• Your initial visit
• Pretreatment Preparation
• Ovulation Induction / Cycle Start
• Oocyte Retrieval and Sperm Collection
• Fertilization and Development in the Laboratory
• Embryo Transfer
• Pregnancy Test and Pregnancy Follow-Up

Initial workup

The first step for a couple that suspect infertility is to determine the cause of infertility. The doctor usually begins by asking both partners about their health histories, their medication usage, their sexual histories, and their sexual practices. Tests are then performed to diagnose infertility and these tests are called pre-screening tests. Before a treatment cycle is initiated, it is important to identify any potential obstacles to achieving a pregnancy and the assessment is determined by the results of both male and female pre-screening tests.

Tests for the woman

The tests to determine occurence of infertilty in a woman begins with a full physical examination and cervical smear.

The doctor then makes sure that the woman is ovulating regularly and assesses whether her ovaries are doing their job of releasing eggs. Having regular menstrual cycles and a biphasic basal body temperature curve usually confirms that ovulation is regular. Blood tests are carried out to determine hormone levels.

The ovaries and uterus are examined by ultrasound, and tests to check for tubal blockage or any abnormality in the uterus are done.

Tests for the man

In the case of the man, to determine, the first step is a physical examination. Male infertility is usually related to sperm health or function, which is mostly tested with a sperm analysis.

In certain cases, the man may have enough sperms, but the sperms may not swim well enough to reach the egg. Also, sperms that are not normal in shape may not be able to penetrate and fertilize the egg. But once the doctor has identified all the problems, most of them are treatable.

Once the diagnosis is established for the couple, a treatment plan is drawn up. This treatment plan depends on the age, diagnosis, the duration of infertility, any previous treatments, and personal preferences if any.

In about 80% of couples, the cause of infertility is either a sperm problem, irregular or no ovulation, or blockage of the fallopian tubes. In 15% of couples all tests are normal, and the diagnosis of "unexplained infertility" is made.

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Indications for ART

I - Male Infertility Testing

• Severe abnormalities with sperm count, sperm motility or morphology
• Absence of sperms in the ejaculate or azoospermia
• Mechanical or psychological issues with erection or ejaculation
• Blood work to check hormone levels, usually of FSH and testosterone, but sometimes also LH, estradiol, or prolactin.
• Genetic karyotyping, if a recurrent miscarriage is a problem.
• Ultrasound.
• Post-ejaculatory urinalysis (urine testing), to check for retrograde ejaculation.
• Testicular biopsy.
• Vasography.

Options for Male Infertility Treatment

Some causes of male infertility are treatable or correctable through surgery. Options for treatment may include:

• Treatment with antibiotics, in cases of infection
• Surgical correction, in order to remove a varicocele, reverse a vasectomy, or repair a duct obstruction
• Medications or fertility drugs to improve sperm production

In cases where the above treatments are unsuccessful, or when the cause of male infertility is unknown or untreatable, IUI treatment or IVF treatment may be suggested.

II - Female factors

• Older age leading to compromised oocyte quality and chromosomal abnormalities
• Cervical factors
• Antisperm antibodies - Can be present both in the male or female
• Disorders of ovulation - e.g. PCOD or polycystic ovarian disease
• Disorders of fallopian tubes - Tubal blockage either due to infections or scarring
• Endometriosis

Disorders of Fallopian Tube

Tubal factor infertility is diagnosed when all or a portion of the fallopian tubes is blocked. The most common causes are scar tissue from pelvic inflammatory disease, historical STDs, endometriosis or from previous pelvic surgeries. Anatomical abnormalities may also be a cause.

If surgery isn’t able to remove scarring enough to improve unassisted fertility rates, IVF is the standard treatment for tubal factor infertility diagnosis.

Diminished ovarian reserve

Diminished ovarian reserve means you don’t have as many eggs left, and fewer or the eggs you have left are viable for a healthy pregnancy. Age is the most typical reason for women to experience diminished ovarian reserve (see above). However, women may also experience diminished ovarian reserve as the result of genetics, premature menopause or even environmental factors.

Usually, diminished ovarian reserve is treated via IVF to preserve as many viable eggs as possible.

Secondary Infertility

Secondary infertility takes couples by surprise because they’ve already been pregnancy and had a healthy child in the past. However, secondary infertility is actually twice as common as primary infertility, and can be caused by a range of factors, including:

• Advanced maternal age ( see Age-related Infertility above)
• Side-effects of medications
• Latent infections
• Scarring or pelvic damage from previous pregnancy, C-section or surgery
• Lifestyle changes (see Infertility Risk Factors below)
• Immunological causes
• Un-diagnosed infertility factors such as endometriosis, PCOS, fibroids, etc., that didn’t affect conception the first time but are complicating infertility now

If you’ve been pregnant and given birth before, we recommend checking in with a fertility specialist sooner than you would have the first-time around – particularly if you have any of the following symptoms:

• Irregular periods
• Heavy or painful periods
• Pelvic pain and/or discomfort
• Pelvic discomfort during intercourse
• Abdominal swelling or discomfort

All of these are symptoms of potential female infertility factors requiring treatment.

Recurrent pregnancy loss (recurrent miscarriage)

By and large, the most common reason for recurrent miscarriages (three or more miscarriages in succession) are chromosomal and/or genetic defects. Both of these can be identified if the fetal tissue is able to be saved and tested by your fertility specialist, better targeting the fertility treatment plan.

Other causes include:

• Uterine abnormalities (fibroids, a uterine septum or other deformities) that make it difficult for a fertilized egg to implant and/or for a fetus to develop to full size.
• Incompetent cervix (the cervix dilates when the fetus reaches a certain size/weight) causing the baby to slip out of the uterus before it’s reached full-term.
• Immunological causes, including clotting issues, partners with similar or incompatible genetic material, the recognition of the sperm and/or fetus as a “foreign invader,” etc.
• Endocrine/hormonal imbalances.
• Blood disorders.
• Abdominal swelling or discomfort

All of these are symptoms of potential female infertility factors requiring treatment. Your fertility specialist will identify the cause so you proceed with the right fertility treatment.

Endometriosis

Endometriosis is one of the leading causes of female infertility. It occurs when the endometrial tissue lining the uterus winds up outside of the uterus where it isn’t supposed to be, most often in and around the fallopian tubes, outside the uterus, and/or on ovarian tissue. Endometrial blockages, inflammation and resulting scar tissue affects everything from healthy ovulation and the ability for the sperm to meet the egg, and for successful implantation and fetal development to occur.

If you’ve been diagnosed with endometriosis in the past or have typical symptoms of endometriosis (heavy and/or really painful periods, intense pelvic pain during menstruation, etc.), and you’re not getting pregnant as planned, endometriosis could be the culprit.

Treatment could be as simple as regulating endometriosis for a few months via birth control pills before trying again. It may also require laparoscopic surgery to remove excess endometrial tissue and scarring and/or or other assisted reproductive technology (ART) options.

Unexplained infertility

In some couples all the investigations might be normal both in the male and the female and there seems to be no apparent cause for infertility. Such couples are said to be experiencing unexplained infertility though the exact reason might be at a more cellular level - pertaining to the oocyte or sperm or a combination of both. Or sometimes, there could be issues with the binding of the oocyte and the sperm.

III - Combination of both male and female factors.

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Female Infertility Treatment

Your doctor may order several tests, including a blood test to check hormone levels and an endometrial biopsy to examine the lining of your uterus.

Hysterosalpingography (HSG). This procedure involves ultrasound or X-rays of your reproductive organs. A doctor injects either dye or saline and air into your cervix, which travel up through your fallopian tubes. With this method, your doctor can check to see if the tubes are blocked.

Laparoscopy:

If you've been diagnosed with tubal or pelvic disease, one option is to get surgery to reconstruct your reproductive organs. Your doctor puts a laparoscope through a cut near your belly button to get rid of scar tissue, treat endometriosis, open blocked tubes, or remove ovarian cysts, which are fluid-filled sacs that can form in the ovaries.

Hysteroscopy:

In this procedure, your doctor places a hysteroscope into your uterus through your cervix. It's used to remove polyps and fibroid tumors, divide scar tissue, and open up blocked tubes.

After you have finished all of your screening, an individualized treatment plan will be developed. You will follow your plan until pregnancy is achieved. Since each patient is different, each treatment plan will be different.

Pregnancy Test

A pregnancy test is performed approximately two weeks after your egg retrieval. Pregnancy symptoms are not a reliable sign of pregnancy success or failure, because symptoms may come and go. Bleeding is also more common following IVF. If you discover vaginal bleeding after the transfer, it does not mean that the procedure was unsuccessful. We will ask you to get a blood pregnancy test (hCG level), approximately 12 days after embryo transfer. You’ll take this test even if you’re bleeding. When the test is positive, you will return for a follow-up test two to three days later. The test is to confirm that the level of hCG is rising appropriately.