An Overview of Basic Infertility
Infertility diagnosis is an overwhelming experience for patients. Not only are they faced with the news that conception of a child may be only possible through medical treatment, they are also presented with information that is totally new to them. New medical jargon along with recommendations for treatments and tests that are completely unfamiliar can be very intimidating for the newly diagnosed. Servicios Medicos Reproductivos de Tijuana believes in creating a partnership with the patient and we have found that the most successful partnerships occur when the patient is well-informed and can play an active role in their treatment. We value an open and ethical relationship with each patient in an environment that fosters trust and mutual respect, an environment where questions are welcome and encouraged as well.
This web site is dedicated to educating the patient about infertility. You will find basic information about diagnoses, testing procedures and pregnancy tools along with a glossary of infertility terms and medical articles related to specific conditions and treatment options. If you have additional questions after reading this information, please ask your physician or send us an e-mail.
Infertility is a condition which affects the reproductive system, in either a male or a female, decreasing the ability to conceive and deliver a child. Infertility is the inability to conceive after one year of trying with unprotected intercourse for couples in which the female is under 35 and six months of trying for couples in which the female is over 35.
Infertility is not just a medical problem and you are not alone in your battle. One in six couples in the United States are affected by infertility and many of those people deal with medical, psychological and financial stresses related to their condition. At Servicios Medicos Reproductivos de Tijuana, the medical team plays an active role in the treatment of each patient. We work together with the patient and partner as a team to develop a treatment plan that will make the best use of the resources available to solve the problem as quickly, safely and inexpensively as possible.
There are a number of factors, both male and female, that can cause infertility. In fact, in nearly 30% of cases the cause is attributed to the female, in 30% the cause are attributed to the male; in 30% the cause is attributed to both and in 10% of cases the cause is unknown. Once the cause of infertility has been determined, a plan can be customized for the patient to fit their unique situation and move them along on the path to conceiving a child. In fact, nearly 90% of infertility cases are treatable with medical therapies such as drug treatment, surgical repair of reproductive organs and assisted reproductive techniques such as in vitro fertilization.
When to look for medical treatment for infertility? If you are under the age of 35 and you and your partner have been trying to conceive for one year without success; or if you are over the age of 35 and have been unsuccessful after trying to conceive for six months, it is time to seek medical treatment for infertility.
The first step is to have an infertility evaluation. We realize that most patients have limited resources so our philosophy is to treat patients as quickly, effectively and inexpensively as possible to make the best use of all available resources. The main concern during the evaluation is to only conduct the tests that will give the physician clues to the cause of infertility and ultimately lead to the development of an effective treatment plan. There are a number of tests that have traditionally been run as part of the initial work up but may be unnecessary in many cases, such as the diagnostic laparoscopy, post coital test and endometrial biopsy.
The results of the evaluation lead the physician to determine the cause of infertility which is most often related to age, endometriosis, ovulatory dysfunction, tubal factor, uterine, male factor, unknown or a combination of any of these factors.
History and Physical
The first step for many couples seeking medical treatment for infertility is to discuss their infertility with an OB/GYN. The doctor will review the couple’s medical history and conduct a complete physical on the female. The evaluation of the male’s medical history includes a discussion of previous pregnancies, developmental problems, surgeries, testicular trauma or infections and environmental exposure and at least one semen analysis. The female medical history includes review of previous pregnancies, painful periods or pelvic pain, infections and previous surgeries. The age of the patient must be taken into consideration when developing a cost-effective, medically appropriate evaluation and treatment plan. While there is little necessity to initiate aggressive therapy for a 20-year old with unexplained infertility, those over 35 deserve a more aggressive approach.
Based on the results of the medical history evaluation and physical, the OB/GYN will often recommend that the couple see a reproductive specialist for a routine infertility work-up to determine the cause of infertility. After the cause is determined, your physician will develop a specific treatment based on your diagnosis to help you conceive.
Hormonal studies measure the levels of certain hormones produced by your body during each menstrual cycle. Hormones affect every step necessary in achieving pregnancy from stimulating the development of an egg to ovulation and implantation of a fertilized egg in the uterus. If the hormones that affect fertility are not produced in specific amounts at specific times during your cycle, your chances of conceiving a child may be greatly inhibited.
Your physician may run tests to determine the levels of the following hormones that play a role in ovulation and implantation of the egg:
The overproduction of the following hormones can negatively affect ovulation:
A hysterosalpingogram is an X-ray of the uterus and fallopian tubes which allows visualization of the inside of the uterus and tubes. The picture will reveal any abnormalities of the uterus as well as tubal problems such as blockage and dilation (hydrosalpinx). If sterilization reversal is planned, the point at which the tubes are blocked can be seen. This helps to plan the reconstructive procedure.
If the tubes are not blocked by scar tissue or adhesions, the dye will flow into the abdominal cavity. This is a good sign but it does not guarantee that the tubes will function normally. It does give a rough estimate of the quality of the tubal structure and the status of the tubal lining. Some cases where the tubes appear to be blocked where they join the uterus may in fact be normal. Often blockage at this location may be due to spasm of the opening from the uterus into the tube or from accumulated debris and mucus blocking the opening. This can be managed by passing a thin catheter into the fallopian tube either at the time of hysterosalpingogram or during a hysteroscopic procedure.
A hysterosalpingogram may also indicate endometrial polyps, submucus fibroids, intrauterine adhesions (synechia), uterine and vaginal septa, uterine cavity abnormalities, or the after-effect of genital tuberculosis. The hysterosalpingogram may or may not be able to detect pelvic adhesions, mild hydrosalpinx, small polyps, endometriosis, tubal phimosis (clubbing of the fimbria at the end of the tube), or immotility of the tube. Other tests, such as hysteroscopy saline sonohysterography or laparoscopy may be necessary to accurately evaluate your uterus. Although the purpose of the hysterosalpingogram is not therapeutic, sometimes forcing dye through the tube will dislodge any material which blocks it. A number of women have become pregnant following a hysterosalpingogram without further treatment.
Generally there is no special preparation needed for this test. However, depending upon your diagnosis, you may need to take antibiotics to guard against possible infection. To ensure that you are not pregnant, the study is done between Day 7 and 10 of your cycle. Prior to the procedure you may take an anti-inflammatory medication (Aleve or Motrin). A small catheter is placed into the cervix and the dye is injected. You may feel heavy cramping during, and for several hours following this procedure. Expect a sticky vaginal discharge for a few days as the dye is expelled from the uterus. Use a pad or panty liner during this time to allow fluid to escape. Any dye that remains will be absorbed without any ill effect.
NOTE: Be sure we are aware of any allergies you may have to Iodine, Betadine, or Novocain prior to the procedure.
If cramping does not subside or if you develop severe abdominal pain or fever following this test, please notify Determining Diagnostic course After Normal Hysterosalpingogram
Women failing to conceive within one year after a normal hysterosalpingogram demonstrate a high incidence of pelvic pathology with laparoscopy. To assess the intraluminal environment of the fallopian tube and endometrium the hysterosalpingogram (HSG) is used. However, its ability to evaluate other pelvic pathologies is limited. Laparoscopy (LSC) in conjunction with the HSG will accomplish this. Various studies have indicated the discrepancies between the findings of HSG and LSC in the same patient. Therefore, some researchers recommend LSC as the initial assessment tool.
Most physicians agree that abnormalities discovered with HSC be followed up with LSC and/or hysteroscopy, but there are questions as to what the follow-up should be for patients with a normal HSG.
Bruce Carr M.D. et al., evaluated infertile couples with a normal HSG and assessed their subsequent fertility rates, their laparoscopic findings after a normal HSG, and their historical data (“Infertile Couples with a Normal Hysterosalpingogram,” Journal of Reproductive Medicine, January 1995; 40:19-23).
Of the 132 couples with a normal HSG, 29% achieved a pregnancy without having a LSC. There was a fourfold higher pregnancy rate during the first three months post HSG than any other three month period. The pregnancy rate after LSC was 35%.
Carr and associates indicate that their study “supports the hypothesis that women failing to conceive within one year after a normal HSG have a high incidence of pelvic pathology at LSC. If pregnancy did not ensue following a normal HSC, LSC revealed pelvic pathology in 50-60% of cases. Proper timing of LSC is essential … because of the potential therapeutic effect of HSG.” Their study revealed that this effect was achieved by performing HSGs with water-soluble contrast media.
Carr and associates offer some guidelines for timing LSC after a normal HSG. In the women who conceived after HSG but before LSC, the majority of pregnancies occurred in the first three months after the HSG. Also, an increased number of abnormal findings was found on LSC when there was an increase in the time elapsed between the HSG and the LSC.
Some tubal diseases are acquired, so their incidence may increase over time. Their recommendation suggests a waiting period of three months after a normal HSG before performing a LSC. In women who have not conceived by one year after HSG, LSC is warranted because of the high incidence of pelvic pathology.
Fibroids, scar tissue, endometriosis and blocked fallopian tubes are all causes of female infertility.Laparoscopy is a surgical procedure that allows a physician to examine your uterus, ovaries and fallopian tubes to determine if any of those causes are present.If your physician determines the cause of infertility during the procedure, it may often be treated on the spot with a surgical instrument inserted through a small incision in your lower abdomen.
In cases of severe tubal disease or scar tissue, in vitro fertilization may be your best option for conceiving a child.
You can expect to feel sore and tired for a few days following the procedure. You may feel pains caused by gas bubbles from the procedure in your shoulders and under your diaphragm.You will most likely have three or four scars resulting from the procedure – one in your navel and others in your lower abdomen.Infection is rarely seen after laparoscopy. Signs of infection include fever, swelling or redness around the incision or stitches, burning during urination or frequent urination and discharge from the incision.
Post Coital Test
Near the time you ovulate each month, estrogen production from the ovaries stimulates mucus production by your cervix. Sperm must penetrate and swim through this mucus, then travel through the reproductive tract to reach the egg for fertilization. In some cases, there is an incompatibility between the sperm and the cervical mucus, causing the sperm to become immobile or die, thus preventing fertilization. The postcoital test (PCT) evaluates the interaction between the sperm and your cervical mucus at a time near ovulation to determine if an incompatibility exists. Abnormal mucus may occur because of infections, surgery or clomid therapy. The PCT is a poor predictor of pregnancy success, but may be useful to determine the need for intrauterine insemination. If it is done too early before ovulation or too late after, the results may be falsely abnormal.
Each month, your endometrium, the lining of your uterus, grows thick with blood vessels, glands and stored nutrients around the time of ovulation to allow a fertilized egg to implant and grow. If no fertilization occurs, the thick lining sheds as menstrual flow. Two hormones, estrogen and progesterone, control the growth and stabilization of the endometrial tissue and if your body does not produce enough of these hormones your uterus may be unable to support a fertilized egg.
An endometrial biopsy is a test performed to evaluate the endometrial tissue that lines the walls of the uterus to determine if your body is producing enough estrogen and progesterone. However, ovulation induction treatment, which is usually part of most fertility treatment plans, corrects this problem if present. As such, little information is actually gained from an endometrial biopsy. Newer tests such as integrin vB3 or endometrial function not traditionally performed along with the endometrial biopsy may provide additional information regarding implantation. If the endometrial biopsy is performed, it should be done 11 to 13 days after a positive ovulation predictor test result. The physician will place a speculum inside your vagina, insert a small catheter through your cervix into your uterus and remove a small sample of your endometrial lining. The sample will then be sent to a pathologist who will examine your endometrial tissue under the microscope. The procedure only takes a few seconds but it may take up to two weeks to receive the results of the test. During the procedure, you may experience a pinch or slight cramping. You may have mild cramps following the procedure along with light bleeding and spotting.
Routine Fertility Workup
Provided by InterNational Council on Infertility Information Dissemination (INCIID)
The following is a listing of tests generally included in a routine fertility work-up. Please note that every reproductive endocrinologist (RE) has his or her own standard protocol, and the following is intended to be a basic guideline.
If you are not seeing an RE and your OB/GYN does not have the facilities to conduct these routine tests, you should seriously consider switching to a doctor who does. Minimally, a doctor treating fertility patients should have the following:
1. Availability of staff and technicians seven days per week. If your doctor or clinic does not offer weekend and holiday hours, you are clearly not in the hands of someone whose priority is helping you get pregnant.
2. An on-site, certified lab to do semen testing and prep for IUIs and post coital tests, as well as facilities to do E-2, blood HCG beta and progesterone tests.
3. Transvaginal ultrasound equipment. You should not undergo clomid, metrodin or pergonal treatment unless this equipment is available for routine monitoring. Though many OBs prescribe Clomid without doing this monitoring, it is in your best interest to have periodic ultrasounds to ensure that the Clomid is indeed stimulating ovulation and that the follicles are releasing the eggs. Under no circumstances should a patient undergo metrodin or pergonal treatment without ultrasound monitoring. If you are using intra-uterine insemination (IUIs), ultrasounds are required for accurately timing insemination with ovulation.
YOUR FIRST APPOINTMENT: Try to schedule your first appointment with your RE during the first week of your cycle. This will enable him/her to take baseline levels of FSH (follicle stimulating hormone) and LH (lutenizing hormone). Most REs also do routine screening of both partners—AIDS, hepatitis, etc. Medical histories for both partners will be taken. Try to keep track of the length of your menstrual cycles for several months beforehand. Charting Basal Body Temps (BBTs) for several months will also give your doctor some insights—as will using home Ovulation Predictor Kits and recording the results.
YOUR SECOND APPOINTMENT: This appointment should be scheduled on the day of LH surge—BEFORE ovulation. In most cases, you will be directed to use home ovulation test kits and call for an appointment on the day you detect a surge. Included in this exam will be:
CERVICAL MUCUS TESTS: including a post-coital test (PCT) to see that sperm can penetrate and survive in the cervical mucus, and a bacterial screening. It is important to note that the appropriate time to do PCTs is just before ovulation when mucus is the most “fertile.” PCTs at other times may give false results.
ULTRASOUND EXAM(S): On the day of LH surge are used to assess the thickness of the endometrium (lining of the uterus), monitor follicle development and assess the condition of the uterus and ovaries. If the lining is thin, it indicates a hormonal problem. Fibroid tumors can often be detected via ultrasound, as well as abnormalities of the shape of the uterus and ovarian cysts. In some cases, endometriosis can also be detected. Many doctors order a second ultrasound two or three days after the first. This second ultrasound confirms that the follicle actually did release and can rule out lutenized unruptured follicle (LUF) syndrome—a situation in which eggs ripen but do not release from the follicle.
HORMONE TESTS: If the blood test at your first appointment indicated a high LH to FSH ratio, an indication of polycystic ovarian disease (PCOD), your doctor will order an “Androgen Panel” to check levels of free testosterone and dihydroepiandrosterone (DHEAS). Other tests that should be conducted on the day of LH surge include LH, FSH, Estradiol and Progesterone. Tests which can be done at any time (and therefore done at the second appointment) include: Prolactin, Thyroid Stimulating Hormone (TSH), Free T3, Free Thyroxine (T4), Total Testosterone, Free Testosterone, DHEAS and Androstenedione.
The normal hormone levels for each of these during specific parts of your cycle are as follows:
Lutenizing Hormone (LH)
Follicular Phase (day two or three) : <7miu/ml
Day of LH Surge: >15mIU/ml
Follicle Stimulating Hormone (FSH)
Follicular Phase: <13miu/ml
Day of LH Surge: >15 mIU/ml
Day of LH Surge: >100 pg/ml
Mid Luteal Phase (seven days after Ovulation) : >60 pg/ml
Day of LH Surge: 15 ng/ml
Prolactin: Thyroid Stimulating Hormone (TSH): 0.4 to 3.8 uIU/ml
Free T3: 1.4 to 4.4 pg/ml
Free Thyroxine (T4): 0.8 to 2.0 ng/dl
Total Testosterone: 6.0 to 89 ng/dl
Free Testosterone: 0.7 to 3.6 pg/ml
DHEAS: 35 TO 430 UG/DL
Androstenedione: 0.7 to 3.1 ng/ml
<= less than ;> = greater than; mIU=milli International Units; ml=milliliter; pg=picograms; ng=nanograms; uIU=micro International Units; dl=deciliter; ug=micrograms
NOTE: These levels are those used at the Chapel Hill Fertility Center laboratory, and have been excerpted from “The Couple’s Guide to Fertility” by Berger, Goldstein and Fuerst, published by Doubleday.
ADDITIONAL TESTING: After the initial workup, many doctors continue with some of the following tests.
HYSTEROSCOPY: If a uterine abnormality is suspected after the HSG, your doctor may opt for this procedure, performed with a thin telescope mounted with a fiber optic light, called a hysteroscope. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths. “Photos” are taken for future reference. This procedure is usually performed in the early half of a woman’s cycle so that the build-up of the endometrium does not obscure the doctor’s view. However, if the doctor is planning to do an endometrial biopsy at the same time, it is done near the end of the cycle.
ENDOMETRIAL BIOPSY: This procedure involves a scraping a small amount of tissue from the endometrium shortly before menstruation is due— between 11 and 13 days from LH surge. It should ONLY be performed after an HCG blood test shows the woman is not pregnant. This test is used to determine if a woman has a luteal phase defect, a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced.
HYSTEROSALPINOGRAM (HSG): This test is used to examine a woman’s uterus and fallopian tubes. It is essentially an x-ray procedure in which a radio-opaque dye is injected through the cervix into the uterus and fallopian tubes. This “dye” appears white on the x-ray, and allows the radiologist and your doctor to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If you are trying to get pregnant in the same cycle as an HSG, make sure to schedule the test PRIOR to ovulation so that there is no danger of “flushing out” a released egg or developing embryo.
Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who DO have blockages, report intense pain. Speak to your doctor about taking a pain medication about 30 minutes prior to the actual procedure.
LAPAROSCOPY: A narrow fiber optic telescope is inserted through a woman’s abdomen to look at the uterus, fallopian tubes, and ovaries and to discern endometriosis or pelvic adhesions, and is the best diagnostic tool for evaluating the ovaries. This test us usually done two or three days before menstruation is expected, and only after an HCG beta blood test ensures the woman is not pregnant.
Diagnosis and Treatment Options to Overcome Infertility
Nearly 90% of all infertility cases, both male and female factor, are overcome through treatment, including surgical and medical techniques. The physicians at Servicios Medicos Reproductivos de Tijuana are committed to developing a treatment plan specific to each patient’s needs that will lead to the desired result of conceiving a child. We treat the patient as a partner in treatment and work with them to determine the treatment option that will be most fitting for their situation based on financial, social, religious, ethical and medical factors. Treatment options include assisted reproductive techniques such as IVF and ICSI, ovulation induction to enhance the production of eggs, surgery to repair reproductive organs and intrauterine insemination to increase the chances for egg fertilization by the sperm.
Ovulation induction. Often referred to as fertility drugs, are used to stimulate the follicles in your ovaries resulting in the production of multiple eggs in one cycle. The medications also control the time that you release the eggs, or ovulate, so sexual intercourse, intrauterine insemination, and in vitro fertilization procedures can be scheduled at the most likely time to achieve pregnancy.
There are risks associated with the use of ovulation induction medications including an increase in the chance for high order multiple births and the development of ovarian cysts. A rare side effect that can occur is ovarian hyperstimulation syndrome (OHSS); symptoms include severe pain in the pelvis, abdomen and chest, nausea, vomiting, bloating, weight gain and difficulty breathing.
The medications most commonly used in fertility treatment are clomiphene citrate, gonadotropins, Metformin and Parlodel. Clomiphene Citrate (Clomid, Serophene) – This medication comes in a tablet form and is used for women who have infrequent periods or long menstrual cycles. Common side effects include headaches, blurred vision and hot flashes.
There are different levels of ovulation induction commonly used to treat infertility related to ovulation disorders, male factor or unknown causes. One method of treatment involves clomiphene citrate (Clomid or Serophene) taken in pill form for 5 days at the beginning of a cycle. For women whose only infertility problem is anovulation, up to 80% of patients will ovulate using this medication and 50% of those will conceive. Clomiphene may be combined with intrauterine insemination to boost the success of the medication by placing the sperm and egg in closer proximity to each other.
The more aggressive level of ovulation induction is called superovulation. This treatment uses gonadotropins or sometimes a combination of clomiphene and gonadotropins to stimulate the production of multiple eggs. Patients undergoing superovulation must be closely monitored by blood tests and ultrasounds. Monitoring ensures that the patient does not hyperstimulate and also helps the physician administer the correct dosage of medication so that only a few follicles develop. This is a critical step to keeping the multiple pregnancy rates low. At the end of the superovulation treatment process, a low dose HCG (human chorionic gonadotropin) may be prescribed to stimulate ovulation. Ovulation will occur between 24-36 hours after HCG. The patient is instructed to either have intercourse during this time or to come in for an intra-uterine insemination. Depending on the cause of infertility, the success rate per superovulation treatment cycle is approximately 10-20% based on the woman’s age.
Intrauterine insemination (IUI) is a procedure in which sperm are placed directly into the uterine cavity through a catheter near the time of ovulation. This procedure is most commonly performed when there are problems with the sperm, such as low count or low motility, or an incompatibility between the sperm and the cervical mucus. It can also be performed to overcome problems associated with a man’s inability to ejaculate inside the woman’s vagina due to impotence, premature ejaculation or other medical conditions. IUI increases the chances of pregnancy because the sperm are placed directly in the uterus, bypassing the cervix and improving the delivery of the sperm to the egg.
IUIs can be performed either with the partner’s sperm or with donor sperm. It is recommended that the patient abstain from sexual intercourse for two to three days before the procedure. In some cases, it may be necessary for the female to take medication to induce ovulation if her cycles are not regular. The male will provide a semen sample one to two hours before the procedure is to be performed. The semen will be washed, a procedure in which the sperm is separated from the seminal fluid and the quality of the sperm is analyzed. Following the wash, it is time for the insemination procedure, which only takes a few minutes and does not cause much, if any, discomfort for the female. The doctor will insert a small catheter into the uterine cavity through the cervix and inject sperm directly into the uterus. The patient is able to resume normal activity immediately following the IUI procedure. If pregnancy does not result from the initial IUI, the procedure may be repeated during the following cycles. It is recommended to discontinue the use of IUI after six unsuccessful attempts as research indicates that there is no additional benefit. Pregnancy rates do not increase beyond the sixth IUI.
No all patients may be candidates for IUIs. Therefore some of them will be offered to go directly to in vitro fertilization, ICSI or donor sperm.