Female Infertility Treatments

At InVia Fertility, our board certified reproductive endocrinologists offer a wide range of reproductive care, including:

Ovulation Induction

• Clomiphene citrate (Clomid, Serophene) treatment. Clomiphene citrate (Clomid® Serophene®): A pill that causes ovulation (the release of eggs from the ovary) by inducing the production of follicle stimulating hormone. This is commonly used to treat women with Polycystic Ovarian Syndrome (PCOS) or unexplained infertility. Patients take one to three tablets by mouth daily for five days (usually cycle days 5 - 9). They are monitored with ovulation predictor kits, ultrasound and/or blood tests to check for ovulation. On the appropriate day, ovulation is triggered with an injection of human chorionic gonadotropin (hCG) followed by intercourse or intrauterine insemination (IUI, see below).
• Gonadotropin treatment. These are fertility injections containing follicle stimulating hormone (FSH, Gonal-F, Follistim, Bravelle) or a combination of FSH and luteinizing hormone (LH) (Repronex, Menopur). They are used for ovulation induction in patients that do not ovulte on their own. They are also used for superovulation (controlled ovarian hyperstimulation) where the ovaries are stimulated to produce more than one egg to increase the chance of conception. The injections are started on cycle day-3 and continue for approximately 10 days based on ovarian reserve. The cycle is monitored with serial blood tests and ultrasounds. On the appropriate day, ovulation is triggered with an injection of hCG followed by intercourse or IUI.

Management of polycystic ovarian disease (PCO). In obese patients with PCO, diet and exercise remain the mainstay of treatment. Metformin (Glucophage XR) is a pill prescribed to women with insulin resistance and/or PCO. This drug is often used in diabetes, and helps lower levels of insulin. It often helps restore normal menstrual cycles in women who do not normally ovulate. A thorough discussion on PCO is included here.

Assisted Reproductive Technologies

In Vitro Fertilization (IVF)

A commonly performed fertility treatment where eggs are removed from the ovaries and mixed with sperm. Eggs that fertilize become embryos and are transferred to the uterus in hopes that a pregnancy will result. IVF is used to overcome a variety of fertility difficulties. These include cases in which the tubes are blocked or the sperm count is low. IVF is also used in cases where the woman has decreased fertility potential, based on age or other causes. IVF is also used frequently in couples with "unexplained" infertility. This occurs when all the testing is normal, but a pregnancy has not resulted despite trying for 6 or more months.

Intracytoplasmic sperm injection (ICSI)

Intracytoplasmic sperm injection (ICSI) is a laboratory procedure whereby, using micromanipulation, a single sperm is injected directly into the cytoplasm of a mature egg. This process increases the likelihood of fertilization when there are abnormalities in the number, quality, or function of the sperm or when there are problems with sperm penetration of the egg. ICSI must be done in conjunction with an in-vitro fertilization cycle.

Who benefits from ICSI?

• Couples diagnosed as infertile due to male factor infertility. There are several conditions that can cause male factor infertility. Sperm can be completely absent in the ejaculate, a condition known as azoospermia or men can present with very low concentrations of sperm in the ejaculate, a condition known as oligospermia. Asthenospermia, which is poor sperm motility, occurs when the sperm do not have the forward swimming motion needed to unite with the egg in the female oviduct. Men with male infertility may also have a condition known as teratospermia, which is an increased percentage in abnormally shaped sperm. There may also be problems with the function of the sperm, decreasing their ability to bind and/or to fertilize the egg.
• Patients who have had failed natural fertilization during a previous IVF cycle. This may occur even though the male partner appears to have normal sperm counts, motility, and morphology.
• Patients using frozen sperm that may be limited in number and/or quality.
• Diagnosis of antisperm antibodies bound to spermatozoa or female antisperm antibodies that are thought to be the cause of infertility.
• Patients who have a low number of eggs and want to maximize their chances of fertilization.

Intrauterine insemination (IUI) or artificial insemination

An IUI is performed when a woman is releasing eggs (ovulating). The sperm that will be used for insemination will either be produced by the male partner or will be obtained from a sperm donor, depending on your treatment plan. Sperm produced by the male partner will be washed with a special solution in the laboratory. The sperm will be injected into the uterus using a thin tube (catheter) attached to a plastic syringe. IUI is often an effective treatment for diagnosis of poor motility (sperm swimming ability) or if there is an ejaculatory problem. The effectiveness of an IUI is naturally higher if sperm parameters are within the normal limits. Results depend on the age of the female partner, diagnosis and the treatments done in conjunction with IUI.

Assisted Zona Hatching (AZH)

Assisted Zona Hatching (AZH) is a procedure that, in select patients, may help to increase the chances of embryo implantation and pregnancy. The preimplantation embryo is surrounded by a protective "shell" called the zona pellucida. This shell is necessary for embryo development up to the blastocyst stage (about day 5). Once the blastocyst has been formed, the embryo must break free (hatch) from the zona pellucida in order for implantation and pregnancy to occur.

AZH is a micromanipulation technique performed when the embryo is at Day 3 of development. The embryos are usually between the 6 to 8 cell stage. During the AZH procedure, a hole is created in the zona of the embryo using a laser. This is done a few hours before the embryo transfer. This gap in the embryo's zona facilitates the embryos ability to hatch free of the zona pellucida when it expands as a blastocyst in the uterus. One potential explanation for failure of implantation is that the embryo is unable to escape from the zona pellucida.

Who benefits from AZH?

Assisted hatching is most useful for the following types of patients:

• Patients who are older than 38 years of age
• Patients with elevated levels of follicle stimulating hormone (FSH)
• Patients whose embryos have a thicker than normal zona pellucida, as measured by trained embryologists
• Patients who have had multiple previous IVF attempts with failed implantation

What are the benefits of AZH?

Assisted hatching may increase the probability of embryo implantation, thereby increasing the chance of achieving pregnancy through IVF.

What are the risks of AZH?

There is a small risk of damaging the embryos during the assisted hatching procedure. All embryologists performing AZH at InVia Fertility are fully trained in the practice of AZH making the risk minimal.

Cryopreservation of Embryos

In couples with extra embryos after an embryo transfer, these may be cryopreserved (frozen) for future use. Cryopreservation makes future fertility treatment cycles simpler, less expensive, and less invasive than the initial IVF cycle, since a frozen cycle does not require ovarian stimulation or egg retrieval. Once frozen, embryos may be stored for many years. Couples should decide if they are going to cryopreserve extra embryos before undergoing IVF.

Cryopreservation of Eggs

Whereas we have been freezing sperm and embryos successfully for decades, it is only recently that it has been possible to freeze eggs. Eggs are relatively fragile and are unable to withstand the freezing process. It is only with the development of a new technique called "vitrification" which makes it possible to freeze eggs without damaging them. Candidates for egg freezing include patients diagnosed with cancer that are going to undergo treatments (chemotherapy, radiotherapy) that may damage the eggs. It is also possible for women to freeze their eggs if they are worried about time "running out" and they are not ready to have a baby.

Preimplantation Genetic Diagnosis (PGD)

PGD involves taking a single cell, or blastomere, from a developing embryo and testing it for genetic disease or chromosomal abnormality. As a result, for an increasing number of genetic conditions, PGD allows only those embryos diagnosed as being free from the genetic condition to be transferred back to the uterus for implantation and possible pregnancy.

Who Benefits from PGD?

Both fertile and infertile patients can benefit from PGD technology. PGD is an excellent resource for those patients who:

• Are at risk of transmitting genetic diseases to their children. PGD was developed to test the embryo for genetic conditions in which the specific gene involved was known. Single gene disorders, such as Tay Sachs, Huntington's disease, Cystic Fibrosis, and Muscular Dystrophy are some examples; they are passed down in families from the mother or the father.
• Are older than 35 years of age. The sperm and the egg each contribute 23 chromosomes to the resultant embryo for a total of 46 chromosomes (23 pairs), including the sex chromosomes. If there is an extra chromosome present or a chromosome is absent, termed aneuploidy, that embryo is considered genetically abnormal. With advanced maternal age (>35 years old) there is an increased risk of a pregnancy having aneuploidy. The most talked about aneuploidy in women with advanced maternal age is Down's syndrome. This occurs when there are 3 copies of chromosome 21.
• Have had repeated miscarriages. Using PGD we are able to test for 7 chromosomes, #13, 16, 18, 21, 22, and the sex chromosomes X and Y. An extra copy of certain chromosomes (#13,16,18,22) can result in miscarriage or birth of a baby with very serious birth defects that are usually incompatible with life.
• Have been found to be "balanced translocation" carriers. This person has a complete set of 23 pairs of chromosomes (46 in total) and appears healthy, however, 2 of the chromosomes have exchanged pieces. This does not cause any apparent problem in the individual until that time they start trying to conceive. It is possible for the resultant embryo of this person to be an "unbalanced translocation" carrier. Miscarriage is very common in this scenario, however birth of a baby with varying degrees of birth defects is possible.

When is PGD performed? PGD must be done in conjunction with an IVF cycle. After fertilization in the laboratory, the resultant embryo is allowed to grow up to day 3. Specially trained embryologists then perform the biopsy and the cell is analyzed either by Fluorescent In Situ Hybridization (FISH) or Polymerase Chain Reaction (PCR). The embryos diagnosed as normal will then be transferred back to the uterus and/or cryopreserved on day 5 at the blastocyst stage of development.

Donor Oocytes. Some women are unable to produce healthy eggs and achieve pregnancy. In many situations, the use of donor eggs is the only option to help infertile women experience the joys of parenthood.

Reproductive Surgery

Sometimes, anatomical problems may be the cause of infertility. If your physician suspects this is the case, surgery may be the recommended initial treatment to improve the chances of conception. The various surgical techniques include hysteroscopy, laparoscopy or laparotomy (see below for details).

Surgical Treatments

• Endometriosis - The treatment of endometriosis depends upon its severity. If the endometriosis and symptoms are severe, you may require surgery to remove the endometriosis. The treatment may involve laparoscopy. In this procedure, two to four small incisions are made in the lower part of the abdomen and a laparoscope, a tiny camera, is used to examine the pelvic cavity. The endometriosis is removed using microsurgical techniques.
• Adhesions - Adhesions are areas of scar tissue that can occur within the uterus or the pelvis. Pelvic adhesions may be diagnosed and treated with laparoscopy. The laparoscope is inserted into the pelvic cavity through a tiny incision made just below the woman's navel.
  
  Adhesions in the uterus may be diagnosed using an x-ray procedure called hysterosalpingography (HSG) or an ultrasound technique known as hysterosonography (HSN). Once diagnosed, a surgical procedure known as hysteroscopy may be used to remove the adhesions. During this procedure, a hysteroscope (a thin telescope-like instrument) is inserted through the cervix to view the uterine cavity. The adhesions may then be removed using microsurgical techniques.
  
  
• Fibroids - A hysterosonogram may be conducted to detect if there are any fibroids. During this procedure, a small amount of sterile saline is injected into the uterus by passing a small catheter through the cervix. An ultrasound is then performed. This test is usually done in the office. Twenty percent of women have fibroids and most do not need surgery. Generally, only fibroids that are in the uterine cavity need to be removed. Myomectomy is the name for the surgical procedure in which the fibroid tumor or tumors are removed. The number, size, and location of the fibroid(s) are some of the variables based on which the type of surgery to be performed is selected. For small fibroids that are within the uterine cavity, your physician may recommend operative hysteroscopy. For patients with large and or multiple fibroids, major surgery involving opening the abdomen with an incision (laparotomy) may be recommended. Sometimes, a less invasive procedure called laparoscopic myomectomy is possible. This procedure offers a much shorter recovery time.
• Hydrosalpinx - In patients with severe tubal disease the tubes may be swollen like a balloon (hydrosalpinx). Patients with hydrosalpinges usually require surgical treatment which may involve repair (tuboplasty) or removal of the tubes (salpingectomy). Recent research has confirmed that hydrosalpinges have a negative impact on success rates with IVF. Your physician, therefore, may recommend tubal surgery prior to an IVF attempt.

Recurrent Pregnancy Loss

Recurrent pregnancy loss is defined by two or more failed pregnancies. Depending on how far along the pregnancy was at the time of the loss, the medical background of the male and the female, and other factors, an evaluation will be undertaken. This evaluation will attempt to determine the cause of the losses, and will be used to develop a treatment plan to prevent future losses. In up to half of couples, despite a thorough evaluation, no cause will be found.

Among the various causes of pregnancy loss are the following:

• Genetic/Chromosomal Causes - Translocation (when part of one chromosome is attached to another chromosome) is the most common inherited chromosomal abnormality. Although a parent who carries a translocation is frequently normal, their embryo may receive too much or too little genetic material. When this occurs, a miscarriage usually occurs. Couples with translocations or other specific chromosome defects may benefit from pre-implantation genetic diagnosis (PGD) in conjunction with IVF.
• Age - The chance of a miscarriage increases as a woman ages. After age 40, more than one-third of all pregnancies end in miscarriage. Most of these embryos have an abnormal number of chromosomes.
• Hormonal Abnormalities - Progesterone, a hormone produced by the ovary after ovulation, is necessary for a healthy pregnancy. Low progesterone levels, often called luteal phase deficiency, may cause repeated miscarriages. Treatments may include ovulation induction, progesterone supplementation or injections of human chorionic gonadotropin (hCG).
• Metabolic Abnormalities - Women with diabetes improve pregnancy outcomes if blood sugars are controlled before conception. Women who have insulin resistance, such as obese women and many who have polycystic ovarian syndrome (PCOS), also have higher rates of miscarriage. Uterine Abnormalities - Distortion of the uterine cavity may be found in approximately 10% to 15% of women with recurrent pregnancy losses. Diagnostic screening tests include hysterosalpingogram, ultrasound, or hysteroscopy. Congenital uterine abnormalities include a double uterus, uterine septum, and a uterus in which only one side has formed. Asherman's syndrome (scar tissue in the uterine cavity), uterine fibroids, and possibly uterine polyps are acquired abnormalities that may also cause recurrent miscarriages. Some of these conditions may be surgically corrected. Antiphospholipid Syndrome - Blood tests for anticardiolipin antibodies and lupus anticoagulant may identify women with antiphospholipid syndrome, which causes up to 15% of recurrent miscarriages. In women who have high levels of antiphospholipid antibodies, pregnancy outcomes are improved by the use of aspirin and heparin (a blood thinner).

Gestational Surrogacy

In patients with problems involving the uterus (hysterectomy, fibroids, severe adhesions, recurrent miscarriages) it is possible to have a baby using another woman as a surrogate. Embryos created with the couples egg and sperm are transferred into the carrier (whose uterus has been prepared using hormones).