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FAQ
What is Assisted Reproductive Techniques (ART)?
Assisted reproductive techniques (ART) include methods of treatment dealing with the manipulation of reproductive cells (sperm and eggs). They are highly demanding techniques requiring both a high standard of erudition and experience in the staff, as well as highly sophisticated technical equipment.
What is intrauterine insemination?
The core of this method consists of facilitating the way of a sperm to the egg by injecting sperm, after special laboratory preparation, by means of a thin tube into the uterine cavity during the period of ovulation. The basic prerequisite for the application of this method is the preserved permeability of the Fallopian tubes. IUI can have a therapeutic effect in cases of disorders in male fertility, immunologically conditioned infertility and also in other indications.
What is Intracytoplasmic Sperm Injection (ICSI)?
It is a process through which an individual sperm is injected inside the oocyte. It is often used for men with very poor sperm counts or in some cases, where no sperm in the ejaculate and we use testicular sperms.
The outline of the procedure is the following: the egg is aspirated from the ovary, it is fertilized by a sperm in the laboratory, and the embryo is then transferred to the uterus. It could be devided to the following stages:
What is Ovarian Stimulation and Monitoring?
In order to maximize the patient's chances for successful fertilization, a patient undergoing IVF usually take hormones in the form of injections to increase the number of eggs produced in a given month and this is known as ovarian stimulation. Monitoring is performed to continuously follow a woman's ovarian response, allowing the physician to adjust and time medication dosage appropriately.
What is Ovum Retrieval or oocyte pick-up?
It is a procedure done with the patient sedated and comfortable, where the ova or eggs are retrieved through the vagina under ultrasound guidance.
Which embryos and how many do we transfer?
The best embryos are transferred directly into the uterus and allowed to implant. The more embryos we transfer the greater the chance for success, but at the same time the greater the risk of a multiple pregnancy: Therefore, as a rule we transfer a maximum of three embryos to the uterus. The remaining healthy embryos may be cryopreserved (frozen).
When should the patient do pregnancy test?
The pregnancy test is performed 14 days after embryo transfer.
What do we mean by Cryopreservation of embryos?
It is a computer aided process of the
gradual freezing of embryos which are not implanted in the uterus in
the given therapeutic cycle to the temperature of liquid nitrogen
(-196 °C).
What do we mean by infertility?
According to the World Health Organization definition (WHO), Infertility is defined as inability of the couple to conceive after one year of regular sexual intercourse without the use of any contraception. It affects about 10% of married couples. Inability to conceive can be very distressing to the couple and can affect individuals in various ways.
When should the couple seek for medical advice regarding their fertility?
Infertility evaluation and treatment should be sought after one year of trying with unprotected intercourse for couples in which the female is under 30 and six months of trying for couples in which the female is over 30.
What are the causes of infertility?
The are two broad categories for causes of infertility, which are male and female infertility. Male infertility and female infertility.
What are the causes of male infertility?
Male infertility is a major cause of couples' infertility. Therefore, one of the first tests in the infertility evaluation is the semen analysis. No treatment of the female should be initiated until it is established that the partner is producing "normal" sperm. Male infertility can be caused by many conditions including testicular trauma, severe infection, congenital, exposure to high does of radiation or harmful chemicals, hormonal imbalance, and retrograde ejaculation. The female immune system may also produce antibodies that mistakenly identify sperm as foreign bodies and destroy them. Many tests are available to help diagnose factors causing male infertility.
What are the possible causes of female infertility?
Inability to ovulate where there is failure to release an egg from the ovary due to hormonal abnormalities e.g polycystic ovarian disease and hyperprolactenemia. Poor egg quality due to aging or other genetic factors. Tubal disease where fallopian tubes that carry the egg from the uterus to the uterus are damaged. Luteal phase defect leading to poor development of the early fertilized embryo due to a short or poor luteal support. Endometriosis which is a condition where tissue that normally lines the` inside the uterus is found outside the uterus within the abdomen that produce toxic sunbstances to the sperms and the fertilized ova. Unexplained infertility where there is no identifiable cause of infertility.
What are the different testing procedures for infertility evaluation?
2. Blood tests · Female Infertility Evaluation 2. Hysteroscopy 3. Laparoscopy
The couple's medical history and a complete physical examination of the female is of extreme importance. The evaluation of the male's medical history includes a discussion of developmental abnormalities, environmental exposures, previous surgeries, testicular trauma or infections and whether he has previously fathered a child. The female’s medical history includes review of previous pregnancies, painful periods, pelvic pain, infections and previous surgeries. A questionnaire is provided to our patients before the initial appointment to facilitate this process.
EVALUATION OF MALE INFERTILITY 40-50% of all infertility is male factor infertility. Evaluation for male infertility is best initiated with a semen analysis. This allows the doctor to examine the count, motility and morphology of the sperm:
For each analysis, patients are instructed to abstain from intercourse for 3 days. Abstinence for a shorter period can decrease ejaculate volume and sperm count whereas prolonged abstinence may impair sperm motility. It is critical that the specimen be collected in a nontoxic container, that there be no inadvertent loss of the specimen, and that the analysis be performed within 2 hours of collection.
The sample is most often collected by masturbation at home or alternatively in a private, comfortable room in the fertility center. Male cultures are done routinely on the semen to assure the absence of organisms that can affect fertility.
A hysterosalpingogram is an X-ray of the uterus and fallopian tubes that allows visualization of the inside of the uterus and tubes. The picture can reveal abnormalities of the uterus as well as tubal problems such as blockage and dilation. If the fallopian tubes are not blocked by scar tissue or adhesions, the dye will flow into the abdominal cavity. This is a good sign but it does not guarantee that the tubes will function normally. It can only give a rough estimate of the quality of the tubal structure and its patency (whether or not it is open). A hysterosalpingogram may also indicate presence acquired uterine cavity abnormalities such as endometrial polyps, fibroids, intrauterine adhesions, and congenital abnormalities such as a uterine septum.
If a uterine abnormality is suspected your doctor may recommend this procedure. The hysteroscopy is performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths.
In laparoscopy, a narrow fiber optic telescope is inserted through the abdominal wall to look at the uterus, fallopian tubes, and ovaries and to find endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the ovaries.
We may run tests to determine the levels of the following hormones that play a role in ovulation and implantation of the embryo:
The overproduction of the following hormones can negatively affect ovulation:
Endometrial biopsy is sometimes performed in the luteal phase (last half of the cycle) in an attempt to diagnose luteal phase defect (a problem with the preparation of the endometrial lining for embryo implantation that can result from inadequacies in estrogen and/or progesterone production during the menstrual cycle).
Near the time you ovulate each month, estrogen production from the ovaries stimulates mucus production by your cervix. Sperm must penetrate and swim through this mucus, then travel through the reproductive tract to reach the egg for fertilization. In some cases, there is an incompatibility between the sperm and the cervical mucus, causing the sperm to become immobile or die, thus preventing fertilization. The postcoital test (PCT) is supposed to evaluate the interaction between the sperm and your cervical mucus at a time near ovulation to determine if an incompatibility exists. Abnormal mucus may occur because of infections, cervical surgery, or Clomid therapy. If it is done too early before ovulation or too late after, the results may be falsely abnormal.
What are the various drugs that are in common use for infertility management and ovarian stimulation?
Several fertility drugs may be used to treat infertility based upon the couple's diagnosis. The following is the list of the most commonly used fertility drugs, and is discussed in detail in separate sections of the Web site.
Clomid (clomiphene citrate)
Clomid is often the first ovulation inducing medication prescribed
by the OB/GYN. It should never by prescribed without evaluation of
the male partner. Treatment of the female with Clomid when an
undiagnosed male problem is present could waste valuable resources
and, most importantly in older women, time. Clomid acts upon the hypothalamus causing it to secrete gonadotropin-releasing hormone, which stimulates the pituitary to secrete FSH. Many factors can cause hypothalamic insufficiencies leading to ovulatory disorders including, excess exercise, stress, PCO sudden weight lose, and some medications. Clomid should not be used for more than three to six months. The length of treatment is dependent upon many factors including the cause(s) of infertility, the age of the patient, her laboratory values and other variables. The likelihood of success with clomiphene is highest during the first three months and diminishes thereafter. Clomid side effects can include visual disturbances, nausea, cramping, and others. The most severe, and very unlikely, side effect is ovarian hyperstimulation. Clomid can also produce multiple births. The chance of multiple births with ovulation inducing agents is minimized when patients are carefully followed by a specialist trained in the administration of infertility medications.
(Gonadotrophes - FSH and LH)
Fostimone or Gonal-F and other FSH products stimulate the ovarian follicles directly. Externally administered FSH is physiologically identical to the FSH produced by the pituitary. They are administered by subcutaneous injection in conjunction with assisted reproductive technologies and intrauterine insemination where multiple eggs are needed. Multiple egg development occurs because of the stimulatory effect of FSH on the follicles. Some women who have very low FSH levels (hypogonadotropic) and functional ovaries have an excellent response to FSH resulting in high pregnancy rates. Either Fostimone or Gonal-F is usually administered at home by the patient or her partner. Merional and Humegon contain FSH and small amounts of leutinizing hormone whereas Gonal-F and Fostimone are pure FSH. The most serious potential side effect of the gonadotropins is ovarian hyperstimulation syndrome (OHSS). In this condition, the ovaries become enlarged and there is a "shift" of body fluid into the abdomen and pelvic cavity after ovulation. The decrease in fluid resulting from this "shift" can reduce blood perfusion and result in clots and poor circulation to the internal organs. The best predictor of hyperstimulation is elevated estrogen levels. Fortunately, the incidence of OHSS is low (approximately 5%). Use of gonadotropins significantly increases the chances of multiple births, usually twins. The incidence of higher order births is reduced when the drugs are properly administered and monitored. These products should only be administered by a physician specially trained in their use.
GnRH analogues
GnRH analogues are further divided into agonists and antagonists. GnRH agonists (Superfact) results in an initial stimulation followed by a prolonged suppression of pituitary gonadotropins, while the antagonists (Cetrorelix) directly cut off LH and FSH production .This action inhibits the release of pituitary gonadotropins FSH, LH, and estrogen levels are lowered. In in vitro fertilization cycles, GnRH analogues are used to lower gonadotropin levels (FSH, LH) during a stimulation cycle. External FSH is administered by injection to replace that suppressed by the antagonist allowing for precise control of the stimulation cycle. Ther are administered in different protocols dependent upon the patient's response. The amount of Gonadotophes required for a stimulation cycle is patient specific. In addition, it is critical that ovulation not occur before egg retrieval. LH is responsible for signaling the ovary to ovulate and is suppressed with the GnRH analogue until the eggs are mature. A premature surge can cause loss of the stimulation cycle. Once the eggs are mature, (hCG) is administered by injection before the retrieval. GnRH analogues may produce some side effects, including hot flashes, vaginal dryness, painful intercourse, headache, mood swings, fatigue, lowered libido, and insomnia.
Human Chorionic Gonadotopines Choriomon or Profasi are Human Chorionic Gonadotopines (HCG), and are used to trigger ovulation in women with infertility due to anovulation and to promote final maturation of eggs in the ovaries of women undergoing assisted reproductive technologies (ART), such as in-vitro fertilization.
Glucophage (metformin)
Metformin has recently been studied as an ovulation-inducing agent
in women with polycystic ovarian disease (PCO). Most women with PCO
do not ovulate, and of those that do become pregnant, 50% miscarry.
It is normally used to treat diabetes and enhances insulin activity. The body temporarily manages low insulin activity by increasing its production of insulin. Preliminary results indicate that PCO is caused by the body's inability to use insulin effectively (insulin resistance). Metformin reverses this "resistance" and causes ovulation. The most common side effects of metformin are upset stomach, and diarrhea. Symptoms of low blood sugar such as dizziness, shakiness, or hunger can also occur.
Parlodel (bromocriptine)
Prolactin is a hormone produced by the pituitary gland that stimulates the development of breast milk and inhibits ovulation. This is why menses often cease while a woman is breast-feeding. Artificially high levels of prolactin can cause anovulation (lack of ovulation) and Parlodel is effective in lowering prolactin levels in many cases. High prolactin levels are sometimes caused by a tumor (usually benign) on the pituitary gland, which can often be treated surgically. Once the prolactin level is normalized, patients typically respond very well to treatment and subsequent pregnancy results are excellent. Parlodel can produce side effects including nausea, headache, fatigue, dizziness and others.
Progesterone
Progesterone (Gestone or Uterogestan) is a hormone produced by the ovaries during the menstrual cycle to help prepare the uterus to accept and support an embryo. The corpus luteum, a gland composed of tissue from the follicle, synthesizes estrogen and begins to produce progesterone. Progesterone causes the lining of the endometrium to thicken and increases its blood supply. Progesterone is administered to women undergoing assisted reproductive procedures. After a pregnancy has been established, the placenta produces progesterone. Side effects of progesterone can include moodiness, and fluid retention, depression, irritability, and hypoglycemia.
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