Fertility Specialists of Texas

Age and Infertility

Infertility that comes with aging is an increasing problem due to general societal trends for women to delay childbearing. Currently, testing is unable to predict with absolute certainty which patients will be successful through fertility treatment. Our office does not refuse treatment based on testing.

Delayed Childbearing

Many women are waiting until their 30s and 40s to have children. In fact, about 20 percent of women in the United States now have their first child after age 35. Women have a set number of eggs when they are born, and as they age their eggs also become older and have an increased risk of chromosomal abnormalities. From the time of birth to puberty, all eggs are “suspended in time”. When menstrual cycles begin, one egg is selected from this pool of eggs every month. This decline in fertility potential, or “ovarian reserve”, is the natural consequence of the aging process on human eggs. Once one egg is selected for a particular menstrual cycle, the LH surge occurs and triggers completion of the ovulation process. Now the egg can be fertilized. The length of time the egg waits for selection as a dominant egg corresponds to the chronological age of the woman. Lower pregnancy rates and higher miscarriage rates are both the consequences of the aging process, and reflective of a decline in egg quality. Women ovulate their healthiest eggs during their 20?s and early 30?s. By the mid 30?s the remaining eggs are of lower quality, and by the early 40?s only eggs with very low fertility potential are available for ovulation. This phenomenon is a normal biological process, which neither fertility medications nor lifestyle changes can halt. A healthy egg has two functions necessary for a successful pregnancy. First, it must have normal chromosomes, and second, it must be able to combine its chromosomes with those of the sperm in a correct and efficient manner to produce a normally dividing and growing embryo. While eggs are suspended in time they are susceptible to injury which may result in chromosomally abnormal embryos. These embryos usually do not continue to grow and no pregnancy is established. If an abnormal embryo does result in a pregnancy, it is more likely to lead to an early miscarriage.

Ovarian Reserve Decreases with Age

In contrast to males, females at birth have their entire oocyte compliment of one million which declines to approximately 400,000 by puberty. Only when the hormonal environment is appropriate will one or more follicles proceed to maturity and ultimately to ovulation while other follicles regress. The later in life an oocyte is recruited, the longer it has been frozen in a relatively unstable state which may allow for damage to the egg. This may result in failure to achieve pregnancy, increased incidence of spontaneous abortion or, more rarely, chromosomally abnormal children. For lack of a better term, this period has been dubbed the period of “diminished ovarian reserve.” During your first visit with one of our physicians, you will undergo an ultrasound evaluation of the ovaries to evaluate your “resting follicle” count which will be one parameter your doctor will use to evaluate your ovarian reserve.

What are the Causes of Decreased Ovarian Reserve ?

Diminished ovarian reserve refers to a group of patients at any age that are cycling regularly but whose ovaries, and the eggs contained within, have a markedly decreased ability to produce pregnancies. Risk factors for this entity include age 35, previous ovarian surgery, single ovary, unexplained infertility, and history of poor stimulation with injectable ovulation drugs (3 or fewer follicles developed and or peak estradiol of less than 1000 pg/ml). Some patients exhibiting diminished ovarian reserve have identifiable clinical characteristics. The patient’s cycle intervals may become subtly but progressively shorter with 21 to 27 day cycle intervals common. This is due primarily to a shortened follicular phase (first 14 days of the cycle) and correlates with patient histories of positive ovulation predictor kits on cycle day 9 or 10 (cycle day one is the first day of menses). We encourage you to ask your doctor specific questions regarding your testing as each person is an individual.

Role of Hormonal testing

We take many other factors into consideration when determining one’s chance of pregnancy, such as age, prior pregnancy history, and reason for requiring IVF treatment, and we find that many patients are still candidates for fertility treatment despite having a low AMH (Anti-mullerian Hormone) level or elevated FSH (Follicle Stimulating Hormone) level. We believe that our role is to counsel the patient as to the probability of success based on our experience and that the ultimate decision is up to her. Two tests that we use most frequently to evaluate the ovarian reserve are the FSH and Estradiol. These blood tests are performed between days 3 and 5 of the menstrual cycle ( the first day of flow is cycle day 1). FSH is the hormone secreted by your pituitary gland to stimulate your ovaries to produce estrogen. When the ovaries become resistant, FSH levels rise in an increased attempt to stimulate the ovaries to function. An FSH value above 10 mIU/ml is considered elevated and an Estradiol value above 68 pg/ml is elevated. By measuring a baseline FSH on day 3 of the cycle, we sometimes get an indication that the women is closer to menopause and has relatively less “ovarian reserve”. Another way of saying this is that if the day 3 FSH is elevated, egg quality is reduced. More recently, another hormone, AMH has been used to help assess ones fertility potential. AMH levels are predictive of the number of eggs retrieved in IVF cycles, but are not predictive of one’s chance of pregnancy and therefore this test as well as others, cannot be used to exclude women from IVF treatment based solely on FSH or AMH levels.

Unexplained Infertility

Unexplained infertility does not mean undiagnosed infertility.

Unexplained infertility means that all known diagnoses have been eliminated. When a couple is diagnosed with “unexplained infertility”, a careful review is conducted of their entire infertility evaluation.

Empirical therapy is treatment based on observation or experience with other infertile couples, rather than on conclusive evidence of what is wrong.

The justification for empirical therapy is that it frequently works.

Through the use of “Assisted Reproductive Technology” or ART, we join hormonal therapy with a form of artificial insemination (i.e. intrauterine insemination) or IVF.

The purpose of ART is to enhance or bypass as many fertility factors as possible.

Sometimes these ART techniques are used to overcome known deficiencies, such as using IVF to circumvent damaged fallopian tubes.

There are Three Levels of Empirical Therapy Treatments

The following are the different levels of treatment based on your age as well as prior history. Each level of treatment involves more time commitment on your part, but is also associated with a higher probability of pregnancy.

Level 1

includes up to three cycles of clomiphene combined with intrauterine insemination, using 100mg/day for 5 days starting on cycle day 5. Transvaginal ultrasound monitoring will be performed. Usually there will be two or three follicles seen. Follicles are fluid filled sacs which contain the eggs. Once the largest follicle is = 18 mm, hCG is given as a single injection and intrauterine insemination with specially prepared sperm is performed 24 to 36 hours later. It is also possible to schedule the timing of the IUI based on urinary ovulation predictor kits.

Level 2

includes up to three cycles of gonadotropins combined with intrauterine insemination. Gonadotropins (Gonal-F, Follistim, Bravelle, Menopur, Repronex) are started on cycle day 3 and administered daily as injections. Transvaginal ultrasound monitoring is begun after five days of treatment and repeated every 1-2 days until 3-6 follicles reach a size of = 18 mm. hCG is given as an injection to induce ovulation and then intrauterine insemination with prepared sperm is performed 24 to 36 hours later. The sperm preparation is done at the Presbyterian ARTS facility and then brought to our office for insemination.

Level 3

involves the use of IVF. Gonadotropins are administered as in level 2, but with the addition of Lupron injections. Transvaginal ultrasound and blood estradiol measurements are done according to protocol, with hCG being administered when mature follicles are detected. Transvaginal ultrasound-guided follicle aspiration is performed 36 hours later. The eggs from the follicles are fertilized with the husband’s sperm in the laboratory. This creates embryos which are then transferred into the uterus 3-5 days later. With IVF, further diagnostic information will be obtained, as we are able to observe the fertilization ability of the sperm, and the embryo development prior to transfer. This information may provide clues to a prior undiagnosed infertility factor.

Polycystic Ovary Syndrome

Polycystic ovarian syndrome (PCOS), also called Stein-Leventhal Syndrome, is the most common endocrinologic disorder in women of reproductive age. Approximately 5-10% of reproductive age women have PCOS. This syndrome can have many symptoms. However, the two key components defining this disorder must include chronic anovulation (inability to ovulate an egg) and clinical hyperandrogenism (elevated male type hormones). The reason for multiple cyst development is not clear, but appears to be related to intrinsic insulin resistance demonstrated in women with PCOS. In comparison to normal ovulation, women with PCOS are not able to completely develop a fully mature egg on their own, and therefore the ovulatory process in not completed.

Importance of Seeing a Specialist

Because PCOS encompasses such a broad spectrum of signs and symptoms, diagnosis can be frustratingly difficult. Because there is not one specific sign or symptom that points directly to PCOS, it is important to see a specialist with diagnosing this disorder and can begin treatment. In 2003, an international consensus expanded the definition of PCOS to include women who demonstrate two of the three following conditions: irregular or absent ovulation, elevated levels of androgenic (male) hormones, and/or polycystic ovaries on ultrasound. Many but not all women with PCOS have enlarged ovaries with many small cyst (fluid-filled sacs) that are visible on ultrasound, a finding that can also be seen in approximately 20% of women with normal menstrual cycles.

Lack of Ovulation

The lack of ovulation in women with PCOS results in a continuous exposure of the lining of the uterus or endometrium to estrogen. This causes excessive thickening of the endometrium and may cause heavy, irregular bleeding. Over years, endometrial cancer may result due to this continuous stimulation.

Metabolic Features Including Insulin Resistance

The causes of PCOS are unknown. Driving the abnormal levels of ovarian hormones in PCOS women is an elevation of the hormone insulin. Additionally, this imbalance contributes to an excess of male hormone production by the ovaries, which can be worsened by insulin resistance. There is no cure for PCOS, though the various symptoms can be addressed and managed, and therefore help reduce the risk of long-term health consequences.

Clinical Features

Polycystic Ovarian Syndrome is comprised of several clinical features, each of which may be present to a greater or lesser degree.

The various symptoms of PCOS can be irregular or absent menstrual cycles, infrequent or absent ovulation, excess facial and body hair, male pattern balding, acne of face/back/chest, and infertility. This pattern and location of the hair growth is important. This is a sign of insulin resistance. Other findings can include an elevated FSH to LH hormone ratio, elevated levels of male hormones, multiple small cysts of the ovaries and elevated cholesterol. Some women have been found to have polycystic ovaries without associated abnormalities of menstruation, hair growth or fertility.

When hormones are elevated in the male level then hair growth occurs in androgen dependent fashion.

Typically women do not have hair on there face or for example on there lower abdomen unless there male hormones are elevated. When this occurs, hair growth does occur in a similar fashion as it does in men and is very suggestive of PCOS.

Acanthosis Nigricans is a discoloration of the skin which is a sign of insulin resistance.

This is usually located at the back of neck, under the arms or at the upper thighs. This physical sign is a very sensitive indicator of insulin resistance and is important to identify on the physical exam.

Specific Goals of Treatment

If you are diagnosed with PCOS, treatment will depend upon your goals. Dealing with PCOS can be emotionally difficult. Women with PCOS may feel self conscious about their excessive hair growth or weight, as well as their inability to have children. If fertility is the primary concern, then ovulation is induced through orally administered medications.

Ruling Out Other Factors

Prior to starting treatment, it is recommended that other factors which may be responsible for irregular cycles be evaluated. This includes ruling out a thyroid disorder or elevated prolactin which may cause irregular menstrual cycles. In cases where ovulation is irregular or absent, drugs such as clomid (Clomiphene Citrate) can be used, as well as insulin sensitizing drugs such as Metformin.

Medications

If fertility is not an immediate concern, hormonal therapies often correct the problems associated with PCOS. Medications commonly used include birth control pills, which may reduce the hirsutism (excessive hair growth) and regulate menstrual cycles, and are often combined with other medications such as spironolactone and Vaniqa cream to reduce body and facial hair.

Weight Loss

For overweight women, simply losing 10-15% of total weight may be enough to allow spontaneous ovulation to occur. Weight loss is associated with lowered androgen effects, less insulin resistance, an improved lipid profile, and resumption of ovulatory function. We understand that it is easy to tell somebody to lose weight, but can be very difficult to actually lose weight. Exercise is also an important component of treatment and has been shown to resume ovulation and increase chances for pregnancy .

Insulin Sensitizers

Studies with Metformin indicate that most women with PCOS will spontaneously ovulate after 3 months of treatment, or if not ovulatory, will become Clomid “sensitive”. One must be carefully screened prior to a course of Metformin, and must be monitored during treatment. Side effects are mostly gastrointestinal (nausea, vomiting, diarrhea). We frequently start Metformin at a dose of 500 mg per day for one week working up to a total dose of 2000 mg per day. If gastrointestinal side effects develop, we can try using a long-acting form of Metformin which has a lower incidence of these side effects.

Fertility Medications

If fertility medications are required, the first and simplest step is to use Clomid (Clomiphene Citrate). We usually start patients at 100 mg of Clomid and increase the dosage of the medication based on individual response. Ovulation is documented with a progesterone level obtained in the luteal phase of the cycle to confirm ovulation. If ovulation is not achieved with a dose of 200 mg/day, then other strategies have to be investigated. If clomiphene fails to successfully induce ovulation, then a group of injectable preparations, known as gonadotropins may be used. Gonadotropins are administered to stimulate the growth of one or two eggs, being careful not to stimulate the growth of too many eggs. Follicular growth and development is carefully monitored by hormone measurements and ultrasound examinations. If monitoring shows that too many follicles are developing, and the risk of multiple pregnancy is high, then the treatment will be cancelled.

Reducing Risk of Multiples in Women with PCOS

In Vitro Fertilization (IVF) is the most successful treatment for women with PCOS. This treatment is used to reduce the risk of multiple gestation that can occur with gonadotropins and intrauterine insemination. IVF is also used when pregnancy has not occurred with any other means.

Endometriosis

Endometriosis is a condition in which normal endometrial tissue is located somewhere outside the uterus. The misplaced endometrial tissue is commonly within the pelvis (ovaries, uterine ligaments, pouch of Douglas, fallopian tubes, rectovaginal septum) and is often multifocal. Less commonly, it is found in remote sites, such as lymph nodes, lungs, heart, skeletal muscle, or bone. Commonly, endometriosis appears as an ovarian cyst, which, when ruptured, oozes a dark brown, hemorrhagic material; such cysts are called “chocolate cysts.”

What are the symptoms of endometriosis?

Although in some individuals endometriosis may cause no symptoms, it can be associated with difficulty conceiving and pain.

The pain may be present as extremely painful menstrual periods.

This pain with periods, known as dysmenorrhea, often becomes worse as a woman gets older. Pain with intercourse is not uncommon in women with endometriosis, and there may even be pain that persists throughout the month but is worse during periods.

Not everyone with endometriosis has pain

in fact, there is little correlation between the amount of endometriosis an individual has and the amount of pain she experiences. Sometimes a single, small implant may cause excruciating pain, while someone with severe disease may be pain free.

How does endometriosis affect fertilty?

The association of endometriosis with difficulty conceiving may occur in several ways.

Endometrial implants are irritating to the body, and as a result, the body produces a group of substances known as prostaglandins. Prostaglandins can alter not only the maturation and development of the egg within the ovary, but also the release of the egg from the ovary.

Endometriosis can affect the ability of the fallopian tube to functioning normally.

By mechanically obstructing the ability of tube to capture the egg, endometriosis may contribute to the inability to conceive. Thus, even if ovulation does occur, the egg may not get into the fallopian tube.

Why do some women develop endometriosis and others do not?

It is not clear why endometriosis occurs in some individuals and not in others, but about 10 to 20 percent of all reproductive-age females have been found to have endometriosis.

Most patients at our center undergo an ultrasound evaluation at their first visit which in addition to a thorough history. Which allows our physicians to evaluate if endometriosis may be contributing to your inability to conceive. Factors associated with the development of endometriosis include delayed childbearing, long periods of uninterrupted menstrual cycles, abnormal pelvic anatomy, and stress. Many other factors have been associated with the development of endometriosis and there is even a genetic factor, meaning that you may inherit an increased likelihood of developing this process if a close relative has it.

Endometriosis is not visible by ultrasound unless there is ovarian involvement; endometriomas are visible by ultrasound.

If significant endometriosis is present, the combination of a history, pelvic exam, and ultrasound will reveal it.

The only way to definatively diagnose endometriosis is by visualizing it.

With a laparoscopy, the physician is able to evaluate if endometriosis is present and any adhesions or scarring that may have formed. Surgical removal of ovarian endometriomas can be removed at that time, if they are affecting your ability to conceive.

Tubal Factor Infertility and Hydrosalpinx

Patent or open fallopian tubes are required for an egg to be picked up by a tube, where it will later be fertilized, as well as for the resultant embryo to have a passageway to the uterus, where implantation occurs. Fallopian tubes can be blocked as a wanted consequence of prior surgery such as a tubal ligation or due to unwanted consequences of pelvic surgery such as adhesion or scar tissue formation. The tubal architecture can also be disrupted by prior pelvic infections such as those caused by chlamydia, gonorrhea, or tuberculosis. A hydrosalpinx is defined as a fallopian tube that is filled with fluid. Injury to the end of the fallopian tube, the ampulla, and its delicate fingerlike endings, the fimbria, causes the end of the tube to close. Glands within the tube produce a watery fluid that collects within the tube, producing a sausage shaped swelling that is characteristic of hydrosalpinx.

Evaluation

Hydrosalpinx can be evaluated with several maneuvers: The hysterosalpingogram (HSG) is a procedure in which dye is placed through the cervix and into the uterus and fallopian tubes. This is x-ray test is done in the first 10 days of the month and is performed by Dr. Goldstein with the radiologist. The X-ray picture on the right reveals the outline of the uterus and tubes. A hydrosalpinx appears as a large-sausage-shaped dilation of the tubes. The folds that are present inside the tube disappear and a flat bulbous shape is seen. Dye does not spill out of the tube.

Ultrasound Diagnosis of Tubal Disease

Ultrasound uses sound waves to image the tubes, and is somewhat safer than HSG and more comfortable. The best view, most of the time, is obtained with a vaginal ultrasound probe. A normal fallopian tube is usually not visible; a hydrosalpinx appears as a characteristic sausage-shaped fluid collection between the ovary and fallopian tube. The wall of the hydrosalpinx is often thick and flat. Ultrasound provides a quick and painless screen of the pelvic organs and is an excellent first assessment of the tubes.

Laparoscopy

Another means of assessing the tubes and involves the use of a small television camera which is introduced through the belly button. The pelvic organs can be visualized on a television screen. It has been said that physicians with expertise at video games excel at the hand-eye coordination required to perform these procedures! Laparoscopy is the gold standard test for evaluation, since looking at the fallopian tubes will usually provide the best view of their anatomy. Diagnostic tests such as ultrasound and HSG are not 100% accurate, and can be misleading, sometimes missing significant tubal disease, and sometimes showing abnormal results when the tubes are actually quite normal. Laparoscopy usually will confirm the diagnostic tests, but can show that tubes that were thought to be normal actually have significant disease, and vice versa. The risks of anesthesia and surgery dictate that laparoscopy is used for definitive therapy, rather than as a diagnostic test.

How do Hydrosalpinx form?

Hydrosalpinx is a result of injury to the tube, usually from an infection. The classic causes of hydrosalpinx are chlamydia and gonorrhea, which can run undetected for years, slowly injuring and destroying the delicate fimbria. IUDs, endometriosis, and abdominal surgery sometimes are associated with the problem. As a reaction to injury, the body rushes inflammatory cells into the area, and inflammation and later healing result in loss of the fimbria and closure of the tube. These infections usually affect both fallopian tubes, and although a hydrosalpinx can be one-sided, the other tube on the opposite side is often abnormal. By the time it is detected, the tubal fluid usually is sterile, and does not contain an active infection. Not only does a hydrosalpinx cause infertility, it can also reduce the success rate of fertility treatment, even those treatments that bypass the fallopian tubes, namely In Vitro Fertilization (IVF). The blocked tube can communicate with the uterus, and the fluid in the tube can be expressed out of the tube into the uterus. This fluid is probably somewhat toxic to early embryo development, and certainly provides an unfavorable environment. The large volume of the fluid flow back into the uterus and can produce enough flow that embryos find it difficult to attach, since they have no ability to move against the tide. Fertility drugs may cause the fluid to build up in the tube, since the tubes are responsive to the ovarian hormones produced during fertility drug therapy.

Complications

Hydrosalpinx can be hazardous during fertility evaluation and treatment, since it is prone to re-infection. Hysterosalpingogram can be a particular problem, since the dye can inadvertently introduce bacteria into the tubes, and a serious infection can result. Fertility procedures like insemination and embryo transfer can cause similar problems. Infection in a hydrosalpinx, salpingitis, can be a serious surgical emergency and result in hospitalization.

Treatment

Hydrosalpinx is a classic fertility problem that prevents embryos from reaching the uterus and limits pregnancy rates.

It can interfere with fertility therapy and cause problems for in vitro fertilization. Fortunately, excellent methods are available to manage the hydrosalpinx. With the proper expertise, such as that provided by a board-certified reproductive endocrinologist, success rates are excellent.

In vitro fertilization is recommended fertility therapy in patients with bilateral hydrosalpinx.

The ability to optimize fertilization rates, place embryos into their correct location, and provide excellent hormonal support to the early developing embryo have vastly improved success rates over the last few years. The ability to bypass the fallopian tubes and allow sperm to fertilize eggs from the ovary allows women with hydrosalpinx to achieve pregnancy.

Hydrosalpinx can be repaired in carefully selected cases, but pregnancy rates remain rather low.

Hydrosalpinx can be treated laparoscopically, a procedure known as neosalpingostomy. In neosalpingostomy, an incision is made in the end of the hydrosalpinx and the edges of the incision are folded or flowered back, leaving an open tube. Unfortunately, the tube often closes back up, and the hydrosalpinx has a high recurrence rate.

A hydrosalpinx can have adverse effects on pregnancy rates with in vitro fertilization.

As success rates with in vitro fertilization have improved dramatically over the past few years, surgical repair of the fallopian tubes holds less appeal. Removal of a damaged tube reduces the risk of complications of therapy and improves success rates with in vitro fertilization techniques.

Today, most patients with a hydrosalpinx do not try to repair it.

Repair can be done in carefully selected young patients with minimal damage to their tubes, but should not be attempted with a large hydrosalpinx in an older woman. In these patients, the tube should be removed, via laparoscopic salpingectomy. Salpingectomy is an easy procedure that takes less than an hour. The risks with an experienced surgeon are low, and the benefits substantial. It is important to choose an experienced surgeon, since considerations of safety and preservation of the ovarian blood supply with improvement to later pregnancy rates require judgment and experience.

Factors

Treatments for male factor infertility are influenced by at least three significant factors:

Is the cause of the infertility identifiable?

What is the severity of the sperm defect?

What is the age of the female partner?

Infertility in Males

Whenever couples or individuals experience fertility concerns, we advise that both the male and female partner have an evaluation to ascertain the most effective treatment approach.

For mild male factor, unexplained cause, Intrauterine insemination (IUI) is usually the first line recommendation.

Intracytoplasmic Sperm Injection (ICSI) has revolutionized the treatment of male factor infertility.

The ideal treatment, when surgical and medical management fails to improve sperm function, is in vitro fertilization and embryo transfer (IVF/ET), usually accompanied by Intra-cytoplasmic sperm injection (ICSI). It allows men who were previously incapable of producing adequate sperm, to father genetically related children. ICSI involves the placement of a single sperm directly into the egg using a microscopic pipette. Men normally produce millions of sperm in each ejaculate. These sperm “swim” through the cervical opening and into the tubes to the site of fertilization. Some men have sperm defects such as a reduced sperm count, deformed sperm, or sperm that cannot swim effectively. When any one of these abnormalities are present, it can prevent normal fertilization. ICSI bypasses sperm defects because a single sperm is “selected” and placed inside the egg. ICSI is performed as a part of the IVF cycle. During IVF, the eggs are retrieved from the ovaries and taken to the embryology laboratory. In ICSI, a stereomicroscope is utilized to manipulate the egg(s). The egg is held in place while it is punctured by the micro pipette, and the sperm is inserted. IVF/ICSI is used in cases of severe male factor infertility and in other conditions such as failed fertilization in previous IVF cycles.

Prior Vasectomy

Couples have the option of a vasectomy reversal or IVF-ICSI with epididymal or testicular sperm extraction. It can sometimes take 6-9 months to recover adequate sperm counts following vasectomy reversal. Also, the greater the length of time between the vasectomy and the reversal, the greater the chances are that the surgery will be unsuccessful or that anti-sperm antibodies will form, preventing the recovered sperm from penetrating the eggs without IVF-ICSI. Microepididymal sperm aspiration (MESA) and testicular sperm extraction (TESE) are outpatient surgical procedures used to harvest sperm from men in special circumstances as part of an IVF-ICSI. The age of the female partner and length of time since prior vasectomy are critical factors in decision-making. The physicians at Fertility Specialists of Texas work closely with several urologists to coordinate these procedures which are done in our facility. When a physician performs MESA procedure, they will put the patient under local anesthesia and general sedation. Then an incision is made in the scrotum, exposing the epididymis and the tubules immediately adjacent to the testicles that collect the sperm. Utilizing an operating microscope an incision is made into these tubules, and sperm is aspirated. Although millions of motile sperm can often be collected, this sperm has not acquired the ability to penetrate an egg and must be injected into eggs via the IVF-ICSI technique. The advantage of MESA over TESE for men with obstructive azoospermia is that sperm collected in this manner can usually be frozen, and even if his partner has to undergo more than one IVF procedure, the MESA should provide adequate sperm for all subsequent IVF procedures.

Testicular Sperm Extraction (TESE)

A TESE or testicular sperm extraction is a procedure that entails directly aspirating the sperm from the testes or retrieving sperm from a testicular biopsy. Generally, it is performed under local anesthesia block and can be performed as an office surgical procedure. In many cases, the disadvantage is that testicular sperm are much more scarce and consequently more difficult to freeze. Typically, there is only enough sperm recovered for one IVF procedure, and if further IVF attempts are needed, the TESE procedure will need to be repeated.

Non-obstructive Azoospermia (NOA)

Men with very poor sperm production in the testicles and no sperm in the ejaculate often demonstrate high blood FSH levels and sometimes low testosterone levels. The testicular size may be small. These men are usually considered to have relative testicular failure. TESE or testicular biopsy is usually the only option for them as there are no sperm in the epididymus and even testicular sperm production can be “patchy” and scarce within the testes. Men with this diagnosis who have been told they have no sperm on routine testicular biopsy frequently can be found, on further investigation, to have sperm present in a scattered distribution within the testicle. If so, these areas can be re-aspirated for IVF-ICSI with some degree of success, depending on the amount of sperm obtained.

Sertoli Cell Only Syndrome

Complete absence of sperm progenitor cells and absence of spermatogenesis is a rare condition. Sperm donation or adoption are the only options in these cases.

IVF in the Dallas Fort Worth Metroplex

In Vitro Fertilization offers new hope and possibilities for couples who would otherwise be unable to have children.

IVF involves stimulating the woman’s ovaries with fertility medications to produce many oocytes (eggs) that mature and ripen, at which point they are retrieved while she is under anesthesia, and fertilized with her husband’s sperm in the laboratory. This creates embryos which are carefully monitored by an embryologist for 3-5 days, and then one or more are placed into her uterus with the hope that implantation will occur and establish a pregnancy. The pregnancy rates for IVF far exceed those of any other form of fertility treatment. Success rates vary from one IVF center to another the physicians at Fertility Specialists of Texas have consistently demonstrated success rates above the national average.

A review of the process of In Vitro Fertilization is detailed in a separate section of the web site.

The decision to proceed with in vitro fertilization can be one of the most important and difficult a couple can make. The amount of information and details involved in an IVF cycle can seem overwhelming, and many questions arise throughout the process. This page of our website is designed to give you a general idea of what to expect, but please, remember that each patient will receive an individualized plan to maximize her chances of pregnancy. It is our goal to provide the highest quality in IVF care, including educational tools and emotional support. While most of the treatments and procedures involve the woman, we encourage the partner to be as much a part of the IVF cycle as possible. The importance of the emotional support of the husband cannot be overemphasized. Daily injections, frequent appointments, ultrasounds and blood tests are required of the woman, in addition to the egg retrieval, and embryo transfer. Therefore, we encourage the partner to administer the injections and attend appointments whenever possible. IVF is an exciting commitment that couples make to each other as they work together to fulfill their dreams of having a baby.

Reasons to do IVF

There are many different causes of infertility, some of which are definite indications that IVF may be the treatment of choice. For example, tubal obstruction means the sperm and the egg cannot meet in the tube, but since IVF bypasses the tubes, pregnancy becomes truly possible. Another factor best treated by IVF is a very low sperm count in the male. In IVF sperm are placed together with the eggs in a petri dish, and are therefore, not required to swim through the cervix, uterus and into the tube to fertilize the egg. During IVF, an additional procedure can also be performed in which a single sperm can be injected directly into an egg. This is known as intracytoplasmic sperm injection or ICSI and is addressed in more detail on the male factor page in this website. IVF is often the most efficient and quickest route to pregnancy for a woman who is over 35. IVF may also be recommended for a patient with unexplained infertility who has undergone several unsuccessful attempts with fertility medications and intrauterine insemination. As you explore your diagnosis and treatment options with our physicians you and your spouse can consider whether IVF might be right for you. All patients and their partners are required to complete a thorough infertility evaluation prior to beginning their IVF cycle.

Testing for Women Prior To IVF

You may have already completed most of the required testing with your initial fertility evaluation. Your nurse will go over your file and will let you know what else may need to be done. The following tests may be ordered:

If you have had a hysterosalpingogram (HSG), your fertility specialist will want to review the results to rule out the possibility that you have a hydrosalpinx.

Your husband will have a semen analysis to assess the concentration, motility and morphology, and a semen culture to check for the presence of bacteria.

Your uterine cavity will be evaluated by Saline Infusion Sonohysterogram (SHG, or SIS) to make sure there are no abnormalities such as uterine polyps or fibroids

which may interfere with implantation.

A trial transfer will be performed at the time of the SIS to measure the depth of the uterine cavity

so that the embryos can be transferred into a predetermined location within the cavity during the actual IVF cycle.

Blood tests for you and your husband will be ordered by the doctor.

IVF Success Rates

“The birth of a healthy baby is the only measure of success”

When couples are considering IVF

they need to gain a complete understanding of the outcome results of any program that they are considering so that they can choose the best clinic to help them conceive a baby. Our IVF success rates at Fertility Specialists of Texas are among the highest in the nation. Our enhanced laboratory environment has led to superior embryo quality and higher live birth rates.

The graph below shows our live birth rates for years 2006 through 2012.

We understand that our patients are interested in having a baby which is reflected in the live births rate. We report our data as live births (birth of one or more infants), as well as clinical pregnancy rate, (positive pregnancy test or cardiac activity on sonogram); however we realize that what patients are really interested in – is taking home a baby. Live Birth Rate per Transfer is recognized as the birth of one or more live babies as a result of an embryo transfer. This statistic can offer some insight into the likelihood of having a child once a patient goes through egg retrieval, and an embryo transfer is performed.

At Fertility Specialists of Texas, we do not eliminate any patients who may have problems becoming pregnant that could potentially lower our statistical success rates.

We are more concerned for the health and well being of our patients and not just in improving our statistics. We partner with each of our patients to determine the right treatment for them. For example, if a patient preferred to first attempt a specific treatment option, understanding that there is a limited chance of success, we would respect that choice, assuming it is medically safe and appropriate. Some patients might wish to attempt an IUI before an IVF, or to utilize their own eggs rather than donor eggs.

At Fertility Specialists of Texas, we realize that getting pregnant is the one thing that matters most to you.

We Follow SART Guidelines in Reporting Treatment Outcomes.

As members, we adhere to the guidelines set forth by the Society for Assisted Reproductive Technology (SART) and The American Society for Reproductive Medicine (ASRM)

setting standards of excellence for fertility treatment. Fertility Specialists of Texas is proud to report its IVF treatment outcomes to SART, which publishes an annual report for all the registered IVF Centers in the U.S. www.sart.org This data is reported to the Center for Disease Control (CDC). According to SART, a comparison of clinic success rates may not be meaningful because patient medical characteristics and treatment approaches may differ from clinic to clinic. When comparing success rates, there may be dissimilarities based on demographics between regions of the country and differences in the difficulty ranking of the patients treated.

The Fertility Specialists of Texas Laboratory has a Clinical Laboratory Improvement Amendments (CLIA)

certificate of accreditation, registered and inspected by the Food and Drug Administration (FDA) and accredited by the College of American Pathologist (CAP) .