Fertility Treatment Options

Intracytoplasmic Sperm Injection (ICSI) involves the direct injection of sperm into eggs obtained from in vitro fertilization (IVF).

How is ICSI performed?
The mature egg is held with a specialized pipette. A very delicate, sharp, and hollow needle is used to immobilize and pick up a single sperm. This needle is then carefully inserted through the shell of the egg and into the cytoplasm of the egg. The sperm is injected into the cytoplasm, and the needle is carefully removed. The egg is checked the following day for evidence of normal fertilization. Once the steps of ICSI are complete and fertilization is successful, the embryo transfer procedure is used to physically place the embryo in the woman’s uterus. Then it is a matter of watching for early pregnancy symptoms. A blood test or ultrasound may be used to determine if implantation and pregnancy have occurred.

Fertility medications are prescribed to control the timing of the egg ripening and to increase the chance of collecting multiple eggs during one of the woman’s cycles. This is often referred to as ovulation induction. Multiple eggs are desired because some eggs will not develop or fertilize after retrieval. Egg development is monitored using ultrasound to examine the ovaries and urine or blood test samples to check hormone levels.

Eggs are retrieved with a minor surgical procedure that uses ultrasound imaging to guide a hollow needle through the pelvic cavity. Sedation and local anesthesia are provided to remove any discomfort that you might experience. The eggs are removed from the ovaries using the hollow needle, which is called follicular aspiration. Some women may experience cramping on the day of retrieval, which usually subsides the following day; however, a feeling of fullness or pressure might last for several weeks following the procedure.

Sperm are prepared for combining with the eggs. In a process called insemination, the sperm and eggs are placed in incubators located in the laboratory which enables fertilization to occur. In some cases where fertilization is suspected to be low, intracytoplasmic sperm injection (ICSI) may be used. Through this procedure, a single sperm is injected directly into the egg in an attempt to achieve fertilization. The eggs are monitored to confirm that fertilization and cell division are taking place. Once this occurs, the fertilized eggs are considered embryos.

The embryos are usually transferred into the woman’s uterus anywhere from 1–6 days later, but most commonly it is done between 2–3 days following egg retrieval. At this point, the fertilized egg has divided to become a two-to-four cell embryo. The transfer process involves a speculum which is inserted into the vagina to expose the cervix. A predetermined number of embryos are suspended in fluid and gently placed through a catheter into the womb. This process is often guided by ultrasound. The procedure is usually painless, but some women experience mild cramping.

These steps are followed by rest and watching for early pregnancy symptoms. A blood test and potentially an ultrasound will be used to determine if implantation and pregnancy have occurred.

Ovulation induction is used to treat infertility caused by anovulation or oligoovulation. Medications are used in a stepwise fashion to induce ovulation while limiting side effects and complications.

Diagnosis
Prior to ovulation, diagnostic tests are utilized to determine the cause of the problem. These tests may include:

• Basal body temperature charts
• Ultrasound
• Ovulation predictor urine tests
• Progesterone levels
• Endometrial biopsy

It is also necessary to rule out other causes of ovulatory problems by testing for thyroid, pituitary or adrenal dysfunction. These glands are tested by a single blood sample on which hormonal tests can be run (TSH, Prolactin, DHEA-S). Other causes of ovulatory dysfunction that might be evaluated include polycystic ovary syndrome, ovarian failure or hypothalamic dysfunction.

Treatment
Ovulation induction involves treating any underlying disorders (PCOS, hypothyroidism and hyperprolactinemia) and/or using ovulation-inducing medications.

Oral medications for ovulation induction include clomiphene citrate (Clomid, Serophene) or letrozole (Femara). These pills are taken for five days at the beginning of the menstrual cycle and cause ovulation in approximately 70% of anovulatory women.

Clomiphene citrate or letrozole may be combined with gonadotropin, injectable medications, to cause ovulation. These protocols are utilized when a woman does not ovulate on the pills alone, or ovulates but does not conceive and all the other tests (semen analysis, hysterosalpingogram and ultrasound) are normal.

Super ovulation cycles utilize only injectable gonadotropin. These cycles have the greatest probability of causing ovulation and pregnancy. They also have the greatest probability of twins or multiples. Because these medications have these risks, women will undergo more frequent monitoring with ultrasound and blood tests than during other ovulation induction protocols.

Often, ovulation induction is used in conjunction with other treatments, such as Intrauterine Insemination (IUI) to improve the chance of conceiving.

These services are for patients who have a known genetic mutation that can be tested via embryo biopsy (PGD). PGS is offered to patients for multiple reasons, the four most common ones being:

• Recurrent pregnancy loss
• Previous IVF/implantation failures
• Severe male factor
• Advanced maternal age

Some infertile couples may have difficulty conceiving due to factors that make it challenging or impossible for the sperm to reach the fallopian tubes. In this setting or in the setting of same-sex couples or single females looking to conceive, pregnancy might occur if the woman undergoes insemination with her partner’s sperm or donor sperm.

Intrauterine insemination (IUI) is an office procedure in which a specially prepared sperm specimen is placed into a catheter and inserted through a woman’s vagina and cervix up into her uterus near the time of ovulation. Women who have had previous cervical procedures may also benefit from IUI to allow the sperm to bypass the cervix so that an increased number of sperm can reach the egg in the fallopian tube, where fertilization usually occurs.

Without stimulation
If no female factors are causing infertility or if donor sperm is being used, IUI may be performed during a natural ovulation cycle with no medications. The timing of IUI is determined by using an “ovulation predictor” urine test, with the procedure performed the day after a positive test. Ultrasound exams may be used to help determine the exact timing.

With stimulation
To improve the chances of ovulation and to increase the number of eggs that are released, some women take medication such as clomiphene citrate (Clomid®, Serophene®) or letrozole (Femara®). These medications are usually taken daily during cycle days 5–9, followed by IUI timed with urine LH kits.

Day of insemination
Generally, your partner will come to our office that morning to provide a semen specimen, which will be processed in our andrology laboratory. Or in the case of donor insemination, the donor sperm will be thawed and analyzed. After a semen specimen is produced or thawed, the sperm are counted and processed. The processing is done to remove the seminal fluid. In some circumstances, your partner may collect a sample at home provided it is delivered in a sterile container to our laboratory within 30 minutes of collection. We will provide a kit for this purpose.

A physician performs the IUI approximately one hour after the semen arrives in the laboratory for processing. After a speculum is inserted into the vagina, a narrow catheter is slipped through the cervical canal. Sperm are deposited in the upper portion of the uterus. No medication or anesthetics are required, and the procedure is usually painless.

Once the catheter and speculum are removed, you will remain lying down with your hips slightly elevated for 15 minutes. You may leave the office and go about your usual activities. Light spotting after the procedure, as well as leakage of some insemination fluid, may occur; this discharge is normal. If you experience light cramping, you may treat with acetaminophen. Do not take nonsteroidals, such as ibuprofen or naprosyn, as these medications might affect ovulation.

Conception normally occurs approximately 24 hours after ovulation, and the embryo will implant between cycle day 20–24. If you do not experience a period by day 14 from your time of ovulation or IUI, we ask you to take a home pregnancy test. If it is positive or if your cycle doesn’t start, you will come in for a serum blood test to check for pregnancy.