INFERTILITY DIAGNOSIS

Understanding the cause and/or causes of your problem ~ Prompt and accurate infertility diagnosis is paramount prior to beginning fertility treatment.

Your diagnostic evaluation

 • Female evaluation

• Male evaluation

• Proceeding to treatment

Your treatment options

• Treatment must address the diagnosis

• Treatments with a gynecologist

• Treatments with a fertility specialist

PROMPT AND PROPER DIAGNOSIS IS IMPORTANT

We try to complete your diagnostic evaluation within one month of your first visit with Dr. Brandeis.

Most patients will be ready to start treatment immediately after evaluation.

Most fertility tests and procedures are timed to your menstrual cycle.

• A menstrual cycle is the number of days between two menstrual periods.
• Twenty – eight days is usually considered the normal cycle length, but most women have cycles between 26-30 days apart.
• The first day of full bleeding from your period is considered day-1 of the cycle.

Female Evaluation

At the start of your cycle, blood is drawn to determine your baseline hormone levels.

• FSH, LH, and Prolactin are the hormones that regulate reproductive function and are produced in the pituitary gland  in the brain.
• Estradiol (E2) and progesterone are the hormones produced by the ovaries  in response to the pituitary hormones.

Dr. Brandeis will explain to you significance of any abnormal level in these hormones.

The ESH and E2 levels tend to fluctuate between normal and  elevated in different cycles for older  women.

Pelvic Ultrasound

A baseline pelvic ultrasound (trans – abdominal and transvaginal) performed by a radiologist is  recommended to determine:

• The size and location of your ovaries, and
• Whether you have any ovarian cysts or uterine fibroids.

At the beginning of your cycle, Dr. Brandeis will also evaluate your ovaries and uterus by transvaginal ultrasound to:

• Check for the pressure of any ovarion cysts, and
• Determine the number of visible follicles (5mm or larger) in your ovaries.

Especially if you are older than 37, this antral follicle count can indicate how you will respond to stimulation.

Uterine / Tubal Studies

These procedures document the condition of the uterine cavity [the space within the uterus in which a baby will grow] and your fallopian tubes.

A Sonohysterogram (SHG), is recommended by Dr. Brandeis if regular ultrasound indicated the presence of fibroids or polyps inside your uterus.

• SHG is an ultrasound procedure that involves injecting saline solution to distend the uterine cavity first so it can be visualized better.
• The presence of a polyp (a soft tissue growth from the uterine lining) or a submucosal fibroid (a fibroid with a component that bulges into the cavity) may interfere with embryo implantation and surgery is advisable before you proceed to fertility treatment.

Hysteroscopy is recommended if a uterine polyp, fibroid or scar tissue are present within the uterine cavity.

• This is a simple procedure performed in a hospital under general anesthesia.

• The hysteroscope – a thin telescope with a light optical lenses attached to a microcamera – is introduced through the cervix to visualize the  interior of the uterus.

• The hysteroscope has a channel through which the surgeon can pass micro – instruments to remove the polyp, fibroid or scar tissue under direct visualization

Male Evaluation

Semen Analysis:

This is the basic male fertility test, which determines

• Semen volume
• sperm concentration – the number of sperm cells present in one milliliter (1 ml or 1cc) of semen.
• Sperm motility – the percentage of moving sperm and how they are moving (rapid, moderate, slow; progressively forward, erratic movement or simply moving in place).
• Sperm morphology – the shape of sperm heads, determined by strict criteria; and whether there is a significant number of immature sperm.

Reference values for these basic characteristics are:

• Volume – 2 ml or moreely
• Sperm concentration – > 20 million/ml of semen
• Motility – > 50% of sperm moving in forward linear motion
• Morphology at least 14% with normal head shapes, using strict criteria.

If the first analysis is unsatisfactory in terms of sperm number, a second semen analysis taken after a month may be advisable.

Even if your semen analysis shows a deficiency in sperm number (< 10 million / cc) or quality (sub-optimal motility and morphology), we can still proceed with your fertility  treatment  immediately by using a technique  called intra – cytoplasmic sperm injection  (ICSI).

With ICSI, only one sperm cell is needed to inseminate an egg. So, theoretically, if the female partner produces 5 mature eggs during  an IVF cycle, only 5 sperm cells are needed for  ICSI.

In many cases, if the semen analysis is poor – especially in younger men Dr. Brandeis would advise the patient to see a urologist who can determine if there are conditions that can be  treated to improve the semen.

Your Treatment Options

The Treatment Must Address Your Diagnosis And Your Age

• If you are older than 37, Dr. Brandeis will usually advice you to begin with a more aggressive treatment even if, for instance, your problem is only ovulation dysfunction.

Fertility Treatment Options

Treatments You May Do with a Gynecologist

The following treatments, in order of complexity, may be done with a gynecologist:

• Well timed intercourse
• Use of fertility medication alone
• Artificial insemination, without medication
• Artificial insemination, with medication

However, these treatments are options only under all of the following conditions:

• Your tubes are open
• Your husband does not have a severe sperm problem
• You are younger than 40
• You have been trying for less than 3 years
• You have not tried these treatments before.

Dr. Brandeis believes that more than 3 months of any one treatment is not advisable.

If you do not conceive after 3 months of one treatment, it is time to move on to the next treatment level.

Treatments With A Fertility Specialist

The following treatments, usually referred to collectively as assisted reproductive technologies (ART), may only be done only with an infertility specialist:

• In vitro fertilization (IVF)  with your own eggs
• IVF with donor egg (Donor – Egg IVF)

IVF itself can be enhanced with:

• Intra Cytoplasmic sperm injection (ICSI)
• Assisted hatching