FERTILITY TREATMENT OPTIONS

Q: WHAT TREATMENT OPTIONS DO INFERTILE COUPLES HAVE?

A: There are several different therapeutic options for infertile couples, depending on the type of infertility that has been diagnosed. For example, in case of ovulatory problems, the vast majority of female patients can be successfully treated with the administration of drugs such as clomiphene citrate or gonadotropins.

In case of tubal damage, in vitro fertilization (IVF) is the preferred treatment.

In cases of male infertility, surgical reconstruction, intrauterine insemination (IUI), in vitro fertilization (IVF), with intracytoplasmic sperm injection (ICSI) are the most common therapeutic options, depending on the severity of the subfertility.

Finally, for women who are unable to use their own eggs, or men who are unable to produce sperm, pregnancy may still be achieved using donor eggs or sperm.

Q: WHAT IS NATURAL CYCLE IVF?

A: In natural cycle IVF, we usually collect a naturally selected, single mature egg from the ovary for fertilization and a single embryo is transferred. This is the easiest way to do IVF, and may be ideal for women who choose to live a drug and chemical-free lifestyle.

It is also beneficial for women who are less likely to produce multiple eggs even if heavy IVF drugs are administered because of age or poor egg reserve. Unfortunately, the cancellation rate can be higher and the success rate lower because usually there is only one egg if any that can be used.

Q: WHAT IS IVM?

A: IVM means in vitro maturation of eggs. Using this method, we are able to collect immature eggs from smaller follicles in the ovary and mature them in the laboratory with the use of specially designed culture conditions.

Several embryos can be created without exposing women to high doses of stimulating injections and their side effects. This procedure is still considered experimental by the American Society for Reproductive Medicine (ASRM).

Watch our informational video about IVM.

Q: WHAT IS NATURAL CYCLE IVF/M?

A: This is a combination of natural cycle IVF and IVM, a new and exciting development in infertility treatment. Recent scientific publications have shown that this could be an alternative approach to conventional IVF.

Natural cycle IVF/M potentially allows us to create more embryos from a natural cycle, without using stimulating drugs. This can be a “win-win” situation for the woman. There are no side effects or risks of drugs, it costs less and can offer the same advantages of stimulated cycles (i.e.: more eggs and embryos from one natural cycle). This procedure is still considered experimental by ASRM.

Watch our informational video about Natural Cycle IVF/M.

Q: WHAT ARE THE ADVANTAGES OF THE ABOVE PROCEDURES?

A: There are several advantages:

– No side effects of stimulating drugs
– Lower cost
– Simple procedure, only a few times of ultrasound exam without any blood test
– The procedures can be repeated every month

Q: WHAT IS THE SUCCESS RATE OF NATURAL CYCLE IVF/M?

A: The success rates of natural cycle IVF/M are encouraging. The pregnancy rates will of course depend on many factors. A recent scientific paper on natural cycle IVF/M published by Maria Fertility Hospital in Korea has shown the following results (Lim et al, Fertility & Sterility Vol. 91, 4, 2009).

A total of 417 cycles were started, and 410 cycles (98.3%) were completed.

Of 410 cycles, 151 (36.8%) were treated by natural cycle IVF/M, 63 (15.4%) underwent IVM alone, and 196 (47.8%) underwent conventional IVF.

With increasing age, fewer cycles can be treated by natural cycle IVF/M or IVM.

Clinical pregnancy rates were 40.4% (61 of 151) for natural cycle IVF/M, 41.3% (26 of 63) for IVM, and 37.8% (74 of 196) for the conventional IVF.

There was no difference in implantation rate in the three groups (17.8%, 16.7%, 20.1%) Natural cycle IVF/M together with IVM can offer about 50% of infertile women acceptable pregnancy and implantation rates.

Q: AM I A CANDIDATE FOR NATURAL CYCLE IVF/M?

A: After performing a basic work-up, if it is determined that IVF is the treatment of choice for you, we perform a baseline ultrasound on day two, three or four of the menstrual cycle.

In order to follow the IVM or natural cycle IVF/M approach, a good number of follicles must be present in the ovaries. If the ovaries have fewer follicles, more traditional approaches should be followed.

Q: HOW IS NATURAL CYCLE IVF/M DIFFERENT FROM MILD IVF?

A: Natural cycle IVF/M uses fewer medications than mild IVF and takes less patient time. It provides embryos from both mature and immature eggs, which can translate into a higher pregnancy rate.

In natural cycle IVF/M, almost every patient can complete the treatment cycle. Higher success rates (nearly same as conventional IVF) and lower cancellation rates make it a more successful procedure in the qualified patients.

Q: WHAT ARE THE ADVANTAGES AND DISADVANTAGES OF MILD/MINIMAL STIMULATION IVF?

A: This approach is milder, and because less medication is used for stimulation, the cost is often lower. Although it may be a desirable approach for many women, mild IVF is less effective than conventional IVF and possibly natural cycle IVF/M, and more tries may have to be done in order to achieve success.

FERTILITY BASICS

Q: WHAT HAPPENS DURING A MENSTRUAL CYCLE?

A: During a menstrual cycle, the development and release of the egg depend on a delicate balance of hormones—chemicals that signal the body’s organs to do particular jobs. Some of these hormones are produced in the ovaries. Others come from two glands in the brain, the hypothalamus and the pituitary.

At the beginning of each menstrual cycle, the hypothalamus releases gonadotropin-releasing hormone (GnRH) into the bloodstream. This hormone prompts the pituitary to release the proper amounts of two more hormones—follicle-stimulating hormone (FSH) and luteinizing hormone (LH).

In the early part of a cycle, FSH triggers the growth of 10 to 20 follicles in the ovary, although usually only one of them will mature fully. As the follicles (and the eggs inside them) develop, the ovary increases its production of the hormone estrogen. Estrogen signals the uterus to build up a thick, blood-rich lining so it will be ready to sustain a pregnancy.

Then, around the middle of the cycle, when (usually) one follicle and its egg reach maturity, the pituitary releases a surge of LH. In response, the follicle breaks open, releasing the egg. This event is called ovulation. Normally, only one egg is released. The other eggs and follicles that had been maturing but were not released are absorbed by the body.

Once the egg leaves the ovary, it enters the flower-like opening of the nearby fallopian tube and travels down the tube toward the uterus. If the woman has had sexual intercourse or insemination within the past few days, the sperm may be in the fallopian tube. If so, then one of these sperm may enter the egg, fertilizing it. The fertilized egg is the first cell of a new human being.

The fertilized egg will continue to travel down the tube and into the uterus. During this time, it will begin to divide, over and over, forming a small clump of cells. Within a few days, this clump of cells attaches to the thickened uterine lining (endometrium), in a step called implantation. The growing ball of cells is now called an embryo.

The high LH level also stimulates the newly ruptured follicle on the ovary (now called the corpus luteum, meaning “yellow body” because it actually turns yellow) to secrete yet another hormone, progesterone. The presence of progesterone keeps the endometrium thick and stable, so it can support the growing embryo.

Meanwhile, the implanted embryo begins to develop a placenta, the organ that will connect the developing baby with the mother’s body. The new placental tissue produces a hormone called human chorionic gonadotropin (hCG). This “pregnancy hormone” tells the corpus luteum to continue making progesterone, which keeps the endometrium in place. After a few weeks, the growing placenta takes over the job of producing progesterone, and the corpus luteum slowly withers away.

If the egg is not fertilized as it passes through the fallopian tube, there is no embryo to implant in the uterus and produce hCG. Toward the end of the cycle, the corpus luteum stops producing progesterone. The drop in progesterone signals to the endometrium that it’s not needed to support a pregnancy this month. The uterus sheds the blood-rich endometrial tissue in a process called menstruation, causing a menstrual period. Then, the cycle repeats itself.

Q: WHAT IS THE NORMAL PROCESS OF CONCEPTION?

A:

For a couple to conceive, several biological processes need to take place successfully and at the right time. The following steps are necessary for conception to take place:

During her menstrual cycle, a woman’s hormones stimulate the growth, maturation, and release of an egg from her ovary. This process begins when the hypothalamus signals the pituitary gland to send a hormone known as follicle-stimulating hormone (FSH) to the ovaries, prompting them to prepare an egg for ovulation. The FSH stimulates a group of follicles to grow on the surface of the ovary.
Over the next two weeks (the follicular phase of the cycle), the eggs mature and levels of estrogen, which is produced by the ovaries, increase.
As the estrogen levels increase, the pituitary gland decreases its production of FSH, and LH (luteinizing hormone) production is then triggered. The cervix begins to produce fertile alkaline mucus to help keep potential sperm alive and to speed their transport.
The LH production peaks, signaling the ovary to release a mature egg (usually only one) from its follicle in a process known as ovulation. The egg enters and begins to travel through the fallopian tube. The egg remains viable for about 24 hours.
For fertilization to occur, a single sperm must locate and penetrate the awaiting egg while it is in the fallopian tube. If fertilization occurs, the fertilized egg, or embryo, continues to travel down the fallopian tube into the uterus.
On approximately the seventh day following fertilization, the embryo develops chorionic villi, which are special protrusions on its surface that enable it to attach, or implant, in the lining of the uterus.
The chorionic villi produce a hormone called human chorionic gonadotropin (hCG) that signals the corpus luteum to continue to increase in size and produce more progesterone to maintain the pregnancy; hCG is the hormone that is detected by a pregnancy testing kit. Thus in order for a couple to conceive, both the male and female reproductive systems must be functioning properly.

For a woman this means:

Ovulation occurs and leads to the production of a viable egg.
The fallopian tubes are open and functioning properly to allow the egg and sperm to meet.
The woman’s vagina, cervix, uterus, and fallopian tubes allow for the sperm to travel to the fallopian tube and attempt to locate the egg.
The fertilized egg is able to move into the uterus and is not blocked from implanting in the wall of the uterus.

For a man this means:

The testes produce viable, or normal sperm, as well as testosterone, the male hormone.
Sexual intercourse involving an erection and ejaculation must occur during the woman’s fertile period.
Ejaculation is normal, with semen going through the man’s urethra into the vagina.
The sperm that are produced are properly shaped, able to move rapidly, and able to find the fallopian tubes to locate and fertilize the egg.

Q: HOW CAN I DETERMINE MY FERTILE PERIOD?

A: Your fertile period is the time during which having sexual intercourse could lead to a pregnancy. Begin counting on the first day of your menstrual period. Women normally ovulate about 14 days from the first day of their period, although this varies considerably from woman to woman. Your fertile period starts about four to five days before ovulation, and ends about 24-48 hours after it. This is because sperm can live in your body for approximately four to seven days, and the egg can live for 24 hours after being released. You are most fertile on the days before ovulation and the day of ovulation. Knowing your fertile days can help you increase your chances of getting pregnant, as well as avoid an unwanted pregnancy.

It’s important to keep track of the start of your menstrual periods. But it is also helpful to know exactly when, and if, you ovulate, rather than simply relying on the 14-day rule. An easy, although somewhat costly method is to use a do-it-yourself ovulation kit, available over the counter, which enables you to predict your ovulation by measuring the LH surge in an early morning urine sample.

This method uses a specially designed dipstick that changes color when the levels of LH increase. When your LH surges it is likely that ovulation will occur in the next 24-36 hours, so it is advisable to have intercourse during this time.

Many women chart their basal body temperatures in order to get a better fix on their fertile periods. When you are ovulating, your basal body temperature should rise for a few days. Your peak fertile period occurs on the days just before this rise. If you are a good record-keeper, you may want to consider this method.

Yet another method for checking your fertile period is to check for changes in your cervical mucus, as well as changes in the feel, shape and position of your cervix. About three to five days before ovulation, as estrogen levels rise, the cervical mucus becomes clear and stretchy and the amount increases. This fertile mucus turns the vaginal fluids alkaline, which helps keep sperm alive and nourished and allows healthy sperm to travel forward. The position, feel, and shape of your cervix also changes to allow for the easy passage of sperm.

Q: HOW OFTEN SHOULD I HAVE INTERCOURSE WHEN TRYING TO CONCEIVE?

A: Whichever method you use to determine your most fertile period, you should have intercourse as soon as you know you are entering this period, and continue to have intercourse every other day for the next several days. Taking a break of 48 hours between intercourse allows the man’s body ample time to maximize sperm volume between attempts, which is also very important.

Q: WHAT ARE THE COMMON CAUSES OF INFERTILITY?

A: Infertility may be caused by one or more factors that affect either the man or the woman, or in some cases both partners.

For men, the most common reason for infertility is a problem with the sperm. Sperm problems may involve the quantity, quality, and/or motility of the sperm. Sometimes a man may not produce any sperm, or perhaps just too few sperm. In other cases, sperm may be malformed and die before they have a chance to reach the egg for possible fertilization.

Abnormalities in the shape of the sperm are observed in the “morphology” part of the semen analysis test. Problems with the delivery of sperm from the penis into the vagina may also be a cause for infertility. These problems include erectile dysfunction, problems with ejaculation, or blockage of the ejaculatory ducts.

For women, the most common reason for infertility is a disorder with ovulation that may prevent the development of a viable egg. Other common reasons include blockage of the fallopian tubes, which can be caused by endometriosis, pelvic inflammatory disease, adhesions and scarring; a poor ovarian reserve, meaning fewer eggs available, or ovarian failure caused by aging or other factors; or a defect in the female anatomy that affects the movement of the egg into the uterus or prevents implantation.

Lately, possibly because of environmental factors, we have observed a great increase of infertility due to premature ovarian aging. The tests that can determine if premature ovarian aging is an issue are AMH (Antimullerian Hormone) and day 3 FSH measurements and ovarian ultrasound.

Q: HOW DOES AGE AFFECT MY FERTILITY?

A: For each follicle that eventually ovulates, close to 1,000 will have limited but unsuccessful growth. The number of eggs that are lost per ovulatory cycle probably varies throughout a woman’s life, but is presumed to accelerate in the 10–15 years that precede menopause. At this time, not only are the numbers rapidly dwindling, but there is also a decline in the quality of the follicles. Hormonal production is not as predictable and robust and the eggs often contain subtle mutations in their genetic make-up.

The decline in the quantity and the quality of eggs during this time explains the diminishing fertility that is seen in women from age 35 and onward. Even when an older woman does conceive, her chances of having a miscarriage increase greatly due to chromosomal damage to her eggs. Moreover, an older woman is much more likely to have developed endometriosis, fibroids, or other abnormalities of the reproductive system that can cause problems with fertility. Read more about age and infertility in our iCare health library.

Q: WHEN IS IT TIME TO SEE A SPECIALIST?

A: If you are concerned about difficulties you have had in conceiving, now is the time to seek help from a medical professional. Infertility is defined as an inability to conceive for more than a year when the woman is under the age of 35, or after six months if the woman is 35 years of age or older. Couples should also seek immediate help if either partner has a known history or disorders of the reproductive system.

Q: WHAT TESTS ARE NECESSARY TO DIAGNOSE AND TREAT FERTILITY?

A: Infertility diagnosis and treatment may require a number of medical tests. Some tests are quite simple, while others are more involved. Adequate testing is a critical part of your infertility workup and treatment. Your doctor will base his/her treatment plan on the outcome of you and your partner’s tests. Your doctor will start with simple, less invasive tests and then move on to those that are more involved.

If you are a man, you can expect your doctor to do a full history and physical examination and request a semen analysis. For a man to be fertile, he must produce a sufficient number of normally functioning sperm that are able to travel though his reproductive tract and be ejaculated into his partner’s vagina. The process requires the appropriate production of male hormones as well as the ability to engage successfully in sexual intercourse.

After your initial workup, your doctor will determine what additional tests, if any, are necessary. The sequence of testing may depend on your medical history and is often coordinated with the evaluation of your female partner. Other tests may include evaluation of male hormones and evaluations of other male issues, including genetics, ejaculatory duct obstruction, testicular function, and sexual function.

If you are a woman, you can expect your doctor to do a full history and examination, and evaluate your ovulatory status, cervix, fallopian tubes, and uterus.
Evaluation of ovulation:

The first step in diagnosing female-factor infertility is determining whether or not a woman is ovulating. The presence or absence of ovulation can be determined by daily changes in your basal body temperature, or with blood or urine tests.
Evaluation of the cervix:

The cervix is the lower part of the uterus that leads to the vagina. After sexual intercourse, ejaculated sperm must pass into the uterus from the vagina. Problems in the cervix may block the passage of sperm into the upper part of a woman’s reproductive tract, thus preventing the sperm from reaching the fallopian tubes and awaiting egg.

Your doctor may need to assess the thickness of your cervical mucus as well as the presence of sperm antibodies in the mucus. In the past this test, also known as the “postcoital test” was routinely performed, but studies have revealed that this test is not very reliable, therefore we perform it only very rarely and mostly for people who refuse a semen analysis for religious reasons.
Evaluation of the fallopian tubes:

To fertilize an egg, sperm must travel through the uterus and into the fallopian tubes. The fallopian tubes are a complex set of organs, one on each side of the pelvis, leading from the right or left ovary to the upper corner of the uterus. The diameter is nearly one-half inch at the open end near the ovary, and narrows to the size of a pencil tip near the uterus.

The fallopian tube is capable of picking up a newly released egg, providing nutrients and movement for the egg, transporting sperm up to the egg, sustaining an environment for fertilization and, finally, transporting the fertilized egg into the uterus. The fallopian tubes play a crucial role during reproduction and, at the very least, must be open throughout their entire length. Scarring, infection and inflammation can all interfere with fallopian tube function by causing blockages and other problems.

Hysterosalpingography (HSG) is a radiologic procedure to investigate the shape of the uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification. A normal result shows the filling of the uterine cavity and the bilateral filling of the fallopian tube with the injection material. To demonstrate tubal patency (openness), spillage of the contrast material into the peritoneal cavity needs to be observed.
Evaluation of the uterus:

The uterus must be able to transport sperm to the fallopian tubes and, after fertilization, accept the fertilized egg, and allow the egg to implant in its wall. A congenital abnormality of the uterus, scar tissue following uterine surgery such as a D & C, fibroids, polyps, or adenomyosis can all interfere with normal uterine function. The Hysterosalpingogram (HSG) also helps in assessing the uterus.

Your doctor may recommend one or more of the following tests to evaluate the structure of your fallopian tubes and uterus:
Ultrasound

Ultrasound, or sonography, involves sending sound waves into the body. These sound waves are reflected off the internal organs, and special instruments then use those recorded reflections to create an image of the organs. No ionizing radiation (X-ray) is involved in ultrasound imaging.

With transvaginal ultrasound, the ultrasound transducer (a hand-held probe) is inserted directly into the vagina. Transvaginal ultrasound is most commonly used to examine the uterus and ovaries and to monitor the health and development of the embryo during pregnancy.

Ultrasound images can help to identify palpable masses such as ovarian cysts and fibroids, as well as ovarian or uterine cancers. IVF cycling patients are checked regularly with a transvaginal ultrasound to monitor the size and number of developing follicles.

Transvaginal ultrasound is performed very much like a gynecologic exam. The tip of the transducer is smaller than a gynecologic speculum. A protective cover lubricated with gel is placed over the transducer, which is then inserted into the vagina. Only two to three inches of the transducer end are inserted into the vagina. The images are obtained from different orientations to get the best views of the uterus and ovaries.
Hysterosonogram

Hysterosonogram, also called a saline-sonohysterogram, is a test to study the inner surface of the uterus. An ultrasound is performed using a vaginal probe, and at the same time saline solution is injected into the uterus through a thin catheter. This helps delineate the inner contents of the uterus. Lumps called submucosal fibroids or polyps cannot be seen well without the injection of saline solution. This test is used to find out the cause of heavy periods and to investigate infertility and repeated miscarriages.

It is best to have the procedure during the second week (days seven to 12) of your menstrual cycle. However, this procedure can be performed at any time during the menstrual cycle while on birth control pills. This timing reduces the chance that you may be pregnant during the procedure, and makes it easier to view the folds of the uterine cavity. Hysterosonograms are not usually uncomfortable, but if you are sensitive to pain or cramping you can ask your doctor about taking pain medication such as Tylenol or Ibuprofen. The test involves the following steps:

An ultrasound probe is placed in the vagina to inspect the uterus and ovaries.
A speculum is placed in the vagina and the doctor examines the cervix. The cervix is cleaned with antibacterial soap.
A thin, soft tube of about one to two millimeters in diameter is placed in the cervix.
The vaginal probe is reinserted into the vagina.
Water is injected into the uterus through the soft tube. The fluid causes the uterus to stretch.
This may cause uterine cramping.
The doctor spends about 3-5 minutes examining the uterine cavity and wall.
A small sample of tissue is sometimes obtained from the lining of the uterus at the end of the procedure, to rule out the presence of abnormal cells.

Your doctor will discuss the results of the hysterosonogram with you after the procedure. Based on the results, further tests may be needed. If a problem is detected, a treatment plan will be discussed with you.

A very few women have minor side effects after a hysterosonogram. These are not serious and usually go away after a day or two. Side effects may include cramps, slight vaginal bleeding, and sticky vaginal discharge as some of the gel and fluid drains out. A pad can be used for the vaginal discharge. Do not use a tampon.
Hysterosalpingogram (HSG)

Hysterosalpingogram is a procedure in which radiographic contrast (dye) is injected into the uterine cavity through the vagina and cervix and X-ray pictures are taken as the dye is expelled from your reproductive system. The uterine cavity fills with dye, and if the fallopian tubes are open, the dye will then fill the tubes and spill out into the abdominal cavity.

In this way we can determine whether the fallopian tubes are open or blocked, and whether the blockage is located at the junction of the tube and the uterus (proximal) or whether it is at the end of the fallopian tube (distal).

If a blockage is detected, we will discuss with you effective treatments for tubal factor infertility. Your HSG can also give us a better picture of the uterine cavity and detect the presence of polyps, fibroids, or scar tissue. The fallopian tubes can also be examined for defects within the tube or suggestion of a partial blockage.

The hysterosalpingogram takes only about five minutes to perform. During the procedure you are likely to experience some mild cramping, so you may wish to ask your doctor about taking pain medication such as Tylenol or Ibuprofen a half hour prior to the HSG.

The test involves the following steps:

The doctor places a speculum in the vagina and examines the cervix. Your cervix is cleaned with an antibacterial soap.
A clamp may be attached onto your cervix to hold it steady. A small, bendable plastic tube is gently pushed through the opening of your cervix into your uterus, and a tiny balloon on the end of the tube is filled with air to hold it temporarily in place.
The speculum is removed but the thin tube will be left in place, with one end (about six inches of tubing) remaining outside of your vagina.
A small amount of contrast dye is injected through the tube into your uterus, and several X-ray pictures are taken.
Your doctor may ask you to move your pelvis slightly or roll from side to side to provide the clearest view of your uterus.
You may experience some uterine cramping as the contrast dye goes into the tube.
The procedure is now complete. The balloon will be emptied of air from the outside and the tube will be gently pulled out.

After the procedure, your doctor will review the X-ray pictures and discuss the results of the hysterosalpingogram with you. You may experience slight vaginal bleeding and cramping after the procedure, and some sticky vaginal discharge as some of the gel and fluid drains out. A pad can be used for the vaginal discharge. Do not use a tampon.

Pregnancy rates in several studies have been reported to be slightly increased for several months following a hysterosalpingogram. This may be due to the flushing of the tubes with the contrast. However, this increase in pregnancy rates is only observed with oil based contrast material which, is not regularly used due to safety concerns.
Hysteroscopy

Hysteroscopy is a diagnostic and operative procedure performed with an instrument called a hysteroscope, which is a thin telescope that is inserted through the cervix into the uterus allowing better visualization of the uterine cavity. Hysteroscopy allows the doctor to clearly make out fibroids, polyps, and other problems that may be causing excessive menstrual bleeding and/or infertility.

Hysteroscopy is performed soon after menstruation because the uterine cavity is more easily evaluated early in the menstrual cycle and there is no risk of interrupting a pregnancy at this time.

During the procedure, an anesthesiologist administers light anesthesia (conscious sedation) to the patient, through an intravenous drip (IV). Hysteroscopes are so thin that they can often fit through the cervix with minimal or no dilation. The doctor will inject saline solution to expand the uterine cavity, clear blood and mucus away and view the internal structure of the uterus directly through the hysteroscope.

If abnormalities such as fibroids, polyps, scar tissue, adhesions, or a congenital defect such as a uterine septum are detected, they may be corrected at this time through the hysteroscope. The procedure usually takes about 30 minutes. It is performed on an out-patient basis and the recovery time is short, usually the same day.

You should not eat or drink for at least eight hours prior to a hysteroscopy.

Q: ARE THERE PARTICULAR HEALTH RISKS FOR WOMEN UNDERGOING INFERTILITY TREATMENT?

A: Hormonal treatments can be an essential part of fertility treatments. Thanks to these drugs, the success of fertility treatments is much greater today than in the past. At the same time we understand that as we all try to live a healthier and toxin-free life, we want to limit the amount foreign substances that we introduce into our bodies.

Our goal is to design treatments that minimize the use and the dosages of fertility drugs. Along with their intended benefits, drugs used to treat infertility may occasionally have adverse effects. In ovulation induction, close monitoring of follicular growth is crucial to avoiding ovarian hyperstimulation syndrome, preventing multiple pregnancies, and ensuring optimal treatment.

Moreover, in some cases an assisted reproductive therapy may lead to an ectopic (tubal) pregnancy. For that reason, in the case of a positive pregnancy test in a woman with an increased risk of a tubal pregnancy, monitoring of the pregnancy by ultrasound is crucial. Abdominal bleeding and abdominal infections can be complications after an IVF procedure, but are fortunately very rare.

Q: HOW SUCCESSFUL IS INFERTILITY TREATMENT?

A: When considering the success rates for any type of infertility treatment, you should bear in mind that the average chance to conceive for a normally fertile couple under 30 years of age having regular unprotected intercourse is around 25-30 percent during each menstrual cycle.

It is estimated that 20 percent of normally fertile couples fail to conceive within their first year of trying, 10 percent after two years and 5 percent after three years.

Similar to normal fertility rates, effective IUI treatments can be expected to have, on average, up to a 25% success rate per cycle of treatment, and may therefore need to be repeated several times before a pregnancy is achieved. Simple ovulation induction to compensate for hormonal imbalances has a very high success rate, with 50% of women suffering from such disorders are likely to conceive after several cycles of treatment with drugs such as clomiphene citrate (Clomid) or injectable fertility drugs.

The chance of achieving pregnancy after IVF treatment can be as high as 80 percent per attempt. Your individual chance of pregnancy is based on a multitude of factors with age being most important.

Depending upon the woman’s age and other infertility factors for the couple, as well as the experience and success rates of the particular treatment facility, your own chances for success during any one treatment may be much higher or lower.

When you are considering a particular treatment facility, you should learn about success rates for people with your medical profile. Also bear in mind that, while it is important to have a positive attitude during your IVF treatment, many couples may require several cycles before they either are able to achieve a successful pregnancy or decide to pursue another route. Learn more about Neway Fertility’s success rates.

Q: WHAT IS AMH (ANTIMULLERIAN HORMONE)?

A: Antimullerian Hormone (AMH) is produced by the eggs within the ovaries, just as eggs are. As a woman ages, her ovaries get smaller, so there are less eggs and less AMH is produced. In contrast, a woman’s day 3 FSH begins to rise as her ovaries become smaller with age and contain fewer eggs.

Q: WHAT IS THE DEFINITION OF INFERTILITY?

A: Infertility is a condition that affects about six million American couples, or roughly 10 percent of the reproductive age population. For many couples trying to conceive, something can go wrong in one or several of the reproductive processes, causing infertility. Knowing the facts about infertility can help you make informed decisions regarding your reproductive health.

A couple is considered infertile if pregnancy has not occurred after one year of unprotected, well-timed intercourse. This rule does not apply to couples where the female is 35 and older or where either partner has a history of fertility-related problems.

If you are a woman 35 years of age or older and have been trying unsuccessfully for more than six months, you should consult your physician. If you a woman over 30 with a history of gynecological problems, or if you know that your partner has a low sperm count, you may not want to wait even that long before seeing a specialist regarding your fertility status.

Infertility is an issue shared by women and men. In approximately 35 percent of infertile couples, the problem can be traced to the female, and in approximately 35 percent of infertile couples the problem can be traced to the man. In the remaining 30 percent of infertile couples the problem is either shared by both partners or is unexplained.

Infertility may be designated as either primary or secondary. Primary infertility is the term used to describe a couple that has never been able to conceive a pregnancy. Secondary infertility is the term used when a couple has conceived previously, but is unable to conceive again, whether or not the first pregnancy resulted in a live or still birth, miscarriage, or termination. This group also includes those who have had a change of mind following sterilization.

Recent medical advances have made it possible to overcome infertility in the great majority of cases. If you are trying to have a child and have been unsuccessful, please consider seeing a reproductive endocrinologist.

Q: WHAT ARE MORPHOLOGY, MOTILITY AND COUNT?

A: A semen analysis is the primary test in a man’s infertility work-up. It focuses on three main areas: the count, the motility (activity), and the morphology (shape). Using the count most men have as the definition of normal, 60 million sperm/ml is considered to be normal for the New York City area, although average sperm counts vary a lot from region to region and a lower sperm count is considered normal elsewhere.

Motility refers to two characteristics of sperm: the percentage that are moving and the quality of the sperm that are moving. A percent motility of greater than 50 percent is generally considered normal. Morphology of the sperm has been found to be predictive of fertility potential.

The best modality to assess morphology is the Kruger or “strict” morphology test. A Kruger morphology of four or greater is considered normal. However, the most commonly used system of reference of semen analysis is the World Health Organization (WHO) manual. In this system, 30 percent or more normal morphology is considered normal.

For a complete evaluation, you may need to give several specimens several weeks apart. You should note that many lifestyle factors can affect a man’s sperm count and quality. Cigarette smoking, alcohol consumption, and recreational drug use are all known to diminish both the quality and quantity of the sperm produced.

Also, many prescription drugs can affect a man’s sperm count and quality and/or his ejaculatory function. These drugs include many of the medications prescribed for high blood pressure or gout, as well as sulphasalazine (used to treat irritable bowel), nitrofurantoin, tetracyclines, cimetidine, ketoconazole, tricyclic antidepressants, monoamine oxidase inhibitors, and propranol.

For best results you should abstain from sexual intercourse for two to three days before producing the specimen. If you wish, you may produce your semen sample at home. If you collect the semen sample at home, you must bring it to the office within one hour.

Keep the sample at body temperature and out of direct sunlight and do not allow it to get too cold or hot. If it is a cold day, carry the semen sample container against your body to keep it as close to body temperature as possible. Do not refrigerate the semen sample.

If the results of your semen analysis are unclear or sub-optimal, your doctor may perform other urological and hormone-level tests to determine the cause, or refer you to a urologist.

NEWAY’S APPROACH

Q: DOES THE FACT THAT THE DOCTORS AT NEWAY ORDER LESS BLOOD DRAWS THAN OTHER CLINICS AFFECT OUTCOME OR SAFETY?

A: Our less-invasive approach has been around for a long time, and has been published upon extensively by researchers in the field. We have successfully followed this approach in our clinics in Korea over tens of thousands of cycles.

This does not imply that we refuse to draw blood to check hormonal values “on principle.” If we feel that checking your hormone levels at some point in the cycle is needed, we will not hesitate to recommend it to you.

Q: ARE YOUR PREGNANCY RATES AFFECTED BY YOUR APPROACH?

A: It’s important to note that our approach to fertility is to do less before more. We try to make sure that majority of our patients conceive without undergoing IVF. Only the patients that fail all other treatments undergo IVF, which means that we take on the most difficult cases.

Contrary to what most centers do, we do not perform any type of patient selection. Patients with very abnormal FSH (follicle stimulating hormone) levels who have been rejected by other centers have been able to cycle with us.

Our approach means that in the end our overall pregnancy rates in the past have been lower than in centers who practice patient selection. We have never withdrawn treatment for our own interests.

Q: SOME PEOPLE SAY THAT IT “ONLY TAKES ONE GOOD EGG” IN ORDER TO GET PREGNANT. IS THIS TRUE?

A: We think this statement is a bit misleading. It is like saying “it only takes one ticket to win it.” In reality, having more eggs increases the chances of success. Although one may want to choose a less-invasive approach in theory, the trade-off is lower efficacy and lower pregnancy with delivery rate.