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Reproductive Endo/Infertility Home
Missouri Center for Reproductive Medicine and Fertility
Infertility Services


In Addition to Full IVF, Andrology, and Endocrine Testing Services, Our Facilities Are Equipped With:

Procedure Room Office Hysteroscopy 3D Ultrasound

Male Factor Treatment
When a sperm problem exists that cannot be corrected, the basic principle of treatment involves getting the sperm closer to the egg. This can be done by a number of methods.

  • IUI (intrauterine insemination)
    • Injection of sperm into the woman's uterus
  • IVF (In Vitro Fertilization)
    • Mixing the sperm with the patient's eggs in the laboratory, where fertilization will take place
  • IVF + ICSI (intracytoplasmic sperm injection)
    • Used in cases where there are very low sperm counts/motility/ and/or low percentages of normal appearing sperm (morphology).
    • Injecting a single sperm individually into each egg in the laboratory to improve the chances for fertilization.
  • Testicular or Epididymal sperm aspiration
    • Used when no sperm in ejaculated specimen
    • Sperm can be directly removed from the testicle or epididymis by a urologist and then frozen for a future IVF + ICSI cycle.
  • Donor Sperm
    • Can be used where there is not even enough sperm for ICSI or in conjunction with intrauterine insemination (IUI) in patients with open fallopian tubes.
  • Sperm Banking
    • For males who are undergoing medical treatment which might make them sterile (radiation or chemotherapy for cancer, surgery of the male reproductive tract, etc.)
    • Allows for future fertility following their medical/surgical treatment.
    • Patients who require removal of sperm directly from the testicle or epididymis also have sperm frozen prior to IVF + ICSI.(cryopreservation or freezing of sperm for use at a later date)
  • Anonymous Donor Sperm Bank
    • Allows our patients more flexibility and choice when donor sperm is required.
  • Vasectomy Reversal
    • In cases of prior male sterilization

Ovulation Disorder Treatment
Polycystic Ovary Syndrome (PCOS)

  • Weight loss (even 5-10%) can be associated with resumption of normal menstrual cycles
  • Fertility medicationmay still be required to help stimulate the ovaries to produce and release eggs.
    • Fertility pills (clomiphene citrate or letrozole) require minimal monitoring
    • Fertility shots (gonadotropins) require more frequent monitoring with ultrasound and blood tests.
    • Insulin-sensitizing agents such as Metformin, have been associated with weight loss, improved ovulatory function, and possibly a reduced rate of miscarriage.
  • Surgical ovarian drilling may be considered as an alternative to fertility shots

Diminished Ovarian Reserve Treatment
Patients who are of increased reproductive age (particularly approaching39-40)or have abnormal ovarian reserve testing are typically treated more aggressively to help them conceive.

  • Treatment may include a limited number of cycles with fertility pillsor moving directly to insemination, fertility shots, or IVF.
  • For patients who are not candidates for IVF, use of a donated egg from a woman of younger age may be recommended.

  • Adoption should also be considered as a potential option

Pelvic, Uterine, and Tubal Factor

Evaluation
There are a number of conditions affecting the uterus, fallopian tubes, and ovaries which may lead to infertility.

  • Endometriosis is a condition in which the lining of the uterus implants outside the uterus to involve the female pelvic organs.
  • Pelvic adhesions (scar tissue) can also be a cause of infertility, and can be caused by previous infection, previous surgery, or endometriosis. If the fallopian tubes are blocked or severely scarred, this may prevent the tube from picking up the egg, or in some cases, lead to an ectopic pregnancy (implantation of the embryo into the fallopian tube).
  • Uterine fibroids are benign tumors of the uterus which can interfere with conception (i.e. if the tubes are blocked) or maintenance of the pregnancy (i.e. if the fibroid tumor is inside the uterine cavity).

Treatment
Hysteroscopy

  • A small telescope is inserted through the cervix and into the uterine cavity while saline solution is infused.
  • An attached camera allows direct visualization of the uterine cavity.
  • Larger telescopes with an operating channel can be used to remove fibroids, polyps, uterine septa and scar tissue, allowing not only diagnosis, but also treatment. The operative portion of the procedure usually requires anesthesia.
    • This can typically be performed under minimal sedation as an outpatient procedure in our clinic.

Laparoscopy

  • Atelescope is inserted through a small incision in the umbilicus (belly-button) and allows direct visualization of the pelvic organs.
  • Performed as an out-patient procedure and requires general anesthesia.
  • Placing 1-3 additional ports through small (1/2 cm) incisions allows surgical procedures to also be performed.
  • This usually includes laser/cautery of endometriosis, or adhesiolysis (cutting scar tissue).
  • Repair of some tubal blockage can also be performed, but this is only successful if the fimbria ("fingers" on the end of the tubes) are normal.
    • If the tubes are completely destroyed at the ends and are swollen (hydrosalpinges), removal of the tubes or tubal ligation is recommended prior to undergoing IVF, and can be performed at the time of laparoscopy.

Other Fibroid Treatment

  • Laparotomyinvolves an open surgical procedure requiring a regular abdominal incision and is performed using general anesthesia.
  • Primarily performed to remove large fibroids from the uterus which are making the cavity abnormal.
  • Injectable medications may be used to "shrink" the fibroids prior to surgery, although there are no medications that can permanently treat fibroids.
  • Fibroid embolization is a radiology procedure in which particles are injected to "cut-off" the blood supply to the fibroid(s).
    • Currently, this procedure is not recommended for patients who wish to conceive in the future.

Unexplained Infertility
It is important to realize that in this situation, treatment is not geared to correct a specific problem, since nonewas found. Instead, treatment is geared towards accelerating the time to pregnancy. Couplesmay still become pregnant without treatment, but we cannot predict if this would occur. Since pregnancy might not occur for several years, most couples opt for treatment with this diagnosis.

There are two main principles of treatment, which must be applied together to optimize success rates. Studies have indicated that using either one of these principles separately to treat unexplained infertility does not improve chances for conception.

  • Increase the number of eggs (using fertility shots or pills)
  • Place sperm and egg closer together (using IUI or IVF) - after ejaculation, millions of sperm are normally present in the vagina; however, much smaller numbers reach the egg. By placing more sperm in close proximity to more eggs (after using fertility drugs) the odds for conception in that cycle increase.

Monthly pregnancy rates for a normal couple trying to conceiveare about 20-25%. Possible treatment options for unexplained infertility are listed below with generalized success rates in women < age 35.

  • Clomiphene citrate (Fertility pill) + insemination: 15% pregnancy rate/cycle
  • Gonadotropins (Fertility Shots) + insemination: 18-20% pregnancyrate/cycle
  • Gonadotropins (Fertility Shots) + IVF: 40-50%pregnancy rate/egg retrieval

Typically, a maximum of 3-4 cycles of a given treatment are recommended before moving to the next step, although couples have the option of moving to the next treatment step before completing the maximum number of cycles. Some studies have found that moving directly to IVF if fertility pills/insemination is unsuccessful is more cost-effective to teh patientthan using fertility shots because of the high pregnancy rate.

Tubal Ligation Reversal (also called microsurgical tubal anastamosis)

  • Asurgical procedure during which the segment of the tube that has been tied is removed and the remaining 2 segments are attached together with the aid of an operating microscope.
  • In many casesit is possible to reverse the ligation on both your right and left tubes.
    • Occasionally, one side may be heavily scarred from the previous tubal surgery and therefore only the other side is amenable for tubal reversal.
    • Very rarely both sides are heavily scarred and the operation cannot be performed.
      • The alternative to tubal ligation reversal is in vitro fertilizationto "bypass" the tied tubes.
  • Pregnancy rate after tubal ligation reversalis anywhere from 60%to 80% in women age <35 years, but may decrease with age.
    • Success depends on which method your tubes were tied
    • Success rates are higher if the remaining total length of the tube after it has been surgically put back together is more than 4 centimeters (a little less than 2 inches).
    • Most patients who get pregnant after microsurgical tubal reversal do so in the first 6 months following the surgery, although some patients may take longer to conceive.
    • If only one tube is successfully untied, the time to pregnancy after surgery may be longer.
  • The most commonmethod involves a small "bikini line incision", about 5 centimeters in length (or 2 inches).
    • Sometimes patients can go home that same day, but some may need to stay overnight in the hospital.
  • Laparoscopic methods involve 4 very small incisions (half a centimeter each), and most patients go home the same day.
  • Once childbearing is completed,patients who desire prevention of pregnancy will need a separate form of birth control because their tubes are no longer tied

In Addition to Full IVF, Andrology, and Endocrine Testing Services, Our Facilities Are Equipped With:

Procedure Room Office Hysteroscopy 3D Ultrasound

Male Factor Treatment
When a sperm problem exists that cannot be corrected, the basic principle of treatment involves getting the sperm closer to the egg. This can be done by a number of methods.

  • IUI (intrauterine insemination)
    • Injection of sperm into the woman's uterus
  • IVF (In Vitro Fertilization)
    • Mixing the sperm with the patient's eggs in the laboratory, where fertilization will take place
  • IVF + ICSI (intracytoplasmic sperm injection)
    • Used in cases where there are very low sperm counts/motility/ and/or low percentages of normal appearing sperm (morphology).
    • Injecting a single sperm individually into each egg in the laboratory to improve the chances for fertilization.
  • Testicular or Epididymal sperm aspiration
    • Used when no sperm in ejaculated specimen
    • Sperm can be directly removed from the testicle or epididymis by a urologist and then frozen for a future IVF + ICSI cycle.
  • Donor Sperm
    • Can be used where there is not even enough sperm for ICSI or in conjunction with intrauterine insemination (IUI) in patients with open fallopian tubes.
  • Sperm Banking
    • For males who are undergoing medical treatment which might make them sterile (radiation or chemotherapy for cancer, surgery of the male reproductive tract, etc.)
    • Allows for future fertility following their medical/surgical treatment.
    • Patients who require removal of sperm directly from the testicle or epididymis also have sperm frozen prior to IVF + ICSI.(cryopreservation or freezing of sperm for use at a later date)
  • Anonymous Donor Sperm Bank
    • Allows our patients more flexibility and choice when donor sperm is required.
  • Vasectomy Reversal
    • In cases of prior male sterilization

Ovulation Disorder Treatment
Polycystic Ovary Syndrome (PCOS)

  • Weight loss (even 5-10%) can be associated with resumption of normal menstrual cycles
  • Fertility medicationmay still be required to help stimulate the ovaries to produce and release eggs.
    • Fertility pills (clomiphene citrate or letrozole) require minimal monitoring
    • Fertility shots (gonadotropins) require more frequent monitoring with ultrasound and blood tests.
    • Insulin-sensitizing agents such as Metformin, have been associated with weight loss, improved ovulatory function, and possibly a reduced rate of miscarriage.
  • Surgical ovarian drilling may be considered as an alternative to fertility shots

Diminished Ovarian Reserve Treatment
Patients who are of increased reproductive age (particularly approaching39-40)or have abnormal ovarian reserve testing are typically treated more aggressively to help them conceive.

  • Treatment may include a limited number of cycles with fertility pillsor moving directly to insemination, fertility shots, or IVF.
  • For patients who are not candidates for IVF, use of a donated egg from a woman of younger age may be recommended.

  • Adoption should also be considered as a potential option

Pelvic, Uterine, and Tubal Factor

Evaluation
There are a number of conditions affecting the uterus, fallopian tubes, and ovaries which may lead to infertility.

  • Endometriosis is a condition in which the lining of the uterus implants outside the uterus to involve the female pelvic organs.
  • Pelvic adhesions (scar tissue) can also be a cause of infertility, and can be caused by previous infection, previous surgery, or endometriosis. If the fallopian tubes are blocked or severely scarred, this may prevent the tube from picking up the egg, or in some cases, lead to an ectopic pregnancy (implantation of the embryo into the fallopian tube).
  • Uterine fibroids are benign tumors of the uterus which can interfere with conception (i.e. if the tubes are blocked) or maintenance of the pregnancy (i.e. if the fibroid tumor is inside the uterine cavity).

Treatment
Hysteroscopy

  • A small telescope is inserted through the cervix and into the uterine cavity while saline solution is infused.
  • An attached camera allows direct visualization of the uterine cavity.
  • Larger telescopes with an operating channel can be used to remove fibroids, polyps, uterine septa and scar tissue, allowing not only diagnosis, but also treatment. The operative portion of the procedure usually requires anesthesia.
    • This can typically be performed under minimal sedation as an outpatient procedure in our clinic.

Laparoscopy

  • Atelescope is inserted through a small incision in the umbilicus (belly-button) and allows direct visualization of the pelvic organs.
  • Performed as an out-patient procedure and requires general anesthesia.
  • Placing 1-3 additional ports through small (1/2 cm) incisions allows surgical procedures to also be performed.
  • This usually includes laser/cautery of endometriosis, or adhesiolysis (cutting scar tissue).
  • Repair of some tubal blockage can also be performed, but this is only successful if the fimbria ("fingers" on the end of the tubes) are normal.
    • If the tubes are completely destroyed at the ends and are swollen (hydrosalpinges), removal of the tubes or tubal ligation is recommended prior to undergoing IVF, and can be performed at the time of laparoscopy.

Other Fibroid Treatment

  • Laparotomyinvolves an open surgical procedure requiring a regular abdominal incision and is performed using general anesthesia.
  • Primarily performed to remove large fibroids from the uterus which are making the cavity abnormal.
  • Injectable medications may be used to "shrink" the fibroids prior to surgery, although there are no medications that can permanently treat fibroids.
  • Fibroid embolization is a radiology procedure in which particles are injected to "cut-off" the blood supply to the fibroid(s).
    • Currently, this procedure is not recommended for patients who wish to conceive in the future.

Unexplained Infertility

It is important to realize that in this situation, treatment is not geared to correct a specific problem, since nonewas found. Instead, treatment is geared towards accelerating the time to pregnancy. Couplesmay still become pregnant without treatment, but we cannot predict if this would occur. Since pregnancy might not occur for several years, most couples opt for treatment with this diagnosis.

There are two main principles of treatment, which must be applied together to optimize success rates. Studies have indicated that using either one of these principles separately to treat unexplained infertility does not improve chances for conception.

  • Increase the number of eggs (using fertility shots or pills)
  • Place sperm and egg closer together (using IUI or IVF) - after ejaculation, millions of sperm are normally present in the vagina; however, much smaller numbers reach the egg. By placing more sperm in close proximity to more eggs (after using fertility drugs) the odds for conception in that cycle increase.

Monthly pregnancy rates for a normal couple trying to conceiveare about 20-25%. Possible treatment options for unexplained infertility are listed below with generalized success rates in women < age 35.

  • Clomiphene citrate (Fertility pill) + insemination: 15% pregnancy rate/cycle
  • Gonadotropins (Fertility Shots) + insemination: 18-20% pregnancyrate/cycle
  • Gonadotropins (Fertility Shots) + IVF: 40-50%pregnancy rate/egg retrieval

Typically, a maximum of 3-4 cycles of a given treatment are recommended before moving to the next step, although couples have the option of moving to the next treatment step before completing the maximum number of cycles. Some studies have found that moving directly to IVF if fertility pills/insemination is unsuccessful is more cost-effective to teh patientthan using fertility shots because of the high pregnancy rate.

Tubal Ligation Reversal (also called microsurgical tubal anastamosis)

  • Asurgical procedure during which the segment of the tube that has been tied is removed and the remaining 2 segments are attached together with the aid of an operating microscope.
  • In many casesit is possible to reverse the ligation on both your right and left tubes.
    • Occasionally, one side may be heavily scarred from the previous tubal surgery and therefore only the other side is amenable for tubal reversal.
    • Very rarely both sides are heavily scarred and the operation cannot be performed.
      • The alternative to tubal ligation reversal is in vitro fertilizationto "bypass" the tied tubes.
  • Pregnancy rate after tubal ligation reversalis anywhere from 60%to 80% in women age <35 years, but may decrease with age.
    • Success depends on which method your tubes were tied
    • Success rates are higher if the remaining total length of the tube after it has been surgically put back together is more than 4 centimeters (a little less than 2 inches).
    • Most patients who get pregnant after microsurgical tubal reversal do so in the first 6 months following the surgery, although some patients may take longer to conceive.
    • If only one tube is successfully untied, the time to pregnancy after surgery may be longer.
  • The most commonmethod involves a small "bikini line incision", about 5 centimeters in length (or 2 inches).
    • Sometimes patients can go home that same day, but some may need to stay overnight in the hospital.
  • Laparoscopic methods involve 4 very small incisions (half a centimeter each), and most patients go home the same day.
  • Once childbearing is completed,patients who desire prevention of pregnancy will need a separate form of birth control because their tubes are no longer tied

Recurrent Pregnancy Loss

Similar to infertility, treatment depends on identifying a cause. Treatments may include

  • surgical correction of uterine abnormalities
  • blood thinning medications
  • hormonal supplementation
  • nutritional supplementation
  • lifestyle modification
  • correction of thyroid disease
  • IVF with preimplantation genetic diagnosis (PGD)

Psychosocial Aspects
Patients have the opportunity to have counseling visits with a social worker who is very familiar with the psychological toll of infertility and/or recurrent pregnancy loss.

Recurrent Pregnancy Loss
Similar to infertility, treatment depends on identifying a cause. Treatments may include

  • surgical correction of uterine abnormalities
  • blood thinning medications
  • hormonal supplementation
  • nutritional supplementation
  • lifestyle modification
  • correction of thyroid disease
  • IVF with preimplantation genetic diagnosis (PGD)

Psychosocial Aspects
Patients have the opportunity to have counseling visits with a social worker who is very familiar with the psychological toll of infertility and/or recurrent pregnancy loss.




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