Basic Infertility Evaluation and Treatments

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IVF and IUI are frequent procedures mentioned in fertility literature. Check out this fact sheet to learn more.
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During your first visit to our center, we will review your medical history and ask a variety of questions to begin understanding possible infertility causes. Based on our initial findings, we will recommend further evaluation and diagnostics, leading to a customized treatment plan focused on your unique clinical history and personal goals. Click here to learn more about your first visit.

In about 85 to 90 percent of cases, treatment focuses on basic medical therapies such as medication or surgical repair of reproductive organs. At this treatment level, our patients enjoy the opportunity to achieve parenthood in as natural a manner as possible.

Ovarian Reserve Screening

Ovarian reserve is the ovary's analogy to the semen analysis for the male and is the best indicator of a woman’s reproductive potential. As a woman ages, so do her ovaries and eggs. The reproductive potential of the aging ovary begins to decline after a woman reaches age 30, and the rate of decline is unique to each woman.

Before beginning most infertility treatments, the Bethesda Fertility Center offers women an assessment of ovarian reserve using one or a combination of tests. Ovarian reserve screening can make a significant difference in helping couples determine the next course of treatment and evaluate cost efficiencies associated with potential outcomes. With diminished ovarian reserve, a woman's chances of achieving a live birth with her own eggs decreases to less than 1 percent. Some couples choose to accept their infertility at this point and seek no further treatment. Others choose to seek treatment with either their own eggs or with donated eggs/embryos.

What Tests Are Used for Ovarian Reserve Screening?

Tests for ovarian reserve include an ultrasound for the measurement of antral follicular count (AFC), or blood work for the measurement of anti-mullarian hormone (AMH) or menstrual cycle day 3 follicle-stimulating hormone (FSH) levels. The Clomiphene Citrate Challenge Test (CCCT) also can aid in determining ovarian reserve. For the CCCT, hormone measurements for FSH and the hormone estradiol are made on menstrual day 3. Clomid/Serophene is then administered orally on days 5-9, and FSH and progesterone levels are measured on menstrual day 10. Elevated FSH levels on either menstrual day 3 or 10, and/or an elevated day 10 progesterone level, are all indicative of diminished ovarian reserve. Abnormal levels of FSH must be determined for each laboratory, so caution should be taken when interpreting the results.*

Who Needs Ovarian Reserve Screening?

While age is the most common factor for diminished ovarian reserve, unexplained infertility is a significant risk factor as well. About 33 percent of women with a prior diagnosis of unexplained infertility demonstrate diminished ovarian reserve, thus making their diagnosis no longer unexplained. Using the below screening criteria, 1 out of 6 women screened will demonstrate diminished ovarian reserve.

  • Any woman over the age of 35
  • Any woman of any age with a diagnosis of:
    • Unexplained infertility
    • One ovary or a history of significant surgery on an ovary (usually from endometriosis)
    • Poor response to past fertility treatment
    • Recurrent pregnancy loss
     

* The Bethesda Fertility Center is the only center in the region with a long history of offering ovarian reserve screening. Our research has contributed extensively to published national literature in this field, helping to establish industry standards for this important screening tool. 

Semen Analysis

Approximately 40 percent of couples having difficulty conceiving experiences some degree of male infertility. Most men produce millions of sperm each day; however, many of these may be abnormal either in count, shape (morphology), movement (motility) and function. The semen analysis is a primary diagnostic tool for determining both urological and infertility issues. Included in the semen analysis report are semen volume and viscosity, liquefaction time, sperm count, viability, motility and grade, white cell count, pH, and morphological assessment with classification of abnormal forms present.

When and Where Should a Man Have a Semen Analysis?

A semen analysis should be done very early in the evaluation of a couple seeking fertility treatment, preferably as one of the very first tests and clearly before any invasive or uncomfortable tests are performed on the woman (HSG or surgery). The best place to have a semen analysis performed is at a laboratory associated with reproductive endocrinologists who perform sophisticated, high-tech procedures. These laboratories are board certified and report their results in a manner that is understood by anyone who works with infertility patients. Insurance coverage also will direct you to a service on your provider list.

HSG/SIS

Hysterosalpingography (HSG)

Hysterosalpingography is a radiologic procedure used to investigate the uterine cavity and patency (openness) of the fallopian tubes. The procedure is performed in the Department of Radiology and lasts about 10 minutes. The physician injects contrast dye into the uterine cavity via a catheter inserted through the cervix. If the fallopian tubes are open, the contrast dye will fill the tubes and spill out into the abdominal cavity.

Because the procedure can be painful, patients are encouraged to take oral pain killers both before and after the procedure to reduce pain. In certain cases, antibiotics are used prior to the procedure to reduce the risk of infection.

Saline Infusion Sonohysterogram (SIS)

The purpose of the SIS exam is to evaluate the uterine cavity and possibly the patency of the fallopian tubes. However, while SIS is more sensitive for uterine cavity evaluation, HSG is more sensitive for evaluating the fallopian tubes. SIS is an ultrasound test performed in the office where a catheter is inserted through the cervix and saline (fluid) is injected to distend the uterine cavity during the ultrasound. Once the uterine cavity is distended with fluid, the physician can detect the presence of polyps (overgrowth of the uterine lining or endometrium) or fibroids (overgrowth of the uterine muscle). Intracavitary fibroids or polyps may interfere with pregnancy (implantation).

SIS may be painful; however, it is typically better tolerated than HSG. Patients are encouraged to take oral pain killers an hour before the procedure to reduce pain. In certain cases, antibiotics are used prior to the procedure to reduce the risk of infection.

Polycystic Ovarian Syndrome (PCOS)

Polycystic ovary syndrome is one of the more common problems presented to gynecologists and fertility specialists. It is characterized by many small follicles (12 or more) on the surface of each ovary and by the inability to ovulate. Women with PCOS typically present with either:

  • Have irregular menstrual cycles (longer than 35 days or not at all) or
  • Evidence of androgen excess – excessive male hormone production, most typically demonstrated as facial hair (hirsutism), leading up to a full beard, acne or a male hair pattern on the abdomen

Contributing Factors to PCOS

Frequent findings associated with PCOS are obesity, which seems central to the pathology of PCOS, and insulin resistance, as often evidenced by the dermatologic disorder Acanthosis Nigricans. Severe cases of PCOS, with elevated blood pressure, abnormal lipids and type II diabetes, may be indicative of metabolic syndrome and require more immediate care from a gynecologist.

PCOS Treatment

Before treatment to improve fertility can begin, we perform a comprehensive fertility workup, including hormone studies, a semen analysis, and testing of the uterine cavity and patency (openness) of the fallopian tubes. Once all other fertility-related factors are eliminated or corrected, we focus on ovulation induction to encourage ovulation in a timely and predictable fashion. This is usually accomplished with the oral medications Clomid (Serophene) or Femara (Letrazole). Occasionally, other medications are required in addition to these, such as dexamethasone or Metformin. Learn more about ovulation induction.

Weight loss, sometimes as little as 5 percent can help menses resume, and weight loss is central to all treatment plans for PCOS. Women who still cannot ovulate after receiving a combination of oral medications can pursue ovulation induction with injectable hormones, which boost ovulation for most, if not all, PCOS patients. The down side of injectable medications is cost, an increase in office visits to monitor medication response and a significant increase in the multiple birth rate compared to oral medications.

The Bethesda Fertility Center will review your history as a couple, complete a full fertility workup and then provide an ovulation induction protocol tailored to your individual needs.

Endometriosis

All women, if they have open fallopian tubes, experience some menstrual blood reflux back through the tubes and into the pelvis. Endometriosis occurs when the menstrual blood contains living cells from the endometrium (lining of the uterus), and these cells grow in the pelvis. This is the most popular cause of endometriosis. If the endometrium cells form a cyst on the ovary, it is called an endometrioma.

Endometriosis may cause gynecologic symptoms, such as pelvic pain, pain with periods and pain with intercourse or bowel movements. These problems are best treated by a woman’s gynecologist. When endometriosis is associated with infertility, a specialist maybe required.

How Does Endometriosis Affect Fertility?

Endometriosis is classified as minimal, mild, moderate or severe. All stages of endometriosis can cause gynecologic symptoms. Minimal and mild forms of endometriosis rarely by themselves cause infertility. More advanced endometriosis may be associated with infertility by causing distortion of the normal pelvic anatomy.

Can I Still Become Pregnant with Endometriosis?

Treatment of endometriosis with Lupron is helpful for some women. It requires three to six months of treatment and has significant reversible side effects of menopause such as hot flashes, vaginal dryness and bone loss. Unfortunately, there are no studies to predict which women will benefit the most or at all with Lupron treatment. Lupron should not be used for more than six months because it causes irreversible bone loss after that time.

Often, with moderate to severe endometriosis,  IVF (in vitro fertilization) is required. In these cases, the presence of endometriomas is used to diagnose moderate to severe endometriosis. Previously, surgical removal of the endometriomas was thought to improve IVF outcome. However, women with endometriomas will have fewer eggs retrieved form the ovary regardless of whether endometriomas are present or have been removed. Thus, surgical removal prior to IVF is no longer advised.

Considering that ovaries with endometriomas will yield fewer eggs than those without,  ovarian reserve screening must be considered prior to attempting IVF. Diminished ovarian reserve associated with severe endometriosis is a common finding and will affect how we approach ovulation stimulation for IVF. Based upon findings, patients may desire to pursue other options such as egg donation.

As with all fertility diagnoses, we will provide a full fertility workup before starting treatment. We will evaluate all aspects of your care and create a treatment plan specific to your needs.

Reproductive Surgical Procedures

Infertility and pregnancy loss (miscarriage) can be the result of various anatomical disorders. These anatomical disorders can be congenital (birth defect), like a uterine septum, or acquired, like polyps, fibroids or adhesions (i.e., Asherman’s syndrome). Most of these anatomical conditions can be surgically corrected to improve reproductive outcome.

Overview of Laparoscopy and Hysteroscopy

Currently, the majority of reproductive corrective surgeries are performed in a minimally invasive manner using laparoscopy or hysteroscopy. With laparoscopy, the patient is given general anesthesia, and a camera is inserted into the abdomen through the umbilicus to visualize the abdominal and pelvic structures. Surgery is performed on the uterus, ovaries or fallopian tubes using special instruments introduced into the abdomen through 5 to 10 mm incisions.

With hysteroscopy, a camera is introduced through the cervix into the uterine cavity for visualization while the patient is under sedation or anesthesia. Surgery is performed on the inside of the uterus using special instruments that are introduced through the camera itself without making any incisions. Laparoscopic and hysteroscopic procedures offer patients the advantages of same day surgery, shorter recovery times and a sooner return to normal activities – as early as a few days with hysteroscopic procedures.

Reasons to Consult a Reproductive Endocrinologist

Infertile women who require reproductive surgery should seek treatment by trained reproductive endocrinologists since they:

  • Perform such surgeries on regular basis for optimal results
  • Offer trained eyes capable of detecting subtle abnormalities in a woman’s reproductive tract that may lead to infertility and
  • Are experienced in handling the delicate structures – ovaries, uterine cavity, fallopian tubes – of the female reproductive system

Surgical Procedures on the Uterus

The uterine cavity is where the embryo implants and grows throughout the pregnancy. Several conditions of the uterus may interfere with the implantation and growth of the embryo and lead to infertility or miscarriage. Some of these conditions can be surgically corrected to improve reproductive outcome.

  • Uterine fibroids are benign tumors of the uterus that are very common in women of reproductive age. Not all uterine fibroids need to be removed for a successful pregnancy. However, large fibroids, or those that are pushing against and distorting the uterine cavity, referred to as submucosal fibroids, need to be treated. Submucosal fibroids are commonly treated with hysteroscopy while other types of fibroids may need more extensive surgery.
  • Uterine polyps are another common structural disorder of the uterus that may interfere with achieving pregnancy. A uterine polyp is an overgrowth of the lining of the uterine cavity (the endometrium) and is most commonly benign in women of reproductive age. Uterine polyps can be easily missed on ultrasound and are often diagnosed using a special type of testing called saline infusion sonohysterogram. Uterine polyps are best removed with hysteroscopy since polyps often are missed when a dilation and curettage (D & C) is performed, which is a common practice.
  • Uterine scaring or adhesion (Asherman’s syndrome) can result from infections or prior surgery on the uterine cavity, most commonly D & C procedures. Uterine scaring can prevent pregnancy by preventing implantation of the embryo or can result in significant complications in a pregnancy by restricting the growth of the baby. Uterine scaring can be difficult to diagnose and once diagnosed, it is best treated with hysteroscopy. Treatment of uterine scaring with hysteroscopy requires advanced surgical skills due to the level of complexity of the procedure and the increased complication and failure rate.
  • Uterine septum is a birth defect of the uterus, which may not necessarily lead to infertility but is a known cause of recurrent miscarriage. A uterine septum is easily diagnosed with a three dimensional (3D) ultrasound. The uterine septum is best treated with hysteroscopy. Again, treatment of a septum requires advanced surgical skills due to the complexity of the procedure and increased complication and failure rate.

Surgical Procedures on the Ovary

Ovarian cysts are common in reproductive age women, and the vast majority are non-cancerous. Most ovarian cysts are transient and resolve in few months after being diagnosed. Some cysts (i.e., endometrioma, dermoid or cystadenoma) are persistent and may need surgery. Ovarian cysts are surgically treated with laparoscopy. To preserve the best chance of fertility, the surgeon must remove these cysts with the least damage to the ovary. Attention should be paid to removing the ovarian cyst wall with the least amount of surrounding healthy ovarian tissue affected.

Surgical Procedures on the Fallopian Tube

The two fallopian tubes on each side of the uterus “catch” the ovulated (released) egg from the ovary. Egg fertilization occurs when sperm are present in the tube. The fertilized egg becomes an embryo and starts dividing into cells and travels through the tube to enter the uterine cavity and implant. If the fallopian tubes are blocked, pregnancy fails to occur because sperm cannot reach the egg to fertilize it.

Conditions that may lead to tubal blockage include sexually transmitted diseases and pelvic infection, endometriosis, previous pelvic surgery and adhesion formation. Laparoscopy is used to diagnose and treat tubal disease. A skilled surgeon can restore tubal patency (openness) and function when the damage to the tube is not significant. Although patency of a profoundly damaged tube can be restored, its function is usually not. Severely damaged tubes are a risk factor for ectopic pregnancy (abnormal embryo implantation, typically in fallopian tube). Therefore, women with severely damaged tubes are advised to undergo  in vitro fertilization to achieve pregnancy.

Surgical Treatment of Endometriosis

Endometriosis is a condition where the cells of the endometrial lining grow in the abdominal cavity. Pelvic pain and painful menstrual cycles (dysmenorrhea) are two main symptoms of endometriosis. However, some women with endometriosis present with only infertility. Endometriosis can cause infertility by either affecting the tubal function or by causing pelvic adhesions. Endometriosis also can grow on the ovary and affect its function. Endometriosis is diagnosed and treated by laparoscopy.

Our physicians offer more than 35 years of combined fertility surgery experience. Equally important, we provide expansive diagnostic procedures prior to any surgical recommendation, ensuring the most appropriate treatment course for each patient.

Intrauterine Insemination

Intrauterine insemination (or artificial insemination as it is commonly known) involves the preparation of a highly concentrated sperm sample to be placed into the uterus at the time of ovulation. Depending on the infertility cause, IUI can be coordinated with your normal cycle or done in conjunction with ovulation induction medications. Each cycle is carefully monitored through office visits, ultrasound and blood work. The cost is relatively low for IUI, and it is usually the first step in low-tech treatment.

The IUI is performed by threading a very thin flexible catheter through the cervix and injecting washed sperm directly into the uterus. The procedure is similar to a Pap smear exam and can be done in the comfort of our center. The patient is encouraged to rest for a few minutes and then given instructions to contact our center if she does not start a period 14 days after insemination, at which point, we will test for pregnancy.

Ovulation Induction

Ovulation induction (OI) means to induce the ovaries to ovulate (release an egg) using oral medications and/or injectable hormones, collectively known as gonadotropins (hMG). Because the course of treatment depends on the woman’s ovulatory history, we perform a full workup to identify potential underlying conditions such as  polycystic ovarian syndrome or hormonal dysfunction (i.e., thyroid). We also evaluate for male factor infertility for a comprehensive approach to infertility diagnosis and treatment.

Women needing OI typically fall under two categories: 1) Those who ovulate irregularly or not at all and 2) Those who ovulate regularly and have normal menstrual cycles.

Women with Irregular Ovulation Cycles

Women in this category will start an oral medication – either Clomid (Serophene) of Femara (Letrazole) for five to seven days during a designated point in their cycles. Other medications (Metformin, Dexamethasone) may be added as required. For a woman who rarely ovulates, the goal of oral medication is to produce one egg (two at the most), based on the assumption that she is fertile but just doesn’t ovulate in a timely and predictable manner.

To ensure the medication goal is met and not exceeded, we perform a vaginal ultrasound on cycle day 12 or 14 to count the number of eggs the ovaries are producing and to measure the thickness of the uterine lining. With the goal being met, the patient receives a trigger shot (Ovidrel or Novarell) to encourage ovulation. An intrauterine insemination is performed two days after the injection. The patient then waits for her period. No menses by day 34 requires a phone call to our office. Depending on the patient’s age, four to eight months of OI may be indicated before considering more advanced treatment.

Women with Normal Ovulation Cycles

Women with normal menstrual cycles receive OI, as previously described, but with different medication goals. Because these women already produce one egg every month, the goal is to empirically stack the deck and stimulate the ovaries to produce more than one egg. The number of eggs desired should be at least two or more, depending on the woman’s age. For older women, three to four eggs are acceptable. Again, an ultrasound on cycle day 12 or 14 is required to ensure the medication goal is achieved and not exceeded in order to reduce the incidence of high order multiple births, which is an unavoidable risk of ovulation induction.

Women Who May Require Injectable Hormones

For women with hypothalamic amenorrhea (absence of menses due to hypothalamus dysfunction/hormone insufficiency) or women who have failed ovulation induction with oral medications, injectable hormones are an option. Using injectable hormones versus  in vitro fertilization (IVF) depends on many factors such as the woman’s age or the results of semen analyses.

Injectable hormone treatment requires more intensive monitoring of a woman’s response to the medications since they are more potent than oral medications. In addition to a greater risk of multiple births when compared to oral medications, there is a greater risk of the ovary twisting on its blood supply (torsion), which could become a surgical emergency, or ovarian hyperstimulation syndrome, which can be life threatening if severe. OI with injectable hormones requires five to seven office visits with daily blood work and ultrasounds. Typically, three to six cycles with injectable hormones are done before moving forward to IVF.

An important point to consider when choosing a fertility center for ovulation induction is that treatment requires attention seven days a week. Some women will need blood work or ultrasounds every day, including weekends. The Bethesda Fertility Center is open seven days a week, providing responsive, high quality care to ensure our patients receive the highest possible fertility success.

Acupuncture

For centuries, Eastern cultures have practiced herbal medicine and acupuncture for healing. Slowly, very slowly, Western medicine has opened its eyes to the incredible power of these Eastern practices. No longer is the concept of acupuncture for healing as foreign as it once was.

Can Acupuncture Help Infertility Patients?

The Bethesda Fertility Center became interested in acupuncture (where illness is considered energy disharmony) when working with women receiving donated eggs. These women must have the lining of their uterus hormonally prepared to be receptive to embryo implantation and pregnancy. Uterine readiness is determined by the thickness of the uterine lining. Some women, despite different hormonal preparations (Western style medicine), were not achieving thick enough uterine linings.

We became curious and through research learned that acupuncture might potentially solve this problem. After consulting with a local colleague, Dr. Peter Sheng, we learned that acupuncture could improve blood flow to the uterus, thereby thickening the uterine lining. Dr. Sheng explains that Chi energy flows through the body via the 14 meridians, and in various illnesses, energy flow is disrupted. With acupuncture, the energy flow can be redirected to specific organs. Now, we recommend our egg recipient patients to Dr. Sheng. Our Doppler readings have confirmed the effectiveness of acupuncture for this purpose.

How Can Acupuncture Help IVF Patients?

In addition to improving uterine lining thickness, a scientific study suggests that acupuncture can improve outcome for  IVF (in vitro fertilization) patients. We encourage all patients undergoing IVF to consider acupuncture during their IVF stimulation treatment. This is the time window where a benefit, if to be had, can best be realized.

We also encourage our patients to consider acupuncture for relief of the stress a woman’s body endures during treatment. We observed—and scientific literature later confirmed – that women who had undergone IVF previously and were stressed and perhaps even angry about failed treatment, all had a better sense of well-being when starting their next IVF cycle after receiving acupuncture. Whether they were successful or not, they tolerated the stress of the IVF cycle better.

We are happy to share the names of acupuncturists we feel can provide you the highest quality care and a relaxed and comfortable experience.

Recurrent Pregnancy Loss

Miscarriage, or pregnancy loss, before 20 weeks of gestation complicates 15 to 25 percent of all pregnancies. It is estimated that 25 percent of women will experience at least one pregnancy loss during their reproductive life. The miscarriage rate increases with a woman’s age.

The vast majority of miscarriages cannot be prevented, and most are due to developmental or genetic problems in the developing embryo. The earlier the pregnancy loss occurs, the higher the probability it is due to a genetic abnormality.

Recurrent pregnancy loss is defined by three or more miscarriages. Fewer than 5 percent of women will experience two consecutive pregnancy losses; only 1 percent will experience three or more. General causes of recurrent miscarriages include anatomic, immunological, genetic, endocrine, infectious, thrombophilic (tendency to form blood clots) and environmental factors.

Can I Still Carry to Term After Recurrent Miscarriages?

Recurrent pregnancy loss is emotionally stressful to patients, especially when a definitive cause cannot be found, which is true for a large percentage of cases. In the absence of an apparent cause, the prognosis is usually good with a live birth rate above 50 percent even after six consecutive pregnancy losses. We can also reverse the impact of several known causes through a variety of treatment options.

We are cognizant of the frustration and stress recurrent pregnancy loss causes for patients. Our goal is to perform scientifically-proven testing and treatment in a supportive environment that offers you the highest possibility of a successful pregnancy and birth.