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| Treatment Options > Clinical |
Clinical Treatment Options : : Surgical
In women, anatomical abnormalities are a common cause of infertility. Rarely congenital, most structural damage to the reproductive organs is acquired and results from previous pelvic surgery, infection or endometriosis. Any of these conditions may cause scarring or closure of the fallopian tubes and thereby block the key passageway for conception.
Diagnosis
The diagnosis of anatomical infertility is not always straightforward. Certain aspects of a woman's history may suggest an anatomical blockage, but seldom is this revealed on physical exam. Most often, the diagnosis is determined on the basis of x-ray (hysterosalpingogram) and/or a laparoscopic evaluation. If confirmed, therapeutic modalities may include a variety of surgical procedures, including operative laparoscopy, operative hysteroscopy or microsurgical reconstruction via laparotomy.
Laparoscopy
Laparoscopic surgery is done through a thin, illuminated telescope that is placed through the abdominal wall. It may be simply diagnostic, as when it is used to confirm the normality of the pelvic structures, or therapeutic, as when it is used to correct internal pelvic problems. Advances in instrumentation such as endoscopic video cameras and lasers enable experienced surgeons to perform even complicated reconstructive procedures on an outpatient basis. In many circumstances, laparoscopy may be done in our on-site surgical suite.
Hysteroscopy
Hysteroscopy is a procedure in which a thin telescope is placed, without incision, through the cervix in order to visualize the inside of the uterus. As with laparoscopy, hysteroscopy may be therapeutic as well as diagnostic. Procedures such as removal of fibroids or polyps, resection of scar tissue or a septum and opening of blocked tubes may be performed at the time of hysteroscopy. Diagnostic hysteroscopy is almost always done at the GENESIS surgical suite.
Sperm Retrieval
A small percentage of men produce no sperm in the ejaculate, a condition known as azoospermia. Specially trained urologists can retrieve sperm from some of these men using microsurgical epipidymal sperm aspiration (MESA) if the problem is a blockage in, or absence of, the vas deferens. Testicular biopsy (TESE) is used when a patient produces only a few sperm in the testicle. In many cases a single procedure will yield sufficient sperm to be used for the current IVF procedure and also to be frozen for future use.
Microsurgery
Although telescopic surgery, or endoscopy, has largely replaced the need for open abdominal surgery, occasionally the need does arise for such surgery, called laparotomy. Microsurgical reconstruction of the pelvis, in particular, always requires laparotomy. In such cases, surgery is done through a specialized microscope that allows for magnification and meticulous dissection of the involved structures.
The physicians at GENESIS are all trained in the use of sophisticated surgical techniques. Surgery can be used to correct problems that partially or completely impair fertility. Surgery alone can be sufficient to allow conception and pregnancy to occur. Depending on the nature of the underlying problem(s), additional medical therapy may be necessary to enhance the chances of successful pregnancy.
Should you require diagnostic or therapeutic surgery, the nurses, physician assistants and medical assistants you have come to know at GENESIS are the very same people who will care for you in our on-site operating and recovery rooms. Our medical personnel are sensitized to the particularly emotional and stressful circumstances surrounding your situation, and they will take the time to explain procedures to you. When entering the operating room for any procedure, it is normal to feel a certain amount of apprehension. Know that we are here to help you and truly care about your experience. We keep our OR a safe haven, a place where we begin the process of fulfilling your dreams. So, if you need to have surgery, be sure that we will provide this too with our very special "human touch."
Clinical Treatment Options : : Non-Surgical
Therapeutic Donor Insemination
Couples whose infertility is due to a significant sperm abnormality in the male sometimes choose to undergo insemination using sperm from an anonymous sperm donor. In therapeutic donor insemination (TDI), the donor's sperm is inseminated into the woman's uterus at the time of ovulation, enabling the woman to conceive.
When is donor insemination needed?
Donor insemination is an option in a number of circumstances, including when the sperm count is very low, when no sperm are present, or when sperm repeatedly fail to initiate pregnancy. These circumstances stem from a number of causes such as the absence of sperm production, previous vasectomy, or residual effects from chemotherapy or radiation therapy. Donor insemination may also be used in cases where both the male and female are carriers of a genetic disorder or a female is severely Rh immunized and the male is Rh positive. Donor insemination is also an option for single women who wish to become pregnant.
Donor semen
GENESIS acquires cryopreserved (frozen) sperm only from reputable, licensed sperm banks. Semen is frozen in liquid nitrogen at a temperature of -196°C, where all sperm activity is essentially halted until it is thawed. After thawing, most sperm return to the pre-freeze motile and functional state. To insure safety, the sperm donor is tested for HIV and other infectious diseases at the time of sperm donation, and the sperm is then frozen for six months. The donor is retested at this time, and if the donor’s testing for infectious diseases remains negative, the frozen sperm is made available for use. While this does not totally eliminate the possibility of disease transmission, it makes the risk extremely low. Sperm banks provide profiles outlining the physical characteristics, race, ethnicity, educational background, career history, and general health of each donor. In addition to screening for infectious diseases, donors are also screened for genetic abnormalities and Rh factor. Donors are usually between the ages of 18 and 40, have had a thorough medical history check and often have a history of proven fertility. Our clinical staff will provide you with the latest sperm bank catalogs and can assist you in selecting your donor if you wish.
The insemination procedure
Insemination of donor sperm is timed as closely as possible to the time of ovulation. The patient can monitor her ovulatory cycle by testing her urine for a luteinizing hormone (LH) surge, which precedes ovulation. Usually inseminations are done on two consecutive days following the LH surge. The donor sperm specimen is thawed in our laboratory on the day of the insemination, and then it is loaded into a small plastic catheter. During an intrauterine insemination (IUI), the prepared sperm are inserted into the uterus via the catheter. An IUI is a simple procedure that takes only a few minutes and is usually painless. After a short time following the procedure, the patient can resume normal activity.
Psychological Aspects
The decision to use donor sperm in order to become a parent can raise complex questions and concerns for people. As part of our caring staff, we have a clinical psychologist who will meet with you to explore these issues.
Ovulation Induction
Ovulation, the release of an egg from the ovary, is necessary for conception to occur. Approximately 0-40% of infertile women have ovulatory problems. Often ovulation is induced with the aid of medications.
Who is a candidate for ovulation induction?
Medications can be used to stimulate ovulation in women who rarely or never ovulate (anovulation) and to treat women who have no menstrual cycles (amenorrhea). They can also be used to increase the frequency of ovulation in women who ovulate infrequently. Medications are sometimes prescribed to treat luteal phase defect, a condition in which the second half of the menstrual cycle is shortened and the uterus is not properly primed to receive an embryo. These medications are also used to stimulate multiple egg development in order to enhance the success rate of assisted reproductive procedures such as IVF.
Ovulatory Drugs
Clomiphene citrate
The most commonly used medication to induce ovulation is clomiphene citrate (trade names Serophene®, Clomid®). Clomiphene is taken for five consecutive days early in the menstrual cycle. Clomiphene works by "fooling the body" into thinking estrogen is low; certain hormones are then released which cause egg development. Once the clomiphene is stopped, the body recognizes the high estrogen level and responds with an LH surge (resulting in the color change seen in an ovulation predictor kit). The LH surge causes ovulation, or the release of an egg from its follicle. If ovulation does not occur, the dose of clomiphene can be increased over the next few cycles.
Outcome with clomiphene
Because more than one follicle may develop when taking clomiphene, the chance of having twins is about 5%. The chance of having triplets is much less.
Gonadotropins
Human menopausal gonadotropin (hMG, trade names Pergonal®, Repronex®) and human follicle stimulating hormone (FSH, trade names Gonal F®, Follistim®), are injectable medications given over a period of 5-12 days to produce growth and maturation of ovarian follicles, which contain eggs. The dose used to produce maturation of the follicles is individualized for each patient and may vary from cycle to cycle. Response to the medication (follicle number and size) is monitored with the use of blood estrogen levels and ultrasounds. When follicles are of the appropriate size and an appropriate estrogen level is achieved, ovulation is usually triggered with the use of hCG (human chorionic gonadotropin, trade names Profasi®, Novarel®, Ovidrel®) so that intercourse, insemination or egg retrieval may be timed. Outcome with Gonadotropins
Usually several eggs are produced with the use of gonadotropins. Multiple pregnancies occur in approximately 25% of gonadotropin cycles. Of these, most are twins, but triplets or more may occur.
GnRH Analogs
GnRH analogs (Lupron®, Antagon®, Cetrotide®) are synthetic hormones similar to gonadotropin releasing hormone (GnRH), which is released by the brain to control the pituitary gland. Normally a rhythmic release of GnRH stimulates the pituitary to secrete FSH and LH, the hormones needed to cause egg production and ovulation. When a synthetic GnRH analog is given, the opposite effect occurs. Lupron® causes an initial increase in FSH and LH and the subsequent suppression of these hormones. Antagon® and Cetrotide® cause immediate suppression. The use of GnRH analogs in conjunction with gonadotropins allows for better hormonal control of ovulation induction and fewer canceled cycles.
Outcome with GnRH Analogs
In IVF cycles, GnRH analogs are used routinely to enhance egg production and to prevent spontaneous ovulation. The use of these medications has significantly lowered the cancellation rate for all assisted reproduction cycles by at least 75%. The use of GnRH analogs for ovulation induction that is not being performed in conjunction with assisted reproduction is also sometimes used. This is especially the case in older women who may not be as sensitive to the effects of gonadotropins alone.
Conclusion
Hormonal therapy with a variety of medications can temporarily correct ovulatory problems and increase a woman’s ability to become pregnant. Your physician will discuss all the specific indications for usage, physiology, side effects and risks associated with these medications.
Artificial Insemination with Husband's Sperm
Artificial insemination is the term used for the placement of sperm in the female reproductive tract by means other than intercourse. Artificial insemination with the husband's sperm can lead to a pregnancy for many infertile couples.
Who is a candidate for artificial insemination?
Artificial insemination is often, but not exclusively, used to treat couples who are infertile because of a male factor. For example, semen abnormalities such as moderately poor sperm count, motility or morphology are often overcome by the use of artificial insemination. Less commonly, but with good success, artificial insemination is used in cases where the male’s sperm are unavailable for contact with the female’s reproductive tract. Retrograde ejaculation is one such disorder, and it refers to male ejaculate being released backward into the bladder. This can be found in men with a history of diabetes or trauma to the neck of the bladder. It can also be a side effect of certain medications. When this is the case, sperm may be extracted from a special preparation of urine containing the ejaculate and inserted into the female partner.
Insemination may be used in cases of impotence or severe hypospadias (a urethral abnormality in the man). Some men may store their sperm in a frozen state prior to vasectomy, chemotherapy or testicular surgery. Should they decide to father children, artificial insemination with the thawed sperm may be done. Artificial insemination may also be indicated in certain cases of female infertility as, for example, when there is a cervical disorder that prevents natural conception. It is also used in cases of unexplained infertility (in combination with medication to stimulate the ovaries).
Intrauterine Insemination
Intrauterine insemination (IUI) is a process by which sperm are placed past the cervix and directly inside the uterus. With natural intercourse, sperm are most concentrated in the cervix and only the most motile ones make their way through the uterus to the fallopian tubes. With IUI, a concentrated suspension of sperm is introduced through the cervix directly into the uterine cavity. This allows large numbers of sperm to reach the fallopian tubes, where fertilization can then occur. This procedure requires that the sperm be “washed” first. That is, the sperm must be separated from the semen (seminal fluid can irritate the uterus, causing severe cramping and pain). Sperm washing is performed under strictly sterile conditions and a variety of safeguards are maintained to insure that semen samples cannot be switched.
The Insemination Procedure
The husband is asked to produce a semen specimen in a clean, sterile container. If the specimen needs to be obtained through intercourse with a condom, a special collection kit may be used. The specimen must be brought to the lab within one hour of production. After the sperm washing procedure is completed, IUI may be done any time within several hours. When the specimen is ready, a speculum is inserted into the vagina and the washed sperm are inserted into the uterus via a small plastic catheter. It is a simple procedure and takes only a few minutes with no or minimal discomfort. When performed during a natural cycle, IUI is timed according to an LH (luteinizing hormone) surge, which precedes ovulation. When used in conjunction with ovulation induction, an injection of hCG (Profasi®, Novarel®, Ovidrel®) is generally used to trigger release of the egg, which allows optimal timing.
Outcome
Success rates for artificial insemination are dependent mainly on the specific indication for which it is being used. When the sperm are inherently normal and only physical or psychological barriers to contact with the female partner exist, correctly timed insemination is most often successful, although not always on the first attempt. Where abnormalities of sperm production are present, success depends on the severity of the abnormality involved. With severely depressed counts, ovulation inducing agents are often given to the female partner in order to enhance the per cycle pregnancy rate. With the severest abnormalities, artificial insemination cannot be done and in vitro fertilization with intracytoplasmic sperm injection (ICSI) is required.
Obviously, the reproductive potential of the female partner is also crucial. Prior to beginning a program of artificial insemination, it is important to exclude any female factors that may also be obstructing conception and to discuss realistically the time frame in which pregnancy is expected to occur. There is no increased risk of congenital abnormalities in children born as a result of artificial insemination.
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Genesis Fertility & Reproductive Medicine
1355 84th Street, Brooklyn, NY 11228 |
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