Infertility Treatment in New Jersey
There are many different treatments for infertility. The treatment that is best for you will depend on your diagnosis, age, insurance coverage and what type of treatment you are comfortable with. We will carefully explain all of the alternatives to you, and together as a team come up with a specific plan tailored to your unique situation. In general there are 3 groups of treatment options:
Treatment of Sperm Abnormalities
- Intrauterine insemination (IUI) with partner’s sperm or Donor sperm
- IVF with or without ICSI and/or PGS
- Urologic surgery or medical treatment
Treatment of mild fertility abnormalities or unexplained infertility often starts with Clomid or FSH shots with IUI for 3 cycles and then onto IVF. Then decision as to whether surgery such as a laparoscopy is needed is based on the patient’s history, physical examination and test results and can occur at any point during treatment.
A problem with ovuation is the most common fertility abnormality for women. If the cause is traced to a medical problem, this should be corrected. Weight loss for overweight patients and weight gain for underweight patients can restore normal ovulation. Thyroid hormone replacement for hypothyroid patients and medications to suppress excess prolactin secretion will help patients with these disorders. Women with PCOS who also have insulin resistance can take medications such as Glucophage to lower their insulin levels and improve their chance of ovulating either on their own or improve their response to fertility medications.
Clomiphine Citrate in New Jersey
The most common treatment for an ovulation problem is clomiphene citrate, most commonly known as Clomid. This is an anti-estrogen pill that tricks the brain into thinking the estrogen levels in the body are too low, which causes the pituitary gland to make more FSH, which in turn stimulates follicles to grow and release one or more eggs. Because of the anti-estrogen properties of Clomid, some patients may have hot flashes, or other side effects. Clomid is taken for 5 days, early in the menstrual cycle (usually days 3 through 7), and an ultrasound is done around cycle day 12 to see if the follicles have grown properly. Usually 1-4 follicles reach 20 millimeters in size, and are ready to ovulate. About 80% of patients respond to Clomid, half of whom will ultimately conceive. There is a 10-20% chance of success per cycle and a 5-10% risk of twins. For patients with side effects to Clomid, other similar medications can be used such as tamoxifen or letrozole (Femara). For patients who do not respond to Clomid or who do not achieve pregnancy after 3-6 cycles, FSH injections or IVF procedures are usually utilized.
FSH Injections in New Jersey
FSH injections have the same hormone the pituitary gland uses to stimulate follicle growth, with the advantage of being able to give FSH in higher doses to get the ovaries to respond. Since the FSH shots are more potent than Clomid, frequent ultrasounds and blood tests (every 2-3 days) are necessary to make sure the correct number of follicles grow. Injections are usually started on cycle day 2-4 after an ultrasound and blood test are done, and continue until the follicles are ready to ovulate. Side effects are generally less than with Clomid, and the chance of pregnancy is higher, but the risk of twins increases to 20—25% and the risk of triplets or more is up to 5%. Over-stimulation of the ovaries can occur, causing fluid retention and bloating, rarely requiring a procedure to drain fluid from the abdomen.
In cases of unexplained infertility or when sperm counts are low, an insemination of sperm can be done during a Clomid or FSH cycle. When the follicles are large enough to ovulate, a shot of hCG is given to cause ovulation 1-2 days later. At that point a fresh sperm specimen is obtained, washed and placed in a small catheter which is gently placed through the cervix and the sperm are placed in the uterine cavity (intrauterine insemination=IUI) closer to the eggs. Inseminations of donor sperm can also be done in the same way.
If the ovaries are running low on eggs or do not respond well to ovulation medications, eggs donated from another woman can be used (donor eggs). This requires an IVF cycle in which eggs are retrieved from the donor, put together with the patient’s partner’s sperm in a dish in the IVF lab, and then the resulting embryos are transferred back to the patient after proper hormonal preparation of the uterus. A less costly alternative is to use donated embryos, but in this case neither the husband nor wife contribute to the genetic make-up of the child.
When all the tests for infertility are normal, the cause of the problem is unknown or “unexplained.” In these cases there are probably subtle problems that are difficult to detect with traditional testing. Many things have to go right for a successful pregnancy to occur, and any step that goes wrong may cause infertility. Eggs, sperm or embryos may not be healthy or genetically normal. These cases could lead to a lack of fertilization or failure of embryo development or implantation. The fallopian tubes may not be catching the egg or may not be moving the embryo into the uterus correctly. If the embryo does make it into the uterus, it may have trouble breaking out of its protective shell and implanting. All of these problems are undetectable by the standard infertility evaluation, and may lead to unexplained infertility.
Patients with unexplained infertility can still get pregnant on their own, but at a much lower rate. Normal monthly fertility rates are 20-25%, but in couples with unexplained infertility the rates are about 3% per month. Since there is no cause identified for the infertility, the treatment is designed to improve the reproductive efficiency of the couple, without knowing which potential subtle problem is being addressed. The therapeutic approach is to get the women to produce more eggs to increase the odds of a good egg making it into the tube, and to put the man’s sperm as close to those eggs as possible. Therefore treatment usually consists of Clomid or FSH shots to produce multiple eggs, often combined with an IUI. If there is no success after 3 cycles of these treatments, then IVF is offered. Success rates vary from 3% per month with no treatment to 10-15% with Clomid with IUI, to 20-25% with FSH shots with IUI and up to 50% or more with IVF. Multiple factors such as previous success, length of infertility and the age of the woman may raise or lower these success rates for any particular couple.
Fallopian Tube Abnormalities
The fallopian tubes may have scarring that limits their ability to catch an egg or may be blocked completely. Scarring around the tubes can usually be fixed by cutting away the scar tissue during a laparoscopy. A laparoscopy is a minimally invasive outpatient surgery in which a slender telescope is placed through the navel, and scissors or a laser is used to cut scar tissue or repair tubal abnormalities. If the tube is blocked at the end near the ovary, it can swell and fill with fluid and is called a hydrosalpinx. Severe swelling can damage the tube irreparably and in these cases the tube is usually removed. In less severe cases the tube can be surgically re-opened. If the tube is blocked near the uterus, it may be possible to pass a catheter through the uterine cavity and into the tube to open the blockage. This is done through a telescope placed in the uterine cavity called a hysteroscope. Sometimes this procedure can be done with the catheter placed under radiological guidance instead of during surgery. If a patient has had her tubes tied (tubal ligation) in the past, surgery can sometimes be done to try to repair the tubes and put them back together (tubal reversal). This surgery is done by a minimally invasive laparoscopy procedure at a surgery center and the patient is able to go home the same day, with a brief 1 week recovery.
If the tubes are damaged to the point that they are not thought to be able to function normally or are not surgically correctable, then in-vitro fertilization (IVF) can be used to by-pass the tubes. In an IVF cycle, FSH shots are given to stimulate multiple follicles to grow. Using ultrasound guidance under gentle anesthesia, a needle is placed through the vaginal wall into the ovaries to retrieve the eggs from the follicles. The eggs are mixed with sperm in a dish in the IVF laboratory, and incubated for 3 to 5 days while the eggs fertilize and divide into embryos. In essence we are substituting the test tube for the fallopian tube. One or more embryos are then placed into the uterine cavity with a small catheter placed through the cervix. Daily progesterone vaginal cream or suppositories are given to support the pregnancy.
Women may be born with an abnormally shaped uterus which can take the form of a half uterus (unicornuate), double uterus (bicornuate) or a single uterus with a wall down the middle (septate). Fortunately, a septate uterus is the easiest to fix surgically and the only one that requires treatment. A hysteroscope can be placed through the cervix and a small pair of scissors can be used to cut and remove the septum. This may reduce the chance of recurrent miscarriages. If a patient develops abnormalities inside the uterine cavity such as polyps, fibroids or scar tissue that are thought to impair implantation of an embryo, these can also be removed with a hysteroscope. In some cases fibroids, which are benign nodular growths of the uterine muscle, can grow large enough to distort the uterus or tubes and lead to heavy, painful menstrual periods, infertility or recurrent miscarriage. These fibroids may need to be removed with a procedure call Myomectomy which may be able to be done with a minimally invasive laparoscopic robotic approach. Each fibroid is removed from the uterus and the uterine wall is sewn back together in a normal shape. If the fibroids are too large or numerous for the robotic approach, an abdominal incision can be done to complete the procedure.
The treatment of low sperm counts depends on the total number of moving (motile) sperm and the percent with normal shape (morphology). If the sperm numbers or morphology are slightly below normal, then an intrauterine insemination (IUI) is usually recommended. In this procedure a fresh semen sample is obtained in the morning and is washed and concentrated into a small volume of fluid. The prepared sperm sample is then placed in a catheter which is placed through the cervix and the sperm are deposited at the top of the uterine cavity. This usually is painless, or may cause mild cramps. An IUI allows a higher concentration of the best sperm to get closer to the eggs just as they are being released. Low sperm counts may also improve with smoking cessation, avoiding excessive heat, and taking vitamin therapy with folic acid, zinc and other nutritional supplements. In some cases a urologist may recommend surgery to remove swollen varicose veins around the testicles to improve sperm counts.
In cases where the sperm numbers or morphology are severely low and it is determined that they may not be able to fertilize the eggs inside the body, then IVF is recommended. With IVF an adequate number of sperm can be placed around each egg in a dish in the laboratory to maximize the chance for fertilization. Often a single sperm is microscopically injected into each egg to enable fertilization. This procedure is called intracytoplasmic sperm injection (ICSI) and it can be done with extremely low numbers of sperm.
Men with no sperm in the ejaculate (azospermia) may have blockage or absence of the vas deferens. This may be congenital and related to some genetic syndromes, or acquired by infection or surgery such as a vasectomy. Other men with azospermia may not produce enough sperm to make it out of the testicles. In these cases sperm may be retrieved from the epididymis or testicle by a urologist and used to fertilize eggs during an IVF-ICSI cycle. Alternatively, donor sperm from a sperm bank may be utilized. In some cases a urologist might recommend a vasectomy reversal or other surgery to bypass the blockage