In vitro fertilization involves both the
female and the male partners. Eggs
are retrieved from the ovaries and are placed with the male partner’s
sperm in a petri dish in a laboratory, where fertilization occurs to
produce embryos. After the
embryos have matured for several days in the laboratory, they are placed
into the uterus for implantation and a pregnancy should result.
At the proper time in her cycle, the
female partner is given hormone medication that should produce multiple
eggs in each ovary. Egg production is monitored by a series of
vaginal ultrasounds and blood tests. When the eggs are ready, the
patient is sedated in the office, and the eggs are retrieved using an
ultrasound guided needle through the vagina. The needle is
advanced into the ovarian follicle and the eggs are aspirated into a
test tube for transport to the lab. After the retrieval procedure, the
patient spends a short time recovering and can then go home.
Limited activity is recommended for a time.
Just prior to egg retrieval, the male
partner’s sperm is obtained and processed. A suspension of the
best population of sperm is added to the eggs for fertilization.
If the quality of the sperm is very poor, ICSI (intracytoplasmic sperm
injection) can be performed. When ICSI is used, a single sperm is
captured in a needle-like pipet and is then injected directly into the
egg to facilitate fertilization.
The eggs and sperm are monitored
regularly to assess fertilization and the production of embryos.
Embryos are allowed to mature for several days until they reach the
blastocyst stage.
When the embryos are ready, 2 or 3 are
transferred into the uterus using a small catheter threaded through the
cervix. No sedation is required; the transfer takes approximately
10 minutes. After a short rest period, the patient can go home.
Again, limited activity is recommended for a time. Any remaining embryos
can be cryopreserved, or frozen, for possible use with another cycle.
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Intracytoplasmic
Sperm Injection:
ICSI (intracytoplasmic sperm injection)
is performed in the laboratory when the quality or concentration of the
sperm is very low and the possibility of fertilization of the eggs is
unlikely. When the eggs are retrieved, one sperm is captured in a
needle-like pipet. Using a microscope for viewing, the sperm is
then directly injected into the egg. ICSI can be used to treat
several sperm issues including, low motility, low concentration,
antisperm antibodies, prior failure to fertilize in IVF, use of frozen
sperm collected prior to cancer treatment. Although ICSI is very
successful, the process may damage some eggs.
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Embryo
Cryopreservation:
Often, an IVF cycle will result in more
embryos than can be used for that cycle. Extra embryos can be
cryopreserved, or frozen, in liquid nitrogen at an extremely low
temperature. They can then be saved for possible use in another
otherwise natural cycle, sparing the patient from undergoing ovulation
induction, egg retrieval, etc. Approximately 50% of frozen embryos
will survive the thawing process.
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Sperm
Cryopreservation:
Like embryos, sperm can also be
cryopreserved, or frozen, in liquid nitrogen at an extremely low
temperature where they can remain viable indefinitely. This can be
useful for patients with poor sperm quality who are undergoing IVF.
Several semen samples can be processed and added together to provide a
specimen with a larger population of higher quality sperm.
Patients undergoing cancer therapy or vasectomy may also choose sperm
cryopreservation prior to their treatments.
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Ovulation
Induction:
Occasionally, a women’s body does not
produce mature eggs on it’s own during a monthly cycle. It may
be necessary to use medication to help stimulate the maturation of one
or more eggs. This is referred to as ovulation induction.
Ovulation induction may be achieved by taking pills for several days
during a cycle or may require alternate medication in the form of
injections.
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Intrauterine
Insemination
Intrauterine insemination is an office
procedure where washed sperm are delivered directly into the uterus
using a small catheter that is passed through the cervix. The
procedure is relatively quick with very minimal discomfort. The
cervical mucus, which can sometimes be hostile to the sperm, is
completely bypassed. All of the sperm in the ejaculation are
placed in the uterus as compared to the 1% (approximately) that make it
during natural intercourse.
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Success in achieving a pregnancy depends
on the quality of both the female egg and the male sperm. In some cases,
treatment for male factor infertility is unsuccessful. Donor sperm from
an approved sperm bank may be used in conjunction with intrauterine
insemination (IUI). The sperm bank provides profiles on various proven
sperm donors and donor can be selected based upon his genetic and
physical factors.
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Post-Coital
Test
The post-coital test is used to assess
the function of the sperm within the cervical mucus and is usually
scheduled 1-2 days prior to ovulation. Several hours after the
patient has intercourse, a small sample of the cervical mucus is
examined under the microscope. The amount of sperm seen in the
mucus and the quality of motility is evaluated. Cervical mucus
that has an adverse effect on the function of the sperm can be
associated with infertility.
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Follicle
Study Ultrasound
Each cycle, eggs mature in the ovaries
within small sacks called follicles. It is important to monitor
the formation of the follicles during the first half of the monthly
cycle as the amount and size of the follicles tell the physician how
many eggs are being produced by the body. Adjusting
medication can regulate the number of eggs produced. A slender
wand attached to an ultrasound machine is introduced into the vagina and
directed towards the ovaries. The ovaries and follicles can be
seen on a screen. Follicles are counted and measured and
medication is adjusted accordingly. The procedure takes
approximately 15 minutes in the office and causes very minimal
discomfort.
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Follicular
Cyst Aspiration
Typically, ovarian cysts are not disease
related and disappear on their own. During ovulation, a follicle
grows but fails to rupture and release an egg. It retains fluid
and becomes a cyst. Ovarian cysts can cause a variety of symptoms
including abnormal uterine bleeding, pelvic pain, and nausea and
vomiting. An ovarian cyst can be drained in the office using a
needle with ultrasound guidance. The procedure takes approximately
15 minutes.
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Endometrial
Biopsy
The lining of the uterus is called the
endometrium. The endometrium responds to changing hormone levels
during the menstrual cycle. Sending a small sample, or biopsy, of
this lining for microscopic examination can tell your doctor if your
ovaries are producing enough progesterone, a hormone needed to support a
pregnancy. The biopsy is usually scheduled just prior to the
beginning of the menstrual cycle. Before the biopsy, a urine
pregnancy test will be performed. If the pregnancy test is
negative, a speculum is introduced into the vagina. Then, a small
catheter is passed through the cervix to obtain a piece of tissue.
The entire procedure takes approximately 5 minutes and may cause minimal
menstrual-like cramping.
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Cultures:
Occasionally a microorganism harbored in
the reproductive tract can be the cause of infertility. Culture
swabs of the area can give your physician valuable information regarding
any unusual organisms.
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Hysteroscopic
Evaluation of the Uterus
The uterine cavity can be visualized by
inserting a small optical tube called a hysteroscope, through the vagina
and cervix. The uterus is filled with saline to enhance visualization.
The physician can evaluate the size and depth of the uterus, the
presence of abnormalities inside the uterus, the presence of polyps or
adhesions, and the quality of the endometrium. The procedure is
usually performed in the early half of a woman’s cycle and can be done
in the office. It takes approximately 20 minutes.
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Reversal
of Tubal Ligation:
Tubal ligation is a term used when the
fallopian tubes have been surgically tied to prevent pregnancy. Patients
usually request reversal due to a change in marital status.
Success depends very much on what type of tubal ligation was done.
Generally, success varies from 50% - 70%. Reversal of tubal ligation is
a surgical procedure, and hospital stay is 2 – 3 days.
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Exploratory
Laparotomy:
Sometimes it is necessary to explore the
pelvis and visualize the reproductive organs and their environment.
Typically, this is for significant endometriosis, adhesions, or
fibroids. An exploratory laparotomy is a surgical procedure
involving general anesthesia and an incision in the abdomen. The surgeon
examines the internal organs directly. The patient usually stays
in the hospital for two nights followed by recovery at home for about 4
– 6 weeks.
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Diagnostic
Laparoscopy:
Laparoscopy is performed to determine
possible causes of infertility, pelvic pain, pelvic mass, irregular
vaginal bleeding, adhesions, and endometriosis. The patient is taken to
the operating room and placed under general anesthesia. The
laparoscope, a narrow optical instrument approximately ½ inch in
diameter, is inserted into the abdomen through a small incision in the
navel. A second, similar incision is made at the pubic
hairline through which another narrow instrument is inserted. The
abdomen is distended with carbon dioxide gas to facilitate viewing of
the internal organs. Using the two instruments, the surgeon can
visualize, manipulate and treat affected tissue such as endometriosis or
pelvic adhesions. The patient can generally go home the same day.
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Laser
Vaporization of Endometriosis:
During a diagnostic laparoscopy, a laser
may be used to vaporize affected tissues.
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Laser
Vaporization of Pelvic Adhesions:
During a diagnostic laparoscopy, a laser
may be used to vaporize affected tissues.
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Hysterosalpingogram:
A hysterosalpingogram (HSG) is a
procedure used to x-ray the uterine cavity and fallopian tubes. It
is performed in the x-ray department and takes approximately 15 minutes.
The patient is allowed to go home after the procedure. A thin
catheter is passed through the cervix into the uterus. The uterine
cavity and fallopian tubes are then flushed with an x-ray contrast dye
(through the catheter). There may be some cramping associated with
the injection of the dye. The movement of the dye is observed as it
makes it’s way through the uterus into the fallopian tubes, and spills
into the pelvic area. An HSG can detect: an abnormally shaped
uterine cavity, fibroid tumors, polyps, scar tissue, partially or
completely blocked fallopian tubes, normally shaped uterine cavity and
tubes.
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Tubal
Catheterization:
When a blocked fallopian tube is
discovered with a hysterosalpingogram (HSG), a tubal catheterization can
be performed to correct the blockage. The procedure is performed
in x-ray and takes approximately 20 minutes. The patient can go
home after the procedure. Under fluoroscopic guidance, a thin
balloon catheter is threaded through the cervix, uterus and into the
affected fallopian tube. At the site of the blockage, the balloon
is inflated correcting the obstruction. The area is then flushed
with an x-ray contrast dye to verify results. There is an 85 –
90% chance that a blocked tube will be opened. About 60% of those
will still be open after 6 months, and 30 – 40 % will conceive.
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