Infertility and Trying To Concieve

Click a main topic:

Beginning test steps	More aggressive female tests
More aggressive male tests/sperm donation	A.R.T. & procedures
Hints/Tips on ART Preparation	Surrogacy
PCO	Resource URL/groups

Most women assume that they will get pregnant as quickly as others. This isn't always true. There are times it can take up to 6 months or more of regular trying before you get pregnant and there be nothing wrong with either you or your partner. You also want to check up on infertility causes from Harvard.

Preliminary steps

When to see a medical professional:
The general guidelines on seeing a doctor are that if you are under 35 (some doctors will go 33) you should try on your own for one year (with no history of diseases or problems), and 6 months if you are 35 or older. If your cycles are regular (anywhere from 28 to 35 days), then you very possibly will get pregnant.

Why you may not get pregnant right away:
If your menstrual cycles aren't within a 28 to 35 day range, you can have ovulation disorders such as PCO. You could also have a condition known as endometriosis, where the uterine lining travels to other parts of the body. It does not always cause pain, so you may still have it and not know it. You can also have scaring on your tubes from the lining if it travels and stays there.
While we're at it: a word on lubricants. Try to not use eggwhites, petroleum jelly, plain glycerin, or saliva. These tend to impede sperm. The body's own natural lubrication or Astroglide, Femglide (I believe available only thru a MD), or Replense are reported to work well.

What can you can do before calling in a doctor:
Take your temperature the first thing in the morning, before getting up. This is called a BBT or Basal Body Temperature. You should see around the 14th to 18th days an almost 1 degree spike in temperature for ovulation. I could list all the details but Beth already has a great explanation on her BBT page. If you need a chart, Fertility Plus has one. If you don't see it consistently for a couple of months, its time to call a doctor.

What the first steps might be:
Most women call their ob/gyn's first. You should get hormonal bloodwork done. These are your normal hormone levels. and some other blood tests results are here. Checking the thyroid is also very important in infertility. You need your T4 and T3 checked. An explanation with values can be found here. If you want to know what your doctor is looking for during exams, this page gives you a chance to look up several different types of regular screening exams by your doctor. Some of the more specific exams, such as both male and female infertility checks are here.
Also, a vaginal ultrasound to check for defects of the uterus and ovaries. Things such as PCO and prolactin problems can be treated with the appropriate therapy. If your bloodwork and ultrasound are negative, your health care professional generally will start with prescribing Clomid or Clomiphene Citrate, a pill that will help you ovulate. You usually end up taking this drug anywhere from days 3 to 5 of your cycle, for 5 days in a row. If this doesn't work after 3 cycles, you will want to consider going to a reproductive endocrinologist. This is a person who is an ob/gyn with 3 extra years of study solely in treating the more advanced women's health problems: PCO; endometriosis; fibroids; and the ART techniques: IVF; GIFT; ZIFT; ICSI. Some of this and previous information can be found at IHR.com.

The next steps in tests:

What this reproductive endocrinologist might do:
First they should check over the bloodwork that has been taken, and complete any tests necessary that haven't been done. You may end up having tests on the 3rd or 5th day of your cycle, and the 21st. This is to see if you have enough hormones being produced to become pregnant on your own. Not only should reproductive hormones be checked, but also the thyroid and prolactin levels. Problems too little or too much of these hormones can be a problem in becoming pregnant. You should also get a thorough pelvic exam and maybe hysteroscopy, endometrial biopsy, or a hysterosalpingogram. The hysteroscopy is simply a procedure that places a small camera in the uterus, to look for fibroids or other abnormalities. A sonohystogram is a little better than this: sterile water is poured into the uterus to extend the walls and then a vaginal ultrasound is used to view for abnormalities. The SHG picks up polyps and other problems that regular vaginal ultrasounds don't. The endometrial biopsy is usually a small piece of the uterus taken just a few days before your period, to be examined for any abnormalities. A hysterosalpingogram checks the patency of the Fallopian tubes by injecting a dye in the tubes and using an Xray/ultrasound to view what happens.

If your HSG came back and your tubes are blocked:
More than likely Invitro Fertilization or IVF will be the next step for you. Although sometimes just the dye going through the tubes is enough to unblock them, it is not a for certain occurance.

More aggressive tests for the female

What a laparoscopy is:
This is general surgery where a small incision in made in the belly button, and a camera is inserted to view the pelvic organs. This is usually done to remove endometriosis and scar tissue from it. It can also be used to correct some abnormalities that are found on the outside of the reproductive organs. Endometriosis, a common cause of infertility, may not always show symptoms and the only way this can be found (diagnosed and removed), is through this procedure. You will more than likely have to take a few days off from work (if you do) for this surgery. It can be performed on an outpatient basis, but you will want to rest up from the anestetic and allow the incisions time to heal.

What a hysteroscopy is:
This is a diagnostic procedure where the cervix is opened and a small camera is passed through the uterine canal, allowing the inside of the uterus to be viewed. At this time, if a polyp or fibroid is found, it can be removed. Unless you are undergoing a laparscopy at the same time, this might be done in your doctors' office, under a local anestetic. You will feel sore, but will be able to resume normal activities unless a doctor has recommended otherwise.

More aggressive tests for the male, including sperm donation

Testing the male partner:
A male is about 40% likely to contribute or cause an infertility problem. This male factor infertility homepage will tell you more about the general specifics of it.
An andrologist or urologist should test the male for producing a fair amount of sperm, with good motility (or movement) and strength (to swim up the female reproductive tract). If the male is having problems with any one of those, medicines may be administered to help. Or you may decide to opt for a sperm donor.

About sperm donation:
You usually can go to a sperm bank, where you can look over lists of anonymous donors along statistics on health and physical characteristics. Here you can pick and choose what you like. These banks usually will perform a number of health checks (request a copy of them) such as HIV and hepatitis testing, along with questions and psychological tests.

Sperm banks online:

Pacific Reproductive Services

Cyrolab

California Cryobank

Northwest Andrology & Cryobank Inc.

Sperm donor resources and related URL's:

Health Library's donor resources

Donor Insemination

Shared Journey's Sperm and Egg Donor information

Parents Place

Dr.Koop's

Elizabeth Noble's book "Having Your Baby by Donor Insemination"

Aggressive Artificial Reproductive Techniques

What an InterUterine Insemination (IUI) is:
IUI (may be called Donor Insemination) does is to take the sperm and place it in the uterus, therefore bypassing parts of the female reproductive tract. This allows more sperm to get to the egg, and also the sperm have less space to travel. This usually gives you more sperm hitting the egg, although the chances of getting pregnant each month are about the same as regular attempts. You usually will be monitored by ultrasound to see out big a follicle (what becomes an egg) is. Once it hits 18 to 22 mm in size, you may get a shot (known as an HCG shot) to trigger ovulation. Within 36 hours of that shot, you have your IUI. Some places give you 2 IUI's in one cycle. It is supposed to give better results, but I've never seen anything in the way of a study proving that. Your partner (if you are not using donor sperm) will be required to give a sample a few hours before this procedure, so it can be cleaned and washed. Later on, you will have a small catheter passed into the uterus and the sperm are inserted high in the uterus. You can lay down for 10 to 30 minutes after the procedure, or you can get up and go on. A more fuller explanation can be found at A Complete Guide to Intrauterine Insemination (IUI).
You may hear of another procedure called ICI. This is intracervical insemination, but when you look at pregnancy outcomes, you will see why it is really not used. This is where the sperm is deposited in the cervical canal, instead of high up in the uterus.

If IUI doesn't work: IVF information:
Your options after this go to IVF or IVF with ICSI. Simplicity and Success in IVF gives some information on having success with IVF. Ovulation induction is a major part of the process. The first thing that will happen is that you may be given Lupron on birth control pills so that the medical professionals can get control of your cycle. Usually after a period, you will start injecting fertility drugs so that your ovaries produce a lot of eggs. At the appropriate time, you will be put under sedation for retrieval of these eggs. The eggs will be collected or harvested, and placed in a petri dish with your husband's sperm for fertilization. The latest techniques keep these fertilized eggs there for 5 days, so that the strongest and best are left. The embryos are then placed back into the woman's uterus. Any embryos left are usually preserved.

Hints and Tips on Preparing for A.R.T.

Some notes on IVF:

You will be need lots of injectable fertility drugs.

Plan for unseen expenses: unpaid time off from work, travel costs, etc.

You will need lots of emotional support.

Icepacks and sterile saline may be needed if your fertility drugs sting or need to be mixed.

Choosing your center
It is important to pick a center who publishes their ART rates. The CDC publishes the ones that you should look at. The ASRM guidelines are about the best all around I've seen. I would add that you want to check out and see if 24/7 care and availability of services is provided.

Acronyms:
ICSI (Intra Cytoplasmic Sperm Injection) is where a sperm is actually placed inside the egg to fertilize during IVF. Most of the major ones I have touched on here. For a more fuller list check out: Art acronyms.

An idea of costs:
IUI can be anything from $200 to $2,000, depending on whether or not you use Clomid, donor sperm or injectible drugs during that cycle. IVF/GIFT/ZIFT/ICSI end up costing around $6,000 to $12,000, depending on injectible drug cost (avg. $2,000 a cycle) and extras like ICSI (avg. $2,000 a cycle) added to the IVF.

Surrogacy

What surrogacy is:
Normally this is where eggs are removed from another female and used for in the IVF process instead of the woman's own eggs. This can be for several reasons: loss of ovaries, loss of ovarian function, genetic problems and age. I use the following 4 URL's to give you a more in-depth look at surrogacy:

TASC: The American Surrogacy Center

Fertility Alternatives

Jenn's Surrogacy Links

Surrogate Mothers.com

PCO specific information

PCO and infertility specific notes:
Clomid does not always work. Check out the PCO pages, because you may be insulin resistant, in which case an anti-diabetic drug will work for you. It will be much cheaper and less invasive than any of the previous mentioned techniques.
OPK's (Ovulation Predictor Kits) can be a problem, due to higher than normal levels of LH. Fertility Plus might be a good place to check on this for further information.
Home pregnancy tests may not be accurate for the same reason, but supposedly Q test and Ovuquick are good.
Your doctor may want to do Ovarian Drilling. This is when 5 to 10 holes are poked in the ovary to help the follicle 'pop out' of the ovary on its own. PCO can cause the ovary to harden, so that the egg can't come out. PCO women seem to do well with this procedure. Dr. Leon Speroff in "Clinical Gynecologic Endocrinology and Infertility" says that ovarian drilling can happen for about 15 to 20 pokes per ovary. Between 70 and 80% of women ovulate, 60% get pregnant, but the adhesions are the biggest problem (pg 1123). It is risky, as you are cutting on the ovary itself. The surgery should only consist of about 10 to 15 at the most holes poked into the ovary. This is to help you ovulate. What happens in PCO is that the ovary can develop a 'hard coating', something like the outer shell of an M&M candy. The holes that are drilled can help the ovary to be able to release eggs and 'crack the outer shell'. Laparoscopic drilling by diathermy is the only online medically reviewed material I know about on this topic. The following is a list of medical articles on the subject that you may ask your doctor about:

In vitro fertilization following laparoscopic ovarian diathermy in patients with polycystic ovarian syndrome, Acta Obstet Gynecol Scand Vol. 76 no. 6 pp. 555-8

Laparaoscopic fenestration of the ovaries in Akush Ginekol Sofiia Vol. 36 no. 2 pp. 20-1 (Bulgarian)

American Journal of Obstetrics and Gynecology Vol 173 no 1 pp 119-25 "Laser vaporization of the ovarian surface in PCOD results in reduced ovarian hyperstimulation and improved pregnancy rates."

Gynecologic Endocrinology Vol 10 no 4 pp 257-64 "Laparoscopic ovarian treatment in infertility patients with PCOS: endocrine changes and clinical outcome."

Human Reproduction Vol 9 no 12 pp 2342-9 "Long term followup in 206 infertile patients with PCOS after laparoscopic electrocautery of the ovarian surface."

International Journal of Fertility and Women's Medicine Vol 42 no 6 pp 436-40 "Reproductive performance and 3 dimensional ultrasound volume determination of polycystic ovaries following laparoscopic ovarian drilling."

Human Reproduction Update (ISSN 1355-4786) Vol 3 no 3 pp 235-53 "Current and future status of ovulation induction in PCOS."

Impaired glucose tolerance in pregnant women with polycystic ovary syndrome, Obstetrics and Gynecology vol 94, no 2 August 1999, Paula Radon, MD, Michael McMahon MD MPH, and William R Meyer, MD

The Journal of Clinical Endocrinology & Metabolism, April 1999, p. 1470-1474 The Endocrine Society Vol. 84, No. 4 Restoration of Reproductive Potential by Lifestyle Modification in Obese Polycystic Ovary Syndrome: Role of Insulin Sensitivity and Luteinizing Hormone

The prevalence of polycystic ovaries in women with infertility, Human Reproduction vol. 14 no 11 pp 2720-2723, 1999, E. Kousta, DM White, E Cela, MI McCarthy and S. Franks

Resource URL's and groups

Treatments and resource URL's:

Infertility information

Fertile Thoughts

Info for those persuing fertility treatments

Fertility Info

Infertility resources

The Science of Infertility

Ohio Reproductive Medicine's site

IVF Online

Preconception.com

Getting Pregnant