Determining the Cause of a Couples Infertility
One of the most frequent concerns conveyed on this web site involves the thought by many that their infertility evaluation, carried out attempting to uncover the "cause" of an infertility problem, may have been incomplete or may have overlooked something.
There are many valid approaches to the work up of a couple who have been unsuccessful in their attempts to become pregnant. While the angle of the approach to a fertility problem may vary from physician to physician, and from Center to Center, it is generally felt by us that there are certain "basics" to be investigated in nearly every couple with an infertility condition. These baseline studies may be slightly modified based on the initial history of the couple involved, but in general, the items presented here are considered very important to us in the study of nearly all couples.
While reading this, it is important to remember that these are generalized protocols and the studies mentioned may not be applicable to every couple. These suggestions represent the protocols in effect at our Centers, and they are not meant to indicate a suggested treatment course. You should always attempt to obtain the most qualified medical help available and work together with your health care providers to obtain the highest quality opinions about your workup. And of course remember that we remain at your service at any time should you elect to see us for an initial evaluation, for a second opinion or after failed treatment elsewhere. We specialize in reevaluating those that have not achieved success in their earlier treatment attempts.
Summary of an Infertility Work Up
At the Fertility Institutes, we ask new patients to complete a very detailed medical history questionnaire prior to presenting for their first appointment. These history forms are forwarded to patients in advance to allow them adequate time to complete the forms at home and to obtain the very detailed information asked for. We include questions related to the patient, details of the pregnancy of the patient's mother (both husband and wife), fertility histories of the patient, brothers, sisters and immediate family members. We question very closely about life styles and diet, history of "health food" ingestion, vitamin history, and any history of food supplement use (herbs, etc.). Questions about possible occupational exposures to hazardous environments or chemicals and high stress environments are included. Possible detrimental effects on fertility of all of the above have been reported. A sexual history is obtained and the correction of any misconceptions or misinformation is carried out and cleared up.
After a complete history has been obtained, we outline a detailed, intense diagnostic program to allow us to arrive at a rapid diagnosis of the underlying fertility problem. While many variations of the protocol are employed to account for items uncovered in the history, we always begin with baseline studies that, if not recently performed elsewhere, include the following:
Vaginal and cervical viral and bacterial cultures
These are used to detect any possible adverse infections that may be interfering with conception.
Semen analysis and semen cultures
Various test to determine if the male is contributing to the infertility
Sperm penetration and sperm function studies
Including genetic and electron microscopy studies where indicated.
Female gonadotropin and other pituitary and ovarian hormone studies
Some of these studies are performed on the third day of the menstrual cycle in order to allow comparison to fertile "control" subjects whose blood was evaluated on the same day 3. Ohter studies such as aMH (anti-mullerian hormone) may be obtained at any point in the menstrual cycle. These studies also include thyroid function studies, and evaluations of the adrenal gland, ovaries, lactation hormones and the uterus.
This X-Ray examination is able to uncover many abnormalities in the lining and configuration of the uterus, as well as demonstrating the fallopian tubes and detecting any partial or complete blockage of the tubes. Scarring around the tubes and ovaries can often be detected as well.
Midcycle testing for the "LH surge"
The LH surge is the brain's signal to the ovaries ordering release of the mature egg. Our patients are asked to monitor their urine at home in anticipation of the LH surge that will occur just prior to ovulation. When the patient detects her LH surge, she is asked to have intercourse in the morning, and then is brought in later that day for several very important timed studies:
Post-coital (after intercourse) examination
A small drop of cervical mucus is taken from the cervix and examined under the microscope for the presence of live, active sperm.
Midcycle estradiol (E2) and ultrasound
The LH surge signals the bodies "satisfaction" with the status of the mature oocyte (egg). The accuracy of this "decision" by the body is tested by looking at the follicle that contains the egg with ultrasound, as well as by measuring the amount of estrogen (estradiol) that the granulosa cells that nurse the egg are producing. The uterine lining can be seen with ultrasound, and measured to assure that the lining has developed to an adequate degree to support a new pregnancy should one arrive. These are crucial studies and are often found to be abnormal in many patients with otherwise "normal" study results.
Luteal phase Progesterone level
One week after ovulation, the "scar" left over after the egg releases from the ovary should be producing abundant quantities of Progesterone. Progesterone performs many crucial functions in the second half of the menstrual cycle. It signals the uterus that ovulation has occurred and prepares the uterus for implantation of the new conceptus, should it arrive. It aps vital hormonal support to the uterine lining, preventing premature breakthrough bleeding or "spotting" . Patients with abnormal Progesterone levels may actually conceive, but lose their early pregnancies before they ever know they were pregnant. This condition can usually be detected and corrected with careful monitoring.
A small fragment sampled from the lining of the uterus just before the end of a menstrual cycle can reveal important information about the response of the uterus to all of the hormonal signals that have occurred during the cycle. We ask a pathologist to evaluate the biopsy under the microscope, and to "date" the uterine lining to test for an appropriate response to the hormone signals delivered during the cycle. An "out of sync" uterine lining is a correctable condition that can cause major infertility problems if undetected or untreated.
his is a hybrid procedure combining the advantages of the hysterosalpingogram with ultrasound while avoiding any exposure to X-Ray. The sonohysterogram is able to clearly outline many common abnormalities of the uterine cavity including the polyps, fibroids and adhesions or scarring.
All of the above represent a sampling of some of the initial studies that we obtain on nearly every patient. As results become available on each study, those results may lead to the need for apitional studies. Each fertility problem should be approached as a unique challenge, and should be afforded a complete, highly detailed evaluation. Success rates rely upon the establishment of an accurate diagnosis. We feel that patients should always be provided their underlying diagnosis, and should use that information to assist them in their own evaluation of any proposed treatment plans.
Summary of Treatment Options
All services at the Fertility Institutes are offered on a seven day a week basis. The Fertility Institutes are registered with the American Society of Reproductive Medicine (ASRM). We maintain an active membership to the Society of Reproductive Technology (SART), and report all treatment outcome statistics to the Society. We were responsible for the first ICSI assisted birth in the Western United States and have continued to maintain state of the art treatment options for our patients at costs that remain highly affordable. Financing for many of our programs is available in many instances. Treatment options are as follows:
Artificial Insemination: Intracervical, intrauterine, intraperitoneal
These procedures are utilized to treat a variety of fertility conditions that may include poor cervical mucus production resulting from previous cervical surgery (freezing, cone biopsy, LEEP), cervical antibodies being produced against sperm, diminished sperm motility and donor sperm placement. Intraperitoneal insemination (IPI) has shown high pregnancy rates in some women who have failed to concieve with other forms of insemination and is always considered by us prior to moving on to more costly and invasive procedures. With IPI, treated sperm are injected by way of the vagina, directly into the pelvic cavity where eggs are released. A very small catheter is used to avoid discomfort.
Gradient Sperm Washing, Filtration and Improvement
Highly effective, inert density solutions are commonly used to prepare sperm for In Vitro Fertilization and related procedures with excellent success. Though more costly and time consuming than other methods for preparing sperm for artificial insemination, it is the method utilized in nearly all of our standard sperm preparations for artificial insemination. This method produces a purer sperm sample with increased motility and fertilizing capacity.
Testicular Sperm Aspiration (Extraction) MESA, PESA, TESA, Including for Failed Vasectomy Reversal
Our urologists, together with our Reproductive Endocrinologists are able to successfully aspirate or extract sperm directly from different areas of the testicle, and use this sperm to microinject (ICSI) a single sperm directly into the harvested eggs of the female. Using these methods, pregnancies and births are now possible with sperm from men who have had vasectomies, have had unsuccessful or failed vasectomy reversals, and in those men with an absence of the vas deferens, and those with extremely low sperm counts (less than 1 million), very poor motility (less than 2%) or, in some cases, even men with no sperm motility or no sperm seen in the ejaculate. We offer comprehensive descriptions of these procedures over the phone, and you are invited to call for more details. We also provide electroejaculation procedures for men with ejaculatory dysfunction resulting from a variety of causes including spinal cord injuries. All of our facilities provide full access for the disabled. MORE ON MESA, TESA, TESE, PESA
Controlled Multiovulation (Fertility Drugs), Including the GnRH Infusion Pump for "Single Egg" Production
We are one of the largest users of native (natural), pulsatile infusion GnRH for the production of single healthy eggs in women with hypothalamic amenorrhea who do not ovulate regularly. By employing very small, portable automated infusion pumps, very tiny doses of fertility medication can be administered in small pulses around the clock. This method more accurately simulates what occurs in a "natural" cycle, and largely avoids the chance of a multiple pregnancy resulting.
Immature Oocyte Harvest
The harvest and culture of immature oocytes is under active development by our program. We have yet to see significant encouraging results from programs carrying out this procedure. Our initial investigational efforts have shown promise but we will wait until further safety and outcome data become available prior to undertaking this procedure clinically. We update our Web site frequently and will report to you developments in the field. (Updated 4/98).
Secure embryo cryopreservation (freezing & storage)
Our entire fertility laboratory is licensed by all appropriate agencies. We hold a valid California Tissue Bank License assuring ongoing compliance with all safety, security and methodology requirements for the handling and cryopreservation of patient specimens. All Nevada State requirements have been met as well.
Oocyte Micromanipulation: ICSI, Assisted Hatching, Preimplantation Genetic Diagnosis
The Fertility Institutes perform highly successful micromanipulation procedures. We achieved the first successful ICSI derived pregnancy in the Western United States as well as the first multiple pregnancy from purely ICSI derived embryos. Our ICSI success has been extended to men with sperm counts far less than 1 million and to patients who had previously failed multiple earlier IVF attempts at other programs.
Immunology, Antibodies and Miscarriage Prevention
We offer complete couple tissue type compatability testing through our association with a leading immunology laboratory. We work closely with the country's leading immunology experts, and offer full laboratory testing that includes preparation for and administration of paternal leukocyte immmunization, aspirin/heparin/prednisone protocols as well as a variety of cutting edge methods to both improve pregnancy outcome associated with advanced fertility procedures, as well as to prevent pregnancy loss from occuring.
Dr. Jeffrey Steinberg