Education : We strongly believe that educating our patients about the normal process of fertility, problems that affect fertility, and treatment options will empower our patients to make the best choices. Understanding the normal reproductive process is essential in knowing when to seek help. Helping our patients develop a deep understanding of their fertility options will make the process smoother. Our goal is to have each and every patient feel as part of our team, a team that is focused on helping them have a healthy baby.
Medications to induce egg development and ovulation : The medications that help stimulate the ovary to develop mature eggs for ovulation come in two forms: pills taken by mouth and injections. The most commonly prescribed pill to stimulate ovulation (generally of one mature egg) is clomiphene citrate. This pill generally is taken from menstrual cycle days 3 – 7. It works in the following way: Clomiphene is an anti-estrogen. It binds in a part of the brain called the hypothalamus, which is essential in stimulating the ovary to grow and release an egg. When clomiphene binds to estrogen receptors in the hypothalamus, it leads to an increase release of an important signaling hormone called GnRH (gonadotropin releasing hormone). This hormone then binds to another area of the brain called the pituitary gland and leads to the release of FSH (follicle stimulating hormone), a hormone that directly binds to cells in the ovary, leading to egg growth and maturation.
The most commonly prescribed injections that stimulate the ovary are called gonadotropins. The gonadotropins in these formulations are FSH, and in some cases, a combination of FSH and LH (luteinizing hormone). These injections are taken nightly, typically for 5 – 10 days, and act directly on the cells of the ovary to stimulate egg development. Once a follicle containing an egg reaches a mature size, another hormone injection called HCG is often given to mimic the natural LH surge that occurs at the time of ovulation. This leads to the final maturation and release of the egg.
Insemination : Intrauterine insemination, also known as IUI, is a process by which sperm is washed and prepared for placement into the uterine cavity, therefore bypassing the cervix and bringing a higher concentration of motile sperm closer to the tubes and ovulated egg. In order to accomplish this, the semen is washed with a solution safe to sperm and eggs, and then centrifuged to separate motile sperm from immotile sperm and other cells. Those motile and viable sperm are then placed in a very small amount of solution, and then very gently and painlessly injected into the uterine cavity using a very thin, soft, and flexible catheter. At least one open tube is required for IUI, and any sperm abnormality cannot be severe, otherwise the sperm will not be able to swim to and fertilize the egg.
In Vitro Fertilization (IVF) : In vitro means “outside the body.” IVF is a process whereby eggs are collected and then fertilized by sperm outside the body, in an embryology laboratory. The first IVF baby was born in 1978 in England. Not long after, the United States delivered its first IVF baby, and the use of IVF has grown dramatically. IVF was a major breakthrough because it allowed for successful pregnancies in women that were previous deemed permanently infertile, such as when the fallopian tubes are both markedly damaged. IVF involves removal of eggs directly from the ovary, fertilization with sperm in the laboratory, followed by transfer of the embryos directly into the uterus, thereby bypassing the tubes. Although tubal disease was the original indication for IVF, many more indications have developed over the years. These include advancing maternal age, severe male factor infertility (whereby ICSI can be used to fertilize the egg), and endometriosis, amongst many others.
IVF is Generally Performed in the Following Manner :
The woman undergoes gonadotropin injections, which stimulate the ovaries to produce many eggs. Once the follicles (fluid filled sacs containing the eggs) reach a mature size, an HCG injection is administered which leads to final development and maturation of the eggs. Just before those eggs would otherwise be ovulated, they are retrieved under mild anesthesia in an operating room. This procedure is done by ultrasound guidance when the surgeon utilizes a narrow needle to retrieve eggs from the ovary through the vaginal wall. This sterile needle is attached to sterile suction tubing and a collecting vial. Once the fluid containing the eggs is removed from the follicles into the vials, they are handed to the embryologist who finds the eggs, places them in tiny droplets on a Petri dish, and then fertilizes the eggs using their partner’s or donor sperm. The sperm can either be mixed with the eggs to allow normal fertilization (conventional insemination) or by injecting one sperm into each mature egg (ICSI).
The fertilized eggs, now embryos, are allowed to grow and develop in culture media for typically 3 to 5 days. Then, generally one or two embryos, which have demonstrated appropriate development, are carefully and gently transferred into the uterine cavity. Embryos transfer is performed in the office under abdominal ultrasound guidance using a small, soft, sterile and flexible catheter. The embryos are placed within the tip of the transfer catheter and then injected within the uterine cavity once the catheter is placed through the cervical canal to the ideal spot within the uterus.
The pregnancy test is then performed 2 weeks after the egg retrieval. This process has revolutionized assisted reproductive technology and the way reproductive endocrinologists can help people in having a baby.
Third party reproduction : This is a general reference to a general process where another person provides sperm or eggs, or where another woman acts as a gestational surrogate, with the purpose of helping another person or couple have a child. The four types of third party reproduction are 1) sperm donation – a process by which donated sperm is used for insemination in the uterus, or for fertilization of eggs in the IVF process; 2) egg or ovum donation – a process by which an egg donor undergoes an IVF cycle in order to obtain her eggs which are then donated and fertilized. The resulting embryos are then transferred into the uterus of the future mother, known as the recipient. Usually no more than 1 – 2 embryos are transferred, and therefore additional embryos can be frozen, or cryopreserved, for future use; 3) embryo donation – a process where a fully developed embryo from another person in combination w/donor sperm, or couple who underwent IVF, are donated to another woman, the future intended mother, for transfer into her uterus; and 4) gestational surrogacy – a process where another woman will undergo an embryo transfer and carry the pregnancy for another person. Your physician will discuss these approaches to having a baby if appropriate to your particular case.
Surgery : After a thorough history, physical examination, and ultrasound are performed, your doctor may recommend surgery to correct and abnormality. In reproductive medicine, the most common surgical procedures are laparoscopy, hysteroscopy, and abdominal myomectomy (removal of uterine fibroids).
Laparoscopy is an operation performed in the abdomen or pelvis through small incisions, generally no more than a centimeter, with the assistance of a laparoscope attached to a camera which projects to a screen. It can either be used to inspect and diagnose certain conditions or to surgically correct an abnormality such as removing scar tissue, endometriosis, or a damaged fallopian tube. The procedure is performed in an outpatient setting in the vast majority of cases, and recovery time can be as little as a few days.
Hysteroscopy is the inspection of the uterine cavity through the cervix by a hysteroscope attached to a camera which projects to a screen. Through this technique, your physician can diagnose abnormalities such as fibroids or polyps within the uterine cavity, and via narrow instruments that run through the hysterosope, can remove or correct the great majority of these abnormalities. This procedure is performed in the outpatient setting. Recovery is generally no more than one day. Hysteroscopy can also be combined with laparoscopy when necessary.
Abdominal myomectomy is a surgical procedure performed through a very low horizontal abdominal incision allowing access to the uterus for removal of fibroids. This procedure can, in selected cases, also be performed laparoscopically, often with the assistance of a robot.