest are infertility, ovulation induction, intrauterine insemination, IVF, fertility preservation, and recurrent pregnancy loss.

I enjoy working with patients on building their families, particularly problem-solving and navigating the challenges of health and life. Deciding to pursue fertility, defer fertility, or choose fertility preservation can be a complicated decision, and it is a topic almost everyone comes across in their lifetime. It requires patients to consider many factors, including their health assessment, emotional reserve, and financial status. I love being the doctor people can trust for guidance with that decision.

I joined Conceptions because the practice stands out to me as a local, ethical, privately held Colorado business model. The dedication is to professionalism and doing right by our patients in the long run, not to corporate shareholders. We focus on the people we care for. We empower patients to make personalized decisions that nurture physical and mental wellbeing on the road to having a baby.

You can follow my Instagram @jasmineleechiang