FAQ - Infertility & ART

Infertility & ART

Quick review of how pregnancy occurs....

A woman ovulates once a month between 10th to 14th day from the start of her last period if her cycle has 28-30 days length. The ovum travels down a fallopian tube and waits for 12 to 24 hrs. Sperms travel up past the cervix to travel through uterus to the fallopian tubes. There it may combine with ovum to make an embryo. For conception this step is essential. The tiny embryo travels down into the uterus and attaches to the lining of the uterus. The embryo then grows and matures into a baby.

What is infertility? Is infertility a woman’s problem ? Infertility is usually defined as not being able to get pregnant despite trying for one year. A broader view of infertility includes not being able to carry a pregnancy to term and have a baby. Infertility affects about 10 percent of the reproductive age population,

It is a myth that infertility is always a “woman’s problem.” About one third of infertility cases are due to male factor and one third are due to female factor. Other cases are due to a combination of male and female factors or to unknown causes.

What causes infertility in men? Infertility in men is often caused by difficulties with quantity and quality of sperm or getting the sperm to reach the egg. Problems with sperm may exist from birth or develop later in life due to illness or injury. Some men produce no sperm, or produce too few sperm and few have many abnormal sperms. Lifestyle can influence the number and quality of a man’s sperm. Alcohol, smoking and drugs can temporarily reduce sperm quality. Environmental toxins, including pesticides and lead, may cause some cases of infertility in men.

What causes infertility in women? Defects with ovulation account for most infertility in women. Without ovulation, eggs are not available to be fertilized. Signs of these with ovulation include irregular menstrual periods or no periods. Simple lifestyle factors - including stress, diet, or athletic training - can affect a woman’s hormonal balance. Much less often, a hormonal imbalance from a serious medical entity such as a pituitary gland tumor can cause ovulation problems. Regardless of the cause of these hormonal imbalances, the end result may be infertility.

Aging is an important factor in female infertility. The ability of a woman’s ovaries to produce eggs declines with age, especially after age 35. About one third of couples where the woman is over 35 will have problems with fertility. By the time she reaches menopause, when her monthly periods stop for good, a woman can no longer produce eggs or become pregnant on her own. Infertility of this sort may be treated through the use of donor eggs.

Other factors can also lead to infertility in women. If the fallopian tubes are blocked at one or both ends, the egg can’t travel through the tubes into the uterus. Blocked tubes may result from pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy.

What are the essential tests done to see for the reason for the infertility ? If you are over 35, one should not wait for one year of trying before seeing a doctor. A medical evaluation begins with physical exams and medical and sexual histories of both partners. If there is no obvious problem, like improperly timed intercourse or absence of ovulation, tests may be needed to help determine the cause of the couple’s infertility.

For a man this begins with tests of his semen to look at the number, shape, and movement of his sperm. Sometimes other kinds of tests, such as hormone tests, are done to help determine if the male is a contributing factor in the couple’s infertility.

For a woman, the first step in testing is to find out if she is ovulating each month. There are several ways to do this. For example, she can keep track of changes in her morning body temperature and in the texture of her cervical mucus. Another tool is a home ovulation test kit, which can be bought at drug or grocery stores.

Checks of ovulation can also be done in the doctor’s office, using blood tests for hormone levels or ultrasound tests of the ovaries. If the woman is ovulating, more tests will need to be done to determine what contribution she is making to the couple’s infertility.

  • Hysterosalpingogram HSG : An examination of the fallopian tubes and uterus after they are injected with dye. It shows if the tubes are open and shows the shape of the uterus.
  • * Laparoscopy : An exam of the tubes and other female organs for disease. An instrument called a laparoscope is used to see inside the abdomen.

What is the treatment for infertility ? Depending on the test results, different treatments can be suggested. Eighty-five to 90 percent of infertility cases are treated with drugs or surgery. Various fertility drugs may be used for women with ovulation problems. It is important to talk with your health care provider about the drug to be used. You should understand the drug’s benefits and side effects. Depending on the type of fertility drug and the dosage of the drug used, multiple births (such as twins) can occur in some women. If needed, surgery can be done to repair damage to a woman’s ovaries, fallopian tubes, or uterus. Sometimes a man has an infertility problem that can be corrected by surgery.

What is assisted reproductive technology (ART) ? Assisted reproductive technology (ART) uses special methods to help infertile couples. ART involves handling both the woman’s eggs and the man’s sperm. Success rates vary and depend on many factors. ART can be expensive and time-consuming. But ART has made it possible for many couples to have children that otherwise would not have been conceived.

*In vitro fertilization (IVF) is a procedure made famous with the 1978 birth of Louise Brown, the world’s first “test tube baby.” IVF is often used when a woman’s fallopian tubes are blocked or when a man has low sperm counts. A drug is used to stimulate the ovaries to produce multiple eggs. Once mature, the eggs are removed and placed in a culture dish with the man’s sperm for fertilization. After about 40 hours, the eggs are examined to see if they have become fertilized by the sperm and are dividing into cells. These fertilized are then introduced inside the uterine cavity.

ART procedures sometimes involve the use of donor eggs (eggs from another woman) or previously frozen embryos. Donor eggs may be used if a woman has impaired ovaries or has a genetic disease that could be passed on to her baby.

What should the uterine lining be at ovulation and at implantation ?

Ideally between 8 and 12 mm this should have a triple line pattern around the time of the LH surge and ovulation. The triple line occurs in response to estradiol; the HH/IE conversion is in response to progesterone.

How do we know if the sperm count is adequate for IUI ?

Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If the functional sperm count (number with normal morphology and rapid forward-progressive motility) exceeds 1 million; chances for pregnancy with well-timed IUI are excellent. See Semen Analysis fact sheet for more information.

What about leftover cysts in the ovaries. What causes these cysts?

A corpus luteum, or functional cyst, is simply a leftover follicle that has outstayed its welcome. Some continue to produce progesterone and estrogen, which may delay the arrival of the next period.

Do they go away?

Functional cysts almost always go away with time. Birth Control Pills are sometimes prescribed to hasten their resolution.

Why do they reduce chances of pregnancy ?

Research has shown that any cyst 10 mm or larger is associated with a lower chance of getting pregnant. Cysts do not eliminate the possibility of pregnancy in a cycle, but they do reduce it. They do this through two mechanisms. First, physically, they can crowd out the development of new follicles. Also, if the cyst is secreting hormones at the wrong time of the cycle, (for example, progesterone during the follicular phase), it interferes with the chemical balance required for good quality ovulation and drastically reduces the chances of pregnancy.

What exactly is an endometrial biopsy ?

In an endometrial biopsy (EMB), a small curette is threaded into the uterus and a sample is taken of the lining, or endometrium, during the last week of your cycle. Once the sample is obtained, it is rated according to the day of a 28- day cycle for which it would be typical. An out-of-phase endometrium means that the endometrial appearance is typical of a time in the cycle other than the time it was taken. This biopsy does have the potential to disrupt a pregnancy in progress. An EMB may also be done to check for abnormal cells in the endometrium (hyperplasia). This is a concern when a woman has very infrequent periods or when ultrasound reveals a thick lining. For this purpose, the EMB can be done on any cycle day.

How long should pt use tabs before moving to Injectables/IUI ?

The vast majority of pregnancies occur during the first 4-5 ovulatory cycles.. (Also, if you do not stimulate well on tab at a reasonably high dosage, you might consider moving on to Injectables earlier. The maximum dosage is 150 mg., according to the manufacturer, and it may be wise to move on if unsuccessful after two cycles at that dosage). The average number of cycles on tabs before moving on is three to six.

How many times should anyone try IUI before moving on to IVF ?

Once a patient has had 3-6 IUI cycles with injectables, they might consider moving to IVF as the chance of a successful IUI cycle is reduced.

What is the maximum recommended dosage for tab (clomiphene citrate) ?

 As mentioned about, the maximum dosage is 150 according to manufactures. It may be wise to move on if there is no response to 150 mg, as the risk of antiestrogenic side effects of Clomiphene citrate increase sharply as the dosage goes up.

How should IUIs be timed ?

In most cases, doctors who do two IUI’s do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective. However, some recent research suggests that higher pregnancy rates may be achieved by doing two IUI’s, one at 12 hours past the HCG shot and one at 34 hours. 11

What are the logistics of injectables ?

Typically, they are taken daily for 7-12 days (although it is possible to take them as long as 14 days). If you are taking subcutaneous injections, they are administered in the stomach, upper arm or thigh, with a 1/2- or 5/8 inch needle. If they are intramuscular, they are given in the hip/buttocks area using a 1.5 inch needle. The partner usually administers the IM shots. You can also give the IM injection to yourself in the thigh. They feel like a flu shot or vaccine.

Should I use a BBT chart ?

A Basal Body Temperature chart is not a very reliable way to predict ovulation. Although the temperature shift associated with ovulation can be detected on a basal thermometer, it can sometimes take as long as two days before this shift shows up on a BBT. This generally means that by the time a temperature shift is detected, it is too late to time intercourse effectively. Further, there are many things that can negatively affect the reliability of BBT monitoring: A change in sleep patterns, getting up to go to the bathroom in the night, a cold or flu, etc., can all change the results.

Multiple cycles with fertility drugs increase the chance of getting ovarian cancer. Is this true?

No. There is no evidence that shows a statistically significant increase in the ovarian cancer risk.

Do your chances increase with each consecutive cycle?

No, each cycle is independent. Your per-cycle chances do not increase.

What is ovarian hyperstimulation.

OHSS (Ovarian Hyperstimulation Syndrome) is when you have an unusually large number of mature follicles that release. When these follicles release, there is an unusually high concentration of estrogen-rich fluid in the peritoneal cavity, and the ovaries are generally enlarged far beyond their usual plum size - in some cases, they can swell to softball size The best pre-ovulation predictor of hyperstimulation is the E2 level, but it is not a perfect predictor. If you experience symptoms of OHSS, you should always play it safe and check with your doctor.

What do you mean by poor egg quality.

You can get somewhat of an idea from the size of the egg and the estradiol level at midcycle. But other factors arise as you get further into your 30s, such as whether the outside covering is too thick to be penetrated easily by the sperm. You really can’t diagnose egg quality until you get the eggs out of the follicles, put them under the microscope, and see how they behave. There are some less invasive screenings for ovarian reserve/egg quality such as the Clomiphene challenge, FSH, and Inhibin B, but they are also not as accurate as looking at the egg directly.

What causes chemical pregnancies ?

Many early pregnancy failures are due to genetic abnormalities, mainly “trisomies” where an extra chromosome is present in what should be a pair. Some pathologists believe that the earlier the failure occurs after implantation, the more likely it is to be genetic. You can also have implantation problems that would cause chemical pregnancies such as hypercoagulation, failure to form the needed blood vessels, or autoimmune issues. Note that chemical pregnancies are early miscarriages.


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