Guide to the Basics of Diagnosis and Treatment
The Center for Human Reproduction (CHR), one of the most prominent fertility research and treatment centers located in New York City, attracts many fertility patients who have (unfortunately) become "expert patients" through their long journey toward parenthood. As a de facto "fertility center of last resort," we serve many patients from all over the world with long treatment histories and many previous IVF failures. We've realized that, as a result, our website may focus mainly on these "expert patients," perhaps leaving those relatively new to fertility treatments rather in the dark. This page is intended to give such new patients a comprehensive overview of infertility conditions and treatments, with links to pages where you can learn about infertility more in depth.
Infertility? When to see a specialist
Affecting about 15% of couples, infertility is defined as the inability to conceive or maintain a pregnancy within a certain period of time. For couples under the age of 35, infertility is diagnosed when they fail to conceive after 1 year of regular unprotected sexual intercourse. In addition, couples who are able to conceive but experience repeat miscarriages may also be considered having infertility.
After the age of 35, both men and women experience a natural decline in fertility. This means that it is natural for them to take longer to get pregnant. However, because older women have a "ticking time bomb" of fertility, we recommend that older women seek expert advise from infertility doctors if they don't conceive after 6 months of regular unprotected sexual intercourse.
Watch Dr. Barad explain infertility diagnosis and treatment
What are the major causes of infertility?
Reproduction is a complex function involving many factors that can affect a couple's ability to become pregnant. About 15% of couples of reproductive age suffer from infertility. At our center, approximately 60% of infertility cases are due to female factors, although in a general infertility population, that ratio is lower. In 15% or so of cases, both male and female partners have infertility issues. In both men and women, most causes of infertility can generally be attributed to either anatomical, hormonal, environmental, or genetic factors that prevent normal reproductive functions.
How is infertility diagnosed?
Couples under 35 years of age who have been having regular unprotected sexual intercourse for more than 1 year are typically diagnosed with infertility. (In older couples, it may take longer to conceive. However, older couples also may not have the luxury to "wait and see," since female reproductive time frame is limited. Older couples, therefore, should seek professional counsel even before a full year of unsuccessful try.) Further testing is needed to determine the specific underlying cause.
Typical diagnostic tests that are prescribed may include:
- Health, social and sexual history interview – Identifies contributing risk factors such as medications, history of sexually transmitted disease, prior ectopic pregnancies, weight, or other health conditions that may impact fertility. Significant family history of infertility, autoimmune problems, etc. can also be discovered in this process. This is the most basic but possibly the most important diagnostic process for fertility patients. Unfortunately, many IVF centers neglect the importance of this step, delegating the responsibility to non-physician staff members.
- Pelvic examination – Both the male and female reproductive structures are evaluated for abnormality.
- Hormone evaluations – Males and females are tested for hormone levels that impact ovulation and sperm production. These may include follicle-stimulating hormone (FSH), luteinizing hormone (LH), thyroid hormone, progesterone, testosterone, anti-mullerian hormone (AMH) and more.
- Sexually transmitted disease testing – Infections from sexually transmitted diseases can negatively impact your ability to become pregnant.
- Ovulation testing – A blood test can be done to help determine whether or not a woman is ovulating each month. This can also be evaluated through the use of basal body temperature readings.
- Hysterosalpingogram (HSG) - This type of x-ray evaluation uses contrast dye to visualize the uterus and fallopian tubes for damage or abnormalities. In the hands of an experienced fertility specialist, HSG is a good technique to diagnose subtle tubal infertility that may be overlooked by a radiologist who does not specialize in fertility care.
- Hysterosonogram (HSN) – An ultrasound (HSN) can help screen for abnormalities of the reproductive organs.
- Semen analysis – This is the most commonly ordered and most important test for diagnosing male infertility. Sperm count, concentration, morphology (shape of sperm) and motility (mobility of sperm) are tested. Semen analysis is an indirect way to assess the sperm's ability to fertilize an egg.
- Genetic Testing – In rare cases where a genetic causes of infertility is suspected, this testing may be indicated.
- Laparoscopy - This procedure used to be common. However, with the development of less invasive and more accurate diagnostic methods, laparoscopy is rarely used for diagnostic purposes only. In most high-quality IVF centers, laparoscopy nowadays is a therapeutic procedure, not a purely diagnostic one.
How is endometriosis infertility treated?
Endometriosis infertility is a problem that affects many women with endometriosis. However, with proper treatment and reproductive technology many women are able to overcome this disease.
What is endometriosis?
Endometriosis is a very common gynecological disease in which cells from the inside lining of the uterus (endometrium) grows outside of the uterus. In a normal menstrual cycle these cells on the inside of the uterus are affected by hormones, first thickening and then shedding through menstrual bleeding. In a women with endometriosis, the endometrial cells that are growing outside of the uterus also thicken and shed during the monthly cycle. However, once they shed, they have no place to go. The body sees this bleeding as "wound" and rushes to heal it. This process creates scar tissue and adhesions.
How does endometriosis cause infertility?
Unfortunately, when endometriosis spreads in a woman's reproductive organs, it often affects the fallopian tubes, ovaries, and pelvic floor, leading to endometriosis infertility. Depending on the extent of the disease, the scar tissue or adhesions can prevent normal egg maturation and release, prevent an egg from passing through the fallopian tubes, or a fertilized egg from implanting inside the woman's uterus. In some cases, endometriosis can also release toxic substances causing harm to eggs or embryos.
How is endometriosis infertility treated?
Depending on the extent of the disease, there are several different ways that endometriosis infertility can be treated. Medications to control hormones along with surgery are two ways that physicians can help reverse the effects of endometriosis in addition to the use of assisted reproductive technology such as IVF. When evaluating the possibility of surgery for endometriosis, however, it is important to discuss with your physician how such a surgery may affect your fertility prospects. Too often, we see patients who, after an endometriosis surgery especially involving the ovaries, experience a sudden drop in their ovarian reserve.
Read more: Endometriosis and Infertility Treatment
Watch Dr. Gleicher explain the unique challenges of fertility treatments for endometriosis patients
(Dr. Gleicher, CHR's medical director, is an international expert in providing fertility solutions to endometriosis patients. He is responsible for confirming the important link between endometriosis, autoimmunity and fertility.)
The term "tubal infertility" refers to the inability to become pregnant due to a problem in the fallopian tubes.
What are fallopian tubes?
The fallopian tubes are the two long hollow appendages on either side of the uterus that connect the uterus to the ovaries. Each month, the ovaries release a mature egg into the fallopian tubes, where they can be fertilized by sperm. Once fertilized, tiny hairs inside the fallopian tubes move the embryo (fertilized egg) down the tubes and into the uterus for implantation and pregnancy.
What Causes Tubal Infertility?
Tubal infertility is most often caused by either damage or blockage in these tiny tubes. This can be due to past infections, sexually transmitted diseases, pelvic inflammatory disease, history of an ectopic pregnancy or endometriosis. Tubal infertility is a mechanical problem that prevents either the fertilization or implantation.
How Common is Tubal Infertility?
It is estimated that approximately 20-25% of all infertility cases involve tubal infertility. However, damage to the fallopian tubes is often missed due to limitations in diagnostic screenings. This statistic likely under-represents the real prevalence of tubal infertility. At CHR, we often see patients with a dubious diagnosis of "unexplained infertility." Many of them have undiagnosed tubal infertility.
How is Tubal Infertility Diagnosed?
The best way to diagnose tubal infertility is through a procedure known as a hysterosalpingography (HSG), in which contrast dye is inserted through vagina to the uterus and fallopian tubes. X-ray images are then taken while the dye is flowing through the structures in order to illuminate any area that may be blocked or partially occluded. It sometimes takes an experienced physician, preferably a fertility expert (not a regular radiologist) to diagnose subtle cases of tubal infertility.
How is Tubal Infertility Treated?
Treatment for tubal infertility depends on the type of damage that is present. In some cases the dye from a HSG exam is enough to clear a blockage whereas in many other cases IVF offers the best hope for pregnancy.
PCOS and infertility
Polycystic ovarian syndrome (PCOS), also known as polycystic ovary disease (PCOD), is a very common cause of female infertility. PCOS is characterized by many small cysts that develop inside of the ovaries and interfere with normal reproductive function.
What Causes PCOS Infertility?
Approximately 30-40% of women with PCOS will experience difficulty becoming pregnant. Women who have PCOS develop a lot of eggs in the ovaries, but these eggs are not released from the ovaries when time for ovulation comes. This means that sperm cannot "meet" a mature egg. Each month, when the egg matures, it becomes trapped inside the ovaries, forming a cyst.
How is PCOS Infertility Treated?
In many case, PCOS infertility can be treated with medications that regulate hormones. However, in some cases, when the cysts interfere with proper ovulation, assisted reproductive techniques such as in vitro fertilization (IVF) or surgery may be considered. (When considering surgical interventions for PCOS, you should discuss your fertility prospects with your physicians below.) As Dr. Gleicher explains in the video below, ovarian stimulation for IVF in PCOS patients should be handled by an experienced IVF expert to avoid hyperstimulation.
Read more: PCOS and Infertility Treatment
Watch Dr. Gleicher explain why PCOS patients need special expertise in IVF cycles
Should I get surgery to treat infertility?
Unfortunately, surgery as an infertility treatment is often over-used and in many cases can actually cause more harm than good. (For example, there is no point in using laparoscopy to open a blocked tube for a patient who is 45. At that age, she would most likely need IVF, which makes her tubal status irrelevant.) In addition, surgical intervention for endometriomas ("chocolate cysts," cysts that develop in the ovary due to endometriosis) and certain other conditions can actually lead to loss of fertility. We believe that it is important to fully consider all other less invasive treatment options available before determining whether or not surgery is truly an appropriate choice.
Read more: Is surgery a good idea for infertility?
Contrary to traditional belief, many cases of infertility (up to 40% of all cases) are due to male factors. These factors may include varicoceles, low sperm count, sexually transmitted diseases, structural anomalies, age, or medications.
Male infertility can be diagnosed through a semen analysis or other diagnostic procedure such as a physical evaluation or ultrasound. The type of treatment needed depends on the exact diagnosis and may include medications, surgery or testicular biopsy. However, in most cases of male infertility, treatment does not restore fertility enough for patients to father children "naturally." The good news, however, is that in most cases of male infertility, we now have assisted reproductive techniques, such as IUI and IVF, to help patients become fathers.
Read more: Low sperm count and abnormal semen analysis
How does IVF work?
In vitro fertilization, or literally "in glass" fertilization, is the process by which a woman's egg is fertilized with sperm outside of her body in a lab setting. This fertilized egg, now called an embryo, is then transferred back into her uterus for pregnancy.
This procedure is a common infertility treatment for women who have viable eggs, but have damage to their fallopian tubes or another fertility factor which prevents the possibility of pregnancy without assistance. IVF is also used when other infertility treatments have been unsuccessful.
The IVF procedure has five different parts: hormone suppression, ovarian stimulation, egg retrieval, fertilization, and transfer.
Step 1: Hormone Suppression
Regulation of hormones is a key part of a successful IVF procedure. In order to achieve this, a woman's own hormone cycle must be suppressed. Suppression is necessary to prevent premature ovulation (release of eggs), ensuring that mature eggs are available for egg retrieval.
Step 2: Ovarian Stimulation
Once a woman's own hormonal cycle is suppressed, medications are given to help stimulate the ovaries to encourage the development of multiple eggs. In a normal reproductive cycle, a women typically matures one egg. However, for an IVF procedure, multiple eggs are created in order to increase the chances of a successful pregnancy. Once the eggs are almost mature, a second medication is administered to help give a final "push" in preparation for retrieval and to trigger ovulation.
Step 3: Egg Retrieval
In egg retrieval, eggs are aspirated from the ovaries. In this procedure, a thin needle is guided by ultrasound through the vagina and to the ovaries where eggs are retrieved. This procedure is usually done under light sedation, and takes only 10 to 15 minutes.
Step 4: Fertilization
Using the partner's sperm or donor sperm, the retrieved eggs are fertilized in a lab setting either by mixing the eggs with the sperm or by injecting a single healthy sperm directly into each mature egg (this procedure is called ICSI). Once the eggs are fertilized, they become embryos. These embryos are allowed to mature for several days. The fertility expert will then decide which embryos are the healthiest and select those to be transferred back into the uterus for pregnancy.
Step 5: Transfer
A few days after the egg retrieval occurs, the female patient will come back to the center for the embryo transfer. The embryos are suspended in fluid and inserted directly into the uterus through a long flexible tube. The process is generally quick and painless; however, the woman will be advised or rest for a short period of time.
Once the IVF procedure is complete the couple will need to wait approximately 2 weeks before taking a pregnancy test.
How likely am I to become pregnant with IVF?
The success rate of IVF depends on multiple factors, including age and endometrial lining. However, the Society for Assisted Reproductive Technology reported that the average successful live birth rate after IVF in the US was 41% (for women under the age of 35). Because CHR treats older women with complex infertility cases, our IVF pregnancy rates cannot be directly compared to the national average or those of other centers.
Read more: How to interpret IVF success rates
Watch Dr. Barad explain the crucial importance of tailoring IVF treatment for each patient
Fertility medications for IVF and ovarian stimulation
Many fertility medications are used in fertility treatment. The list below contains typical fertility medications used. Although many fertility centers use the same small set of medications, the protocols that the fertility experts prescribe to each patient can be very different (and can make all the difference between a successful IVF cycle and a failed one). There are exceptions, of course, such as CHR's innovative use of dehydroepiandrosterone (DHEA) supplementation in women with diminished ovarian reserve. When taking fertility medications, follow your fertility doctor's instruction carefully, as timing can be very important for some medications, such as hCG.
Estrogen patches are used in IVF cycles to thicken your uterine lining (endometrium), so that your uterus is ready to welcome the transferred embryo(s).
Clomiphene citrate (called Clomid, by its brand name) is often the first fertility medication that reproductive endocrinologists prescribe for infertility patients. Clomid is most often used with intrauterine insemination (IUI) to induce ovulation.
In IVF cycles, Leuprolide Acetate (often called Lupron, even though it's a brand name--a bit like Band Aid and Hoover) is used to prevent premature ovulation. Because Leuprolide Acetate does this by suppressing the estrogen production in your body, you will need Follicle Stimulating Hormone (FHS) and/or Human Menopausal Gonadotropin (hMG) to encourage follicular development.
Follicle Stimulating Hormone (FSH)
Follicle Stimulating Hormone (FSH) is used in IVF cycles to stimulate your ovaries to produce multiple mature eggs.
Human Menopausal Gonadotropin (hMG)
hMG contains natural follicle-stimulating hormone (FSH) and luteinizing hormone (LH). In IVF cycles, hMG is used to regulate ovulation and encourage growth of multiple eggs when clomiphene citrate did not work well.
Ganirelix Acetate (GnRH Antagonist)
In IVF cycles, Ganirelix Acetate (often called Antagon, even though it's a brand name--a bit like Band Aid and Hoover) is used to prevent premature ovulation. Ganirelix Acetate suppresses Luteinizing Hormone, which would normally let your ovary to release the mature egg (i.e., ovulation).
Human Chorionic Gonadotropin (hCG)
hCG is similar to LH. In an IVF cycle, one-time injection of hCG is used to trigger ovulation to get your mature eggs ready for insemination.
Progesterone is used to thicken your endometrium (lining of the uterus) so that the implantation of fertilized egg(s) will be easier. Medications used in ovarian stimulation can suppress progesterone levels in your body, so it is important to supplement it with exogenous progesterone. You will be taking both Progesterone injections and Prometrium vaginally.
Micronized estradiol helps maintain and build your uterine lining so that the transferred embryos will find a comfortable environment there.
DHEA is a hormone naturally produced in the body. Introduced into fertility treatments by CHR, DHEA improves the quality of eggs and embryos, improves pregnancy chances, and reduce miscarriage rates.
Aspirin helps increases blood supply to your uterus and ovary. It also prevents clotting.
Prenatal vitamins, such as Folate, will help prevent neural tube defects. Iron will build up your blood count. Calcium helps build your babies' bones and will help you maintain yours.
Prednisone suppresses male hormones and immune function.
Doxycycline is an antibiotic used to prevent infection after the egg retrieval.
How to interpret IVF success rates
IVF success rates represent the number of times a fertility clinic achieves a favorable outcome from a in vitro fertilization procedure. Success rates are published by individual clinics, and CDC/SART provides this information to the public. For patients, it is important to know that there are two different types of IVF success rates: "clinical pregnancy rate" and "live birth rate." Knowing the difference between the two can help you understand major variations in success rates between different fertility clinics.
Clinical Pregnancy Rate
A clinical pregnancy rate is the percentage of women that have a positive pregnancy test following an IVF treatment, regardless of whether or not the pregnancy results in a live birth. Because miscarriage rates are often high among women seeking fertility treatment (25% or more), the clinical pregnancy rate is usually higher than the live birth rate. However, in many cases, clinical pregnancy rates are the only available success rates for fertility clinics.
Live Birth Rate
The live birth rate is the percentage of IVF procedures at a fertility clinic that result in a live birth of a baby. Since this is the desired outcome for couples, this is the type of success rate that is often sought by patients. For many reasons, however, live birth rates are often not available (one difficulty that fertility centers face is the length of time it takes for a pregnancy to reach full term).
In addition, patients should be cautioned that there are many factors that may influence an IVF center's IVF success rate, including their practice specialty or if there are exclusion criteria for IVF patients. For example, clinics that specialized in IVF for the older women will have a lower IVF success rate than clinics that treat a younger patient population. In addition, many clinics artificially keep their IVF success rates high by excluding patients who are less likely to have a successful IVF treatment (criteria includes age, FHS levels, number of follicles, etc.). We don't!
Read more: How to interpret IVF success rates
Comparing IVF and Other Fertility Options
Mini IVF: Is it really cheap?
Low-cost IVF, also often called "Mini IVF," has recently gained popularity as an attractive alternative to regular IVF. These programs may run as low as $5,000, a huge savings compared to standard IVF programs which usually charge upwards of $10,00 per cycle. However, this does not make them cheap. Unlike regular IVF, low-cost IVF cycles have significantly reduced success rates and on average require more cycles to achieve a pregnancy. In other words, couples may wind up spending much more than they would have had they invested in a regular IVF program. In addition, needing more cycles to get pregnant means that you'll have to spend more time trying, a stressful proposition. Unless your primary motivation is to use as little medication as possible for ovarian stimulation, Mini IVF may not be the best option! Although we do offer a type of low-cost IVF called EcoIVF (with proper informed consents), we strongly encourage you to discuss your options thoroughly with your IVF physician before option for Mini IVF cycles.
Read more: Weighing Mini IVF and Regular IVF
IUI vs IVF
Intrauterine insemination (IUI) and in vitro fertilization (IVF) are two of the most common infertility procedures prescribed.
Intrauterine Insemination (IUI)
Often considered a first-line treatment, IUI is one of the least complicated and most cost-effective options available for some fertility patients. In an IUI procedure, the male partner's sperm is "washed" in a lab setting to create a highly concentrated sample of healthy sperm. Then, a woman's cycle is monitored to determine when she is most likely to ovulate and become pregnant. At the time of ovulation, the sperm sample is inserted directly into the uterus through a long thin catheter.
The success rates for IUI depend on the couples' individual factors such as infertility diagnosis, age, etc. Typically, IUI success rates are lower than IVF; however, the cost of the procedure is much less and therefore younger couples who can afford to "wait and see" may undergo more rounds before deciding whether or not to advance to a more complex and expensive treatment options. IUI is generally a good option for couples with regular ovulation, open tubes and mild male factor infertility, who can afford to "wait and see."
In Vitro Fertilization
In vitro fertilization (IVF) is the process by which a woman's egg is fertilized with sperm outside of her body in a lab setting. This fertilized egg, or an embryo, is then transferred back into her uterus for pregnancy.
This procedure is a common infertility treatment for women who have viable eggs, but have damage to their fallopian tubes or another fertility factor which prevents the possibility of pregnancy without assistance. IVF is also used when other infertility treatments have been unsuccessful, or when patients' reproductive time frame doesn't allow for trying less costly but less reliable treatments like IUI.
Read more: IUI vs IVF
Tubal Reversal vs IVF
One reason a couple may need fertility treatment is the past use of tubal ligation as a form of permanent birth control. When life circumstances change, some of those who had tubal ligation realize that they want more children. Without permeable fallopian tubes, a fertilized egg cannot travel to the uterus and therefore pregnancy cannot occur.
Pregnancy After Tubal Ligation
Women who have undergone a tubal ligation but later decide they desire more children have two options to try and become pregnant again: tubal reversal or IVF.
Tubal reversal is an attempt to surgically repair the fallopian tubes. However, the availability of this option depends on the amount of healthy tubes left. When surgery is not possible or the likelihood of a natural pregnancy after tubal reversal is low, IVF is an alternative, often more reliable, option. In an IVF procedure, the need for healthy fallopian tubes is bypassed by extracting mature eggs out of the ovaries, fertilizing them in a lab setting, then implanting them back into the uterus for pregnancy.
Some considerations in deciding which procedure is right for you may include financial factors (many insurances do not cover the cost of this surgery, which can be very expensive), methods used for tubal ligation, or the likelihood of a natural pregnancy after a tubal reversal.
Read more: Tubal Reversal vs IVF
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Last Updated: September 11, 2013