DIAGNOSTIC PROCEDURES
Testing for Fallopian Tube and Uterine Abnormalities

PELVIC ULTRASOUND
This is a noninvasive method for evaluating the uterus and ovaries by using high frequency sound waves rather than x-rays to show what is inside your body. Because the body contains over 90% water, sound can be used just as sonar is used in the ocean. Each time the sound hits a tissue interface, like a blood vessel, an echo is sent back. Sophisticated, high-speed computers can use these echoes to create a picture of your internal organs. Ultrasound carries little risk or discomfort while producing clear images that enable the physician to count any mature follicles present and examine the endometrium. Fibroid tumors and ovarian cysts can be diagnosed as well.

POST-COITAL TEST (PCT)
The post-coital test (also known as a Huhner) is an excellent means of assessing the interaction of the sperm and the cervical mucus. In order to reach the fallopian tube and fertilize an egg therein, the sperm must first migrate through the cervical mucus. There are many factors which can impair the ability of the sperm to survive and traverse the cervical mucus, including infection, prior surgery on the cervix, and production of antibodies (substances that can kill or immobilize the sperm).

During a normal menstrual cycle, there are only a couple of days during which the sperm can survive in the cervical mucus. At other times of the cycle the mucus is a very effective barrier. Around the time of ovulation, the cervical mucus becomes very thin and watery and probably even somehow assists the sperm as they migrate through to the uterus and on to the fallopian tube. The quality of the cervical mucus as well as the number of sperm present and their motility will be assessed. The timing of this test is, therefore, crucial and must be done within 12 hours after Intercourse.

The post-coital test is an important part of the evaluation of difficulty conceiving. If it is not normal, other evaluation or therapy may be suggested.

SPERM ANTIBODY TESTING (INDIRECT IBT)
Is used to rule out the presence of sperm antibodies in female partner's serum. May be drawn at anytime during the woman's cycle.

ENDOMETRIAL BIOPSY
A procedure by which a sample is taken of the endometrial lining of the uterus, shows evidence of ovulation and degree of maturation of the uterine lining, and can reveal uterine cancer, uterine fibroids, uterine polyps, and adenomyosis. This test also reveals if the woman has a luteal phase defect - a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced. The test is typically performed 1-3 days before onset of woman's menstrual flow.

HYSTEROSCOPY
This is a procedure that involves insertion of a narrow telescope-like instrument through the vagina and cervix into the cavity of the uterus (endometrial cavity). The uterine cavity is then distended with fluid and visualized. This procedure allows us to determine whether there are any defects such as fibroid tumors, polyps, scar tissue, a uterine septum, or other uterine problems inside the cavity.

LAPAROSCOPY
About 40% of infertile women whose initial Fertility work-up is unrevealing will demonstrate abnormal tubal or uterine findings on a laparoscopic examination. Laparoscopy requires two small incisions (one at the navel and one above the pubic bone). Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. The laparoscope, a hollow tube equipped with a tiny camera, lenses, and a fiberoptic light source, is inserted through the umbilical incision. A probe is then inserted through the second incision allowing the physician to directly view the outside surface of the uterus, fallopian tubes, and ovaries. Endometriosis, pelvic scar tissue, and blockage at the ends of the fallopian tubes can all be identified using laparoscopy. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants. The procedure is usually done under general anesthetic and the wound itself is minimally painful.

MICROLAPAROSCOPY
A new minimally invasive diagnostic surgical procedure uses telescopes and instruments that are much smaller than normal. If this procedure is appropriate for your condition, smaller incisions will be made and postoperative abdominal tenderness may be reduced.

GENERAL INFERTILITY TREATMENTS

Artificial Insemination (AI):
Places sperm directly in the cervix (called intracervical insemination). Artificial Insemination is useful for women who have structural problems, when the cervical mucus is unreceptive, when donor sperm are required, when the male partner's semen contains very low numbers of sperm, or when unexplained Infertility exists in both partners.

In order to prepare for AI, a woman usually takes Fertility drugs in advance. The man must produce sperm at the time the woman is ovulating. The sperm are then "washed", using high-tech laboratory procedures and are then inserted into the uterine cavity through a long, thin catheter. To reduce the risk of multiple births, the amount of the drug and the response to it is carefully monitored with several ultrasounds and blood tests for estrogen levels.

Intrauterine Insemination (IUI):
Involves placement of sperm following separation from seminal fluid into uterine cavity.

Microscopic Tubal Reconstructive Surgery
Treatment for reversal of tubal ligation or tubal obstruction. Tubal ligation reversal (reanastomosis) is a surgical procedure, which can restore the function of fallopian tubes, which have been blocked by a previous sterilization operation. Reversal operations are performed using microsurgical techniques, in which microscopes or loupes are used to visualize and bring together the very narrow hollow center portion of the fallopian tubes. Microsurgery also uses very thin suture materials, the smallest possible incisions, specially designed instruments and non-traumatic tissue handling techniques. Patients go home the same day

Ovulation Stimulation
Treatment for women who do not ovulate. This treatment requires the use of ovulation-inducing drugs such as Clomiphene, Humegon, Pergonal, Metrodin, or Gonadotropin Releasing Hormone (GnRH). Monitoring involves follicular sonograms and serum hormonal tests.

Advanced Laparoscopic Surgery
Treatment for tubal obstruction, pelvic endometriosis and/or adhesions; ovarian cysts, ectopic pregnancy. Involves a small surgical incision through the naval.

Advanced Hysteroscopic Surgery
Treatment for intrauterine insemination adhesions, polyps, fibroids, and uterine septum; tubal catherization for tubal obstruction. Involves the insertion of a small scope through the vagina and cervix.

ASSISTED REPRODUCTIVE TECHNOLOGY (ART) PROCEDURES

Assisted Reproductive Technologies (ART)
Assisted Reproductive Technologies or ART, include several different techniques or procedures now available to help couples achieve fertility after other surgical and hormonal methods have failed. These procedures employ techniques that retrieve eggs from the ovary and re-implant them. Fertilization may occur either in the laboratory or in the uterus. For many couples, ART offers the best hope of achieving pregnancy. Following is a description of each of these procedures and how they work:

In Vitro Fertilization (IVF)
In Vitro Fertilization is probably the best known and most widely used ART procedure. For well over a decade, IVF has allowed infertile couples the chance to conceive and bear children. . The best candidates for IVF are women with damaged fallopian tubes.

IVF is a four-stage procedure. The beginning of this process involves ovarian stimulation to produce several mature eggs that can be harvested from the ovary before they have been released from the follicles, and the monitoring and collection of eggs. Multiple eggs are removed from the woman and placed in a special medium for two to three hours. The male semen is processed, using different techniques to obtain a vigorous motile sperm. The prepared sperm is then introduced into the medium containing the egg(s).

Many of these eggs will fertilize and develop into embryos, which are then transferred back into the woman's uterus through a simple procedure that requires no anesthesia. In most cases, egg recovery is preceded by a period during which the woman receives daily hormone medications to stimulate the growth of multiple eggs. In some instances, however, it may be possible to accomplish IVF without the use of these ovulation induction medications.

Gamete Intra-Fallope Transfer (GIFT)
GIFT is an ART procedure developed to assist women, particularly those who have normal fallopian tubes, but there is unexplained infertility. In these cases it can be difficult to determine if the sperm and egg ever meet, so this procedure allows for a site where fertilization is most likely to occur.

This technique is similar to IVF with the exception that the harvested eggs are not fertilized. The eggs are mixed with the washed and capacitated sperm and immediately placed directly into the woman's fallopian tubes through a laparoscope (a long thin catheter), thus the sperm and egg are placed exactly where they would be in natural fertilization. Fertilization then occurs in the woman's fallopian tubes, after which they move down into the uterus for implantation according to a "normal" timetable.

Zygote Intra-Fallope Transfer (ZIFT)
This procedure is a combination of IVF and GIFT. The eggs are fertilized with washed and capacitated sperm in the laboratory as in the IVF procedure, but then the beginning-stage embryos are placed directly into the patient's fallopian tubes as in the GIFT procedure. This blending of IVF and GIFT technique offers the advantage of confirming that fertilization has occurred and the eggs can be examined for defects before implantation. This procedure also provides the natural environment of the fallopian tubes for the very early conceptus.

Donor Oocyte Program (DOP)
Age, is the most important determinant when a woman uses her own eggs. Rates for ART are relatively high for both pregnancies and live births among women in their 20's but they decline after 30 and go sharply downward toward the end of the decade and afterward. The patients who can most benefit from oocyte donation are those who lack ovarian function.

The use of donor eggs has made it possible for many older women, (Success rates using donor oocyte's depend on the age of the donor, not the age of the recipient.) This procedure provides healthy eggs from either a known or anonymous donor to women who are unable to utilize their own eggs to achieve pregnancy. Fertilization can be with the sperm of the recipient's husband to the fallopian tubes of the recipient (GIFT), or the eggs can be fertilized In Vitro with the resulting embryos transferred to the recipient's uterus (IVF) or to her fallopian tubes (ZIFT).

Embryo Cryopreservation
In cases where more eggs develop into embryos than are going to be transferred to the patient, the couple will have the option of cryopreservation, or freezing, of the embryos for transfer into the woman's uterus at a later date.

Cryopreservation is used to minimize the risk of multiple births, which increases dramatically if more than four or five embryos are replaced. Once embryos are frozen in liquid nitrogen and stored, viability will remain unchanged for long periods. With current freezing and storage methods, 60 to 80 percent of embryos will be viable after thawing. One of the advantages of embryo cryopreservation is that transfer of the thawed embryo may occur in a natural ovulatory cycle.

Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection (ICSI) is a highly sophisticated technique for injecting one single sperm into an egg using microscopic and micromanipulation instruments. In men with low sperm count, low motility or a high number of abnormal sperm, this technique has proven to be a highly successful remedy. Combined with IVF or ZIFT, the procedure of ICSI is able to achieve a high rate of fertilization and normal embryo development. ICSI has even been successful in cases where sperm must be taken directly from the testes (testicular biopsy) due to the absense of sperm in the ejaculate or a previous vasectomy. ICSI is also the best choice when other andrology tests identify a possible problem with sperm function.

Assisted Hatching
This is a procedure of making a tiny hole in the membrane surrounding the embryo before implanting to assist it in attaching to the uterus. This thinning the membrane of the fertilized egg may increase implantation rates in eggs from certain women, such as those over age 40.

Blastocyst Transfer
This is a procedure that allows a longer time for the embryo to develop in the laboratory (five days instead of two to three). This enables the embryo to reach the blastocyst stage, which is the natural embryonic stage for implantation in the uterus.

Many couples undergoing In Vitro Fertilization accept the risk of multiple gestation as an integral part of the treatment process. They want to maximize their chances of achieving a pregnancy and will transfer three or more embryos to achieve their goal. After all, the chance of taking home a baby is not 100%, and the cost of an IVF cycle can be quite significant. Sometimes, the financial resources of a particular couple may only allow them to undergo an IVF cycle once in their lifetime. The end result of transferring 3 or more embryos has been a significant increase in the rate of triplet and higher order multiple pregnancies. There are enormous medical, social, and financial consequences of this increase in multiple birth rate.

One solution to this problem may be to culture the embryos for 5 or 6 days, to the blastocyst stage. Embryos developing to the blastocyst stage (blastocysts), have a higher implantation rate than embryos grown only three days, and are more likely to succeed in initiating a pregnancy. As result, only two blastocysts need to be transferred to have the same pregnancy rate usually seen when 3 or more embryos that have been grown for only 2 or 3 days are transferred into the uterus. In other words, fewer embryos are needed to achieve the same or higher pregnancy rate, resulting in a lower incidence of multiple gestation.

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