Overview of Standard Care

  Infertility treatment is a series of diagnostic tests and interventional therapies, hopefully culminating with the end result of pregnancy and a baby. Our "basic work-up" is to perform a semen analysis and monitor ovulation. A post coital test is then performed to assess how the spermatozoa are being received around the time of ovulation. We may perform ultrasound exams before and after ovulation to visualize follicular development and release of the egg. Adequacy of the luteal phase is assessed with a midluteal serum progesterone test. All other tests and interventions are based upon this "basic work-up".

If there is an obvious problem with ovulation, it is treated with ovulation induction. Clomiphene fertility pills are usually tried first. Luteal phase defects may simply be supplemented with luteal progesterone. If ovulation and an adequate luteal phase are not achieved, letrozole tablets or low dose human menopausal gonadotropin (HMG) injections may be utilized.

 An impaired semen analysis or poor post coital test may result in a suggestion of intrauterine insemination as the treatment of choice. Severe male factor infertility may require IVF or donor sperm. A urology consultation at the University of Washington or at Oregon Health Sciences University is recommended for those hoping to improve semen quality.

 Intrauterine insemination (IUI) is sometimes used to bypass the cervix. It delivers more motile sperm into the uterus and and tubes than intercourse alone. Intrauterine insemination is appropriate for inadequate cervical mucus, moderately decreased sperm counts, and low volume ejaculates

Sperm freezing preserves live spermatozoa indefinitely. Individuals vary in the percentage of spermatozoa that survive freezing and thawing. We have utilized this technique to create a small sperm bank. It allows us to perform inseminations or IVF when a husband or partner is out of town, or when donor sperm that has been purchased is not yet ready to use. We have also provided this service to men with cancer before they undergo chemotherapy.

Donor sperm is often utilized for severe male factor infertility. We suggest picking a donor who physically resembles your husband or partner. We have a limited supply of sperm available at our office; usually, these are extra samples purchased by patients who no longer need them. Our embryologist, Dr. Cai, can provide patients with extensive and current lists from several sperm banks. These specimens are shipped frozen to us, and stored in liquid nitrogen tanks in our laboratory.

The Path Between

A history of pelvic inflammatory disease, or long-standing infertility with normal ovulation, normal semen analysis, and normal post coital test may require early evaluation of tubal patency with an anti-chlamydia antibody test, the FemVue tubal patency test, hysterosalpingogram, or laparoscopy. Endometriosis is suggested by painful periods, or pain during intercourse. Laparoscopy is required to evaluate endometriosis and plan appropriate care.

The anti-chlamydia antibody test is a blood test for immunoglobulin (IgG) against Chlamydia trachomatis. It suggests "significant" past exposure to a venereal disease that scars the oviducts internally and externally. A negative test result is reassuring that the tubes have not been damaged by infection.

Sonohysterogram is an ultrasound technique that places a balloon-catheter inside the uterus, and instills saltwater. The water assists in visualizations of endometrial polyps and endometrial fibroids. Endometrial polyps and fibroids are thought to increase miscarriages, and are removed prior to further fertility treatments.

FemVue is a saline-air device, which can test tubal patency using ultrasound. The FemVue syringe creates bubbles in saltwater, and with ultrasound the bubbles can be seen passing through normal tubes.

Hysterosalpingogram (HSG) is an X-ray procedure performed in the hospital. Radio-opaque dye is pushed through the cervix via catheter. HSG helps to delineate abnormalities of the uterine cavity and the tubal lumen. It is useful for the diagnosis of blocked tubes and hydrosalpinx.

Hysteroscopy is an in-office procedure, where a flexible telescope is inserted through the cervix to view the endometrial cavity. This diagnostic approach is used to confirm endometrial abnormalities seen during a pelvic ultrasound, sonohysterogram, or hysterosalpingogram. Endometrial polyps and intracavitary fibroids are usually removed at St. Peter's Hospital using general anesthesia and operative hysteroscopy.

Laparoscopy visualizes the pelvic organs with a telescope through the umbilicus. It requires a hospital operating room and an anesthesiologist. The abdomen is first filled with carbon dioxide gas to create an open space in which to work. A tubal dye test can be performed during laparoscopy, and each tube inspected for free flow of tinctured saline. Adhesions and endometriosis, which impair tubal pickup of eggs from the ovary, are best diagnosed and treated with laparoscopy.

Advanced Reproductive Technology (ART)

Superovulation with intrauterine insemination is appropriate for couples with open tubes, who have been unable to get pregnant by simpler treatment. Typically, mild endometriosis and infertility of unknown cause respond well. We utilize a microdose-Lupron protocol with human menopausal gonadotropin (HMG) and recombinant FSH (r-FSH). The microdose-Lupron provides an initial release of FSH from the pituitary and later prevents the occurrence of a premature LH surge. Two intrauterine inseminations are usually performed on these cycles; one before and one after the expected time of egg release. Progesterone is supplemented at 25 mg intramuscularly each day from luteal day 3 until the pregnancy test. The pregnancy rate of this therapy has been 20% in women under 35 years of age.

In vitro fertilization (IVF) is used when tubes are not patent, or the patient has not gotten pregnant by other therapies.

Natural cycle IVF has the advantage of not requiring expensive drugs for ovary stimulation. When pregnant by natural cycle, there is little risk of multiple births because only one embryo is transferred. The downside of this approach is that it requires nearly as much work to obtain and grow one embryo as it would to obtain and grow multiple embryos. In about 15% of natural IVF cycles we do not even get an egg. Only half of fertilized eggs will develop into healthy blastocysts. When one blastocyst is transferred, the pregnancy rate is about 40% in young women. The overall pregnancy rate from natural cycle IVF is about 15% per initiated cycle. This procedure is restricted to women who are under 35 years of age.

Stimulated cycle IVF is more reliable than natural cycle IVF. We almost always obtain multiple eggs and transfer multiple embryos. The pregnancy rate per each cycle attempted is about 30-50%, depending on the patient's age. These cycles are more expensive because of medication, ultrasound, and laboratory costs. There is also a higher chance of twins or triplets.

Freezing embryos may be necessary to preserve extra embryos from a stimulated IVF cycle. These embryos can be transferred at a later date, after hormonal preparation of the uterus.

Donor eggs may be obtained from willing donors on natural or stimulated cycles. The recipient's uterus needs to be prepared hormonally, so as to be receptive when the embryos become available. When possible, friends and family make good egg donors. We also maintain a list of individuals willing to share or donate eggs at a low cost. For an index of available egg donors, please ask to see the list of egg donors at our office.