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- Are the fallopian tubes and pelvic structures normal? This is most often tested by hysterosalpingogram and sometimes laparoscopy.
- Is ovulation occurring regularly and predictably? Most accurately determined in women by the careful history of the menstrual cycle and its symptoms but additionally sometimes by tests such as serum progesterone levels in the last half of the cycle.
- Are there adequate numbers of motile (moving), normally formed sperm in the semen?
- Is intercourse adequately frequent and appropriately timed during ovulation and the days preceding ovulation?
No test can really determine whether the egg, which is microscopic, is actually being released. Tests for ovulation look for the normal events that accompany egg release, including normal menstrual periods, evidence of progesterone secretion in the last two weeks of the cycle, and the presence of ovarian follicles of appropriate size (these appear as ovarian cysts about one inch in diameter on ultrasound) as ovulation is about to occur.
Ovulation detection kits, which detect the increase in the level of the hormone LH (luteinizing hormone) in the day preceding ovulation, are helpful in timing efforts to conceive. It is important to note, that not all women who ovulate obtain positive signals on these tests. Thus, predictor tests do not reliably indicate that ovulation is not occurring.
Failure to ovulate or failure to ovulate regularly are common causes of infertility and arise from a variety of causes. These causes are identified by physical examination and laboratory blood tests. Most of these are treatable with medications, and sometimes such treatment is simple and inexpensive, while in other instances, the treatment is complex and more costly.
Blocked fallopian tubes are most often discovered by a hysterosalpingogram or less commonly during laparoscopy. The most common causes are infections of the tubes that have occurred in the past (often without symptoms), diseases which cause inflammation in the pelvis such as inflammatory bowel diseases or ruptured appendix, or more rarely, endometriosis and other conditions. Most often, surgery to fix blocked tubes is ineffective, and most patients with this condition are best treated by in-vitro fertilization.
Abnormalities of the semen are a major cause of infertility. In most cases the causes are unknown, but genetic factors, certain rare diseases, and prior surgery involving the testes or nearby structures sometimes provide an explanation. Most instances of abnormal semen do not respond to any known treatment, though there are promising new therapies for some men. When the semen has sufficient numbers of motile sperm, insemination of prepared sperm into the uterus (intrauterine insemination) can improve the likelihood of conception. When semen is abnormal, in-vitro fertilization with ICSI (in which eggs from the partner are mechanically fertilized by injection of sperm) is a highly effective therapy. Even when there are no sperm in the semen, sperm obtained by biopsy of the testes can be retrieved and used to create pregnancies with great effectiveness by using in-vitro fertilization.
Endometriosis, a common condition, consists of endometrial tissue (that normally lines the interior of the uterus) found growing on the surfaces of organs in the pelvis such as the uterus, tubes, ovaries, and nearby surfaces. In most cases, it does not block the tubes, and its negative influence on fertility is poorly understood. Endometriosis can be temporarily suppressed by medications, but these therapies do not improve fertility. Endometriosis can often be destroyed by laparoscopy, but such surgical treatment benefits fertility modestly, if at all. Most fertility specialists do not use surgical treatment to help patients with endometriosis get pregnant.
Endometriosis is associated with pelvic pain, particularly at the time of the menstrual period, and also sometimes occurring with intercourse, bowel movements, or emptying the bladder. Surgical and medical treatment is helpful for reduction of symptoms, not correction of infertility. Patients with endometriosis may become pregnant without treatment, though at a slow rate compared to normal women. Treatment with ovulation medications to increase the number of eggs combined with intrauterine insemination increases pregnancy likelihood in women with endometriosis. In-vitro fertilization is as efficient in producing pregnancies in women with endometriosis as it is in other condition. If other treatments fail, in-vitro is an excellent option for treatment of women with this condition.
Many couples have uncertainty about how to have intercourse in a manner that is most likely to result in pregnancy. The likelihood of pregnancy from intercourse becomes measurable several days before ovulation and increases steadily until the time of ovulation. After the time of ovulation, pregnancy is very unlikely to occur. The strategy for timing intercourse should focus on the three or four days leading to and including the day of ovulation. Contrary to popular advice, there is no reason to "save" sperm for the best time. Semen quality is little affected by the frequency of ejaculation, so intercourse daily, or at least every other day, beginning in the days prior to ovulation and continuing until it is clear ovulation has passed is the most effective method of "timing".
Couples often wish to know about matters of technique or positions for intercourse that favor pregnancy. There is no evidence that these bear on fertility nor is there evidence that a complete female sexual response matters as far as the likelihood of conception is concerned. It is commonly advised that remaining in a position that retains semen in the upper vagina is helpful to conception, but there is no evidence for this advice either, though common sense would suggest waiting five or ten minutes before getting up (discharge of semen is normal at this point) after intercourse.
Infertility is stressful, but there isn’t strong evidence that stress contributes to infertility. The belief that stress "causes" infertility is natural, but the facts do not support this belief. Women in the most stressful situations exhibit fertility, and unwanted pregnancies often complicate the lives of women in severely troubled circumstances. The idea that the relief of fertility stresses that accompanies adoption causes fertility is based on common anecdotes of infertile couples who conceive around the time of an adoption. Careful studies have shown that such treatments in independent pregnancies are similar in frequency and timing among similar couples who do not adopt. However, reducing stress in one’s life is an important goal, but one’s infertility because of stress is unfounded.
Stress arises from many sources among infertile couples. Work and family stresses often are present in modern life. Frustration with not getting pregnant is often perceived differently by members of a couple and this difference of perspective is a common source of stress. As pregnancy fails to occur repeatedly, fear ("I may never have children") becomes a prominent stress factor. Jealousy of pregnancies and children occurring to friends, family, and strangers adds to the experience of stress. Anger is a common painful experience. Finally, depression may arise and may interfere with well- being in important ways. The Center hopes to reduce these manifestations of infertility among patients to improve quality of life and encourages patients to discuss these issues. Confronting these emotions through discussion, providing information, and sometimes use of medications can be helpful. Religious beliefs can also be an important path to improved well-being.
Fibroids (the medical term is leiomyomas) are benign ball-shaped growths of the uterine muscle. They are common, and often unimportant to fertility or normally carrying a pregnancy. They are detrimental if they are big enough or close enough to the uterine cavity to change its shape. When they are situated so as to interfere with fertility, they are often associated with abnormally heavy menstrual periods. Removing these growths by abdominal surgery or by hysteroscopy (an operating telescope inserted into the uterus under anesthesia) can improve fertility and is sometimes a necessary part of appropriate treatment for infertility. Determining whether a fibroid should be removed often requires a hysterosalpingogram and/or a procedure known as sonohysterography but is often clear simply from a pelvic ultrasound study.
Endometrial polyps are benign overgrowths of the uterine lining and are common. They lie within the space of the uterine cavity and are usually identified by hysterosalpingogram, ultrasound, or sonohysterography. Their effect on fertility is not clear, but fertility specialists assume that large ones may have an effect like that of an intrauterine contraceptive device, so big polyps are often removed to treat infertility. Polyps can be removed effectively by hysteroscopy, a simple office procedure with light anesthesia.
Scarring of the uterine cavity (Asherman Syndrome) so that its interior shape is no longer normal is rare. It almost always occurs after a D&:C operation that is done for complications of a pregnancy, miscarriage, or abortion. Patients with this condition may have light or even absent menstrual periods, even though they are ovulating normally. Patients with this condition have difficulty with both conceiving and carrying pregnancy. Asherman Syndrome is treated by hysteroscopic surgery, and in severe cases, restoration of normal conditions in the uterus is difficult to achieve. Hysteroscopic treatment of this condition should only be done by infertility specialists with extensive experience.
During development of the embryo, the uterus in humans is formed by the side to side fusion of two parallel uterine ducts and usually results in a uterus with a single, triangular or vase-shaped cavity. In about 2% of women, this fusion is incomplete, so there are two separate uterine half-uterus side-by-side, or more commonly, a single uterus with a partition in the middle to create two cavities, one on each side. This latter situation is called a uterine septum. This condition is easily seen by hysterosalpingogram, ultrasound, and sonohysterogram. Sometimes an MRI study of the pelvis is used to provide a more precise picture of the nature and extent of the abnormality. Although this condition does not reduce fertility, it does increase the chance of miscarriage, and a uterine septum is the most common treatable cause of recurrent miscarriages. Uterine septums can be removed by the hysteroscope, and if not extensive, this can often be accomplished with light anesthesia in an office procedure.
Fertility decreases with increasing age of the female, especially after a woman enters her late 30’s. The main reason is that over time, increasing percentages of eggs released have acquired damage that interferes with their ability to form normal embryos when fertilized. Aging of the eggs stored in the ovaries makes normal conception and implantation less likely. There is also increased incidence of miscarriages and chromosomal abnormalities among offspring of women in their late 30’s and 40’s. A measurement of the blood levels of the hormone FSH early in the cycle is sometimes used to attempt to determine how important a woman’s age is to her fertility. FSH (follicle stimulating hormone) is a pituitary hormone that helps "drive" ovulation, and levels of this hormone rise as age results in a decrease in responsive healthy follicles in the ovaries occur. With or without treatment, higher levels of FSH will be a factor in achieving pregnancy.
The medical term for miscarriage is "spontaneous abortion". Miscarriages occur randomly and commonly in human pregnancies. They are most often related to major errors in the chromosomes of the pregnancy that have arisen because of defects in the sperm, the egg, or the process that unites the chromosomes of the sperm and egg in the first days of pregnancy. Other miscarriages are likely due to genetic errors too small to be perceived by examination of the pregnancy’s chromosomes. Miscarriages occur in one of six pregnancies in younger women and approach a frequency of one in three as women enter their forties (due to increasing numbers of abnormal eggs in older women – see "age" above). Losing a pregnancy to miscarriage is an occasion for grief and a sense of loss and is especially painful when pregnancy has been long awaited or difficult to achieve. None of the treatments employed for infertility specifically increase the chance of miscarriage, though none decrease the likelihood of miscarriage either.
The Center’s practice is to use ultrasound in the first weeks of pregnancy to determine if a pregnancy is healthy and progressing normally. Ultrasound will usually detect abnormalities of a pregnancy (deficient growth of the embryo or absence of a heartbeat in the embryo) that could mean miscarriage will occur. Ultrasound helps determine that a miscarriage will occur before it threatens (bleeding or cramping). Most miscarriages will safely complete themselves on their own, but medications to hasten the inevitable or D&C are sometimes employed when it is clear that a pregnancy has failed. The painful decisions about how to proceed once a pregnancy is abnormal involve the age and size of the pregnancy, the patient’s feelings, and other factors that are discussed with the physician to make the best plan for each individual circumstance.
When miscarriage occurs, it is natural for couples to wonder if there is anything they may have done to prevent it, but that is rarely the case. It is essentially impossible for a woman to engage in activities or practices that would cause a miscarriage, and there are no known preventive measures that can be taken that seem to alter the likelihood of miscarriage. When miscarriage threatens (bleeding in early pregnancy), rest is often recommended. It is not likely that rest alone will alter the outcome in most instances.
Recurrent miscarriage is an especially frustrating and painful obstacle to having a family. Because miscarriage randomly occurs in otherwise normal couples, the occurrence of two miscarriages in a row is normally not diagnosed as "recurrent miscarriage". The evaluation and treatment of recurrent miscarriage involves seeking uterine, genetic, immune, or hormonal factors that explain miscarriages to form a basis for treatment to improve the chance of successful pregnancy. The Center sees many couples with these problems and often collaborates with other specialists in the Department to establish a diagnosis and plan for treatment.
Pregnancies occurring outside the normal location in the uterus are termed "ectopic," and most of these are located in the fallopian tube; much more rarely they are found in the ovary or even the cervix. Pregnancies are ectopic in about 1% of all pregnancies. They are more likely to occur when there has been damage or surgery on the fallopian tubes, and women who have had tubal surgery are at much higher risk. If unrecognized and allowed to proceed, many times these pregnancies grow to the point that they damage the tube (or other site where they are growing) and dangerous bleeding that can be life threatening can occur. Emergency surgery may be necessary. Sometimes these pregnancies subside on their own without harm.
Early ultrasound of pregnancies and monitoring of pregnancy hormone levels (HCG levels in the blood) usually permit diagnosis of these pregnancies before they can cause harm. This allows for conservative treatment with medications or minimally invasive surgery (laparoscopy). Some early pregnancies show signs of failure, indicated by faltering or falling HCG levels, and their location (uterine or elsewhere) cannot be clearly determined. D&C (often in the office) can clarify the diagnosis in some cases, and in others, treatment of the patient for presumed ectopic pregnancy, without ever knowing the location of the pregnancy, is simpler and as safe.
Often, a clear cause for infertility is not apparent after the basic evaluation. There may be hints from slight abnormalities of the semen analysis or a history suggesting endometriosis, but the picture may seem vague. Because it is natural to want to know "what is wrong," this is especially frustrating for many infertile couples. Fertility specialists used to try to determine whether the mucus of the cervix was compatible with sperm, whether subtle hormonal abnormalities existed, or whether there were defects in the release of the egg when ovulation occurred. No study has ever produced clear results or been helpful for treatment, and other tests have been abandoned.
When no cause is apparent or a cause is indefinite in its severity, treatment with superovulation, inseminations, or both, or treatments with in-vitro fertilization are helpful. When the diagnoses is unclear after a basic work-up, rather than extend time and cost with tests that yield unclear results, the Center guides couples towards treatment.
Couples with well-established infertility can conceive on their own without treatment, sometimes during evaluation, or sometimes after years of exhaustive treatments. Treatment independent pregnancies illustrate that many couples with infertility, whether due to known or unknown factors, have fertility that is reduced (the probabilities of pregnancy are lower than normal) but not absent fertility. In particular, studies have shown that couples with infertility and a normal basic ovulation are more likely than not to conceive on their own if left alone for another two years. For many couples, this information requires patience if they are relatively young and the initial evaluation finds no major problems. However, the desire to begin a family and the uncertainty of waiting means some couples will prefer to undergo treatments to increase their chances of pregnancy sooner.
The hysterosalpingogram is an x-ray picture outlining the uterus and tubes done by injecting an x-ray dye into the uterus and through the tubes. Although the uterus and tubes are not themselves seen on x-ray, the injection of x-ray dye allows the interior of the tubes and uterus to be clearly seen. Abnormalities of the uterus such as uterine septums, scars, fibroids, or polyps are often clearly seen with this technique. The passage of dye through the tubes allows determination as to whether the tubes are normal, and whether they are open for passage of eggs to allow conception. As performed by specialists, the hysterosalpingogram is only mildly uncomfortable. It usually takes about five minutes and is performed in the x-ray department of a hospital.
A sonohysterogram is an ultrasound of the uterus using saline injected in the uterus through a small catheter. This gives a clear pictures of the uterine lining andt shows whether the uterine cavity is marred by fibroids, polyps, scars (Asherman syndrome), or abnormal development. A sonohysterogram is an office procedure that takes only minutes. Patients often have cramps during this procedure, but they quickly subside once it is completed.
Laparoscopy is a surgical procedure performed with general anesthesia that uses a telescopy inserted into the abdomen in the vicinity of the navel to view the uterus, tubes, and other surrounding structures. Additional abdominal entry sites for surgical instruments allow some abnormalities to be treated during the procedure. Most often laparoscopy for infertility is relevant to the diagnosis of endometriosis or determination of the nature of tubal blockage that has been discovered by a hysterosalpingogram. Laparoscopy is a "same day surgery procedure" and is performed in a hospital operating room or outpatient surgical center. Recovery to normal activity levels can take up to a week. Laparoscopy was once an important part of the infertility evaluation, but modern specialists do not often find it necessary for optimal diagnosis and treatment for infertility.
Hysteroscopy is a surgical procedure that is accomplished by inserting a small telescope through the cervix to examine the uterine cavity and treat abnormalities within the uterine cavity. Complex problems such as large fibroids, abnormalities of uterine development, and scars within the uterine cavity (Asherman syndrome) often require that hysteroscopy be done with general anesthesia in an operating room. Some problems with the uterine cavity that are not complex can be treated with hysteroscopy in an outpatient setting in the clinic with light anesthesia.
In normal reproduction, intercourse results in deposition of the semen in the upper vagina near the cervix, and sperm find their way into the uterus and the fallopian tubes where they can fertilize an egg. For intrauterine insemination, the sperm can be separated from the semen and concentrated in a small amount of fluid that can be placed in the uterus with a syringe attached to a fine tube. This maneuver is timed to coincide with the time of ovulation and can increase fertility. It is especially helpful when there is mild or moderate reduction in semen quality, or when sperm have been damaged by freezing (as is the case with anonymous donor insemination). If the sperm count is severely reduced, intrauterine insemination offers little benefit.
Failure to ovulate or failure to ovulate very often is a very common cause of infertility. The evaluation of the cause of ovulation failure is complex, and there are several distinct causes for this problem. Fortunately, most causes are treatable, but the treatment depends on the specific diagnosis. The most common treatments are clomiphene (Clomid) or gonadotropins (injectable protein hormones that stimulate the ovary). In both cases, the response to the medication is monitored to determine correct dosage and effectiveness. Sometimes monitoring can be done by basal temperature and LH tests (ovulation detection kits), but often ultrasound is needed to be sure the treatment is having an appropriate effect.
Superovulation refers to the use of medications such as clomiphene (Clomid) or gonadotropins (injectable protein hormones that stimulate ovulation) to produce more than one egg at the time of ovulation. Superovulation is part of therapy for couples where infertility is unexplained, explained by endometriosis or mild abnormalities of semen, and is often combined with intrauterine insemination. Most often, superovulation is monitored by ultrasound to assure the goal that more than one but not too many (usually more than four is "too many") eggs are to be released. Ultrasound monitoring also assures that timing of ovulation is known, and often an injection to cause ovulation is added to superovulation to increase certainty of the time of ovulation. Even when more than one egg is released, multiple pregnancies are not common with superovulation therapy. Twin rates are about 10% of pregnancies, and triplets are less than 1%. Typical rates for conception using superovulation and IUI are10-15% per cycle.
In-vitro fertilization is based on a simple principle. If eggs are obtained and fertilized in the laboratory, most will produce embryos, and some of these will be healthy and will very often produce a pregnancy if placed in the uterus during the third to fifth day of life. Obtaining the eggs requires a sequence of medications that result in the maturation of many eggs at once which can be retrieved with an ultrasound guided needle under light anesthesia. Fresh sperm are used to fertilize the eggs the same day. The resulting fertilized eggs are maintained in sophisticated and carefully controlled laboratory conditions while they undergo repeated cell divisions. After a few days, a few of these will be clearly the healthiest, and generally two are returned to the uterus in a simple procedure using a fine catheter.
In-vitro fertilization is equally effective for almost all infertility conditions. The success rate is dependent on a woman’s age with rates of pregnancy slightly lower after 35 and much lower after 40.
Pregnancy is detectable after two weeks, and close to three quarters of women undergoing this procedure will have a positive pregnancy test. Some of these pregnancies will fade after a few days, but most will persist and thrive. Pregnancy rates in successful clinics such as the Utah Center for Reproductive Medicine will exceed 50% per try.
Normally two embryos are placed to increase the chance of pregnancy overall, but this practice comes at a cost of producing twins in about one-third of resulting pregnancies. Sometimes one pregnancy will fade away while the other succeeds so that only a single baby arrives at term. Sometimes both embryos will succeed, and one will split so that triplets will occur. This will happen in about one of fifty in-vitro fertilization pregnancies in the Center. The Center rarely places more than two embryos, and sometimes only one is placed. It is important to reduce the incidence of triplets as much as possible as these pregnancies are often high risk for the mother and babies and can result in babies with lasting handicaps. Placing too many embryos can do more harm than good. The decision about how many embryos to place is always determined between physician and couple after careful discussion at the time of the embryo transfer.
When infertility is accompanied by reduced sperm numbers and function, the sperm will often not fertilize the eggs obtained for in-vitro fertilization. Intracytoplasmic Sperm Injection (ICSI) is then performed by using an extremely fine needle to pick up one normal sperm for each egg, and each egg is injected with a single sperm. Successful fertilization occurs in about two thirds of the eggs treated with ICSI.
ICSI has revolutionized the treatment of severe male infertility. Even when counts are extremely low or when sperm must be obtained directly from the testicle by biopsy, pregnancy rates are the same as when IVF is done for other reasons – somewhat better than 50% at the Center when all recent cases are considered.
Natural and alternative remedies are increasingly widely used by patients for a wide variety of health concerns, not just in the area of reproduction. The Center is not opposed to consideration of natural and alternative remedies and prefers that patients discuss these if they are using them or have questions. For many natural and alternative approaches, patients will find there are not a lot of answers. Most often this is because there is little evidence of their effectiveness and safety like the clinical studies the Center uses for bases of treatment. Some of these therapies may be helpful and some may be harmful, but there are not enough studies to determine their quality, efficiency, safety, etc. Remember that natural remedies that actually work well ultimately are studied, standardized, and transformed into "conventional remedies" (most medications used at the Center are purified from natural sources). The Center does its best to help find out about treatments in which patients have an interest or feel have been helpful.
Our center features four reproductive surgeons (average experience of over 20 years of performing tubal reanastomosis). The best option for each individual couple (whether tubal reanastomosis or in vitro fertilization) is carefully considered and discussed during an initial consultation. Tubal reversal procedures are planned as same day surgeries at our outpatient surgical center. Reversal procedures are done using magnification through a "minilaparotomy" (small bikini incision). Salt Lake City is such a convenient hub that we have performed tubal reversals for women from many states over the years. We have been able to keep our costs as low as possible. The total cost of the procedure (including facility, surgeon and anesthesiologist fees) is $5,009.00.