For more information, See Chapter 4 and Chapter 6 in The Fertility Solution
Semen Analysis | Hysterosalpingogram | Laparoscopy | Postcoital Test | Transvaginal Ultrasonography | Artificial Insemination | Fertility Drug Stimulation | Antisperm Antibody Determinations | Hormonal Evaluation | Donor Program | Antibiotic Therapy
A semen analysis is performed on a freshly collected specimen following a requested three-day continence period. The numerical evaluation includes volume, pH, motility and morphology. Except for specimens with extremely low sperm counts and compromised parameters, it is unusual for just seminal fluid to be responsible for infertility. With the availability of highly sophisticated in vitro techniques, even a severely oligospermic specimen can be successfully managed. In cases of complete azoospermia, we recommend the resources of our sperm bank.
Improving the sperm count by using fertility drugs is a notoriously frustrating experience. Rather than using Clomiphene, Pergonal or HCG for a lengthy period of time we turn to the IVF procedure. In selected cases, varicocele repair may improve semen quality. The single, most effective therapy for improving semen quality, in our experience, is antibiotic therapy.
The structural evaluation of the female pelvis starts with a Hysterosalpingogram. Between day 5 and day 10 of the cycle, just prior to ovulation, dye is injected through the cervical canal and the uterine cavity and the fallopian tubes are photographed as they fill with the dye. There is no immediate need for a laparoscopy with completely normal findings. If any adhesions, tubal blockage, intrauterine pathology with congenital abnormalities are documented, we proceed to laparoscopy.
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Laparoscopy is performed at The New York Hospital under general anesthesia. The abdominal cavity is inflated with carbon dioxide and a fiberoptic instrument is placed through the navel and through entry sites in the lower quadrants. Small instruments are introduced into the abdominal cavity to accomplish surgical repair of pelvic pathology.
Laparoscopy is performed as an out-patient procedure usually on Fridays so that the patient has the weekend for a full recovery.
This test is performed during the time of ovulation. An ovulation predictor kit is used to predict the exact timing. When the color turns, the couple is instructed to have intercourse that night and the female partner is asked to come to the office the next morning. The test results are considered good if, after twelve hours, highly active sperm are present in a clear, cervical mucous. We do not perform the postcoital test one or two hours after intercourse since conditions, such as anti-sperm antibodies or bacterial contamination in the cervical mucous allow sperm to survive for a few hours, thus giving a falsely favorable reading.
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The routine use of vaginal ultrasound has practically replaced bi-manual examination of the female pelvis. Uterine and ovarian pathology and functional changes in the ovaries and in the uterine lining can be carefully assessed with vaginal ultrasound. Vaginal ultrasound is part of the monitoring protocol during stimulation with fertility drugs, including Clomid, Metrodin, Pergonal and HCG. Prior to intrauterine insemination or postcoital testing, a vaginal sonogram is performed to document the presence of the ovulatory follicle. Vaginal sonography is part of the routine GYN examination and essential in the serial follow-up visits for benign ovarian cysts. Sonographic measurement of the uterine lining during ovulation makes endometrial biopsy for staging obsolete, since the lining measurement of 10mm or more excludes a luteal phase defect.
Through this procedure, washed or unwashed spermatozoa are injected either in the cervical canal or into the uterine cavity. A clear cut indication for the procedure is sexual dysfunction when spontaneous intercourse fails to deposit the sperm. There is much uncertainty about the actual benefit of artificial insemination with oligospermia or when it is coupled with fertility drug stimulation. To overcome a poor cervical factor, using artificial insemination is legitimate only if all other efforts have been exhausted to eradicate a cervical infection that prevents spontaneous sperm migration. We do not see any rationale behind performing artificial insemination if a postcoital test is favorable. In a case of primary infertility, when a poor cervical factor is the only documented obstacle to achieve a pregnancy, there is always a danger of creating a secondary infertility condition if an infectious cervical factor is overlooked. The infection can be introduced into the previously clear uterine cavity by the procedure. Even though a single pregnancy may be achieved, subsequent pregnancies fail to occur due to this contamination process.
To the top of the page | Semen Analysis | Hysterosalpingogram | Laparoscopy | Postcoital Test | Transvaginal Ultrasonography | Artificial Insemination | Fertility Drug Stimulation | Antisperm Antibody Determinations | Hormonal Evaluation | Donor Program | In Vitro Fertilization | Antibiotic Therapy | Contact Us
In clear-cut cases of ovulatory disorders, with associated polycystic ovarian disease, there is a definite place for Clomiphene, Pergonal, Metrodin and HCG stimulation. When all other fertility procedures are exhausted and patients must turn to an IVF procedure, fertility drugs are the only option. It is by far less certain, however, when to resort to fertility drugs in an apparently normally functioning female. Due to published studies, implicating fertility drugs in association with increased ovarian cancer risks, we disagree with the commonly practiced approach of prescribing Clominphene and subsequently, Pergonal and Metrodin therapies, following an incomplete fertility evaluation. Clomiphene in low doses has relatively few side-effects and there is only a remote chance that ovarian cysts will form. Pergonal, HCG and Metrodin, however, need close monitoring with serial vaginal ultrasound examinations and with blood estradiol determinations.
Antisperm Antibody Determinations
A great uncertainty exists about the exact significance of antisperm antibodies either in the male or in the female genital canal. Unquestionably, very high concentrations interfere with sperm migration or with the fertilization process. These cases are clear candidates for IVF procedures. With lower antibody concentrations, however, we try to exhaust all other remedies before resorting to IVF.
To the top of the page | Semen Analysis | Hysterosalpingogram | Laparoscopy | Postcoital Test | Transvaginal Ultrasonography | Artificial Insemination | Fertility Drug Stimulation | Antisperm Antibody Determinations | Hormonal Evaluation | Donor Program | In Vitro Fertilization | Antibiotic Therapy | Contact Us
Day-2 or day-3 determination of estradiol, FSH and LH values are probably the most important predicators of good ovarian function for any cycle. Elevated levels of the pituitary hormones, FSH and LH with variable estrogen levels, suggest resistant ovaries. If genital-tract infections are documented through culture studies, especially Chlamydia trachomatis, there is an excellent chance that the levels will normalize after adequate antibiotic therapy. When Chlamydia trachomatis infects the ovaries, causing an amenorrheic state, the condition can be reversed with antibiotic therapy. When the sonogram shows noraml uterine lining, we find serum estradiol and progesterone determination during the luteal phase unneccesary. To complete the workup, serum prolactin, thyroid hormone and adrenal hormone determination are performed.
The MacLeod Laboratory is a state licensed insemination site with an active sperm bank and donor program. Our donors are selected by using the strictest criteria for medical background, physical health and reproductive performance. Three criteria make this program successful: we only select medical students from our own institution; all donors are married and they all have children in that marriage. These limitations in our donor selection reassures us that we are choosing from the lowest risk category for any kind of sexually transmitted disease.
Once the donor is accepted into our program, we follow standard testing procedures prescribed by the law and by the American Fertility Society.
To the top of the page | Semen Analysis | Hysterosalpingogram | Laparoscopy | Postcoital Test | Transvaginal Ultrasonography | Artificial Insemination | Fertility Drug Stimulation | Antisperm Antibody Determinations | Hormonal Evaluation | Donor Program | In Vitro Fertilization | Antibiotic Therapy | Contact Us
The MacLeod Laboratory offers either non-stimulated, natural cycle IVF procedures or Pergonal/Metrodin/HCG stimulated IVF cycles. With a natural cycle, IVF, a single egg is monitored during the woman’s normal cycle and when ovulation is imminent, using vaginal ultrasound, the egg is retrieved. The fertilization occurs in the laboratory and two to three days later, the embryo is transferred into the uterine cavity. The advantage of this procedure is that no drugs are introduced and there is essentially no limit to how many times the patient can repeat the procedure. Working with one egg, however, gives a considerably smaller success rate when compared to stimulated IVF cycles.
The stimulated IVF cycles use a combination of Lupron, Metrodin, Pergonal, and HCG to stimulate several eggs during the first part of the menstrual cycle, which are subsequently retrieved through vaginal aspiration. The eggs are matured in the laboratory and once embryos form, the best three or four are replaced two to three days after retrieval. The disadvantages of this method include the expense, the potential side effects of the powerful drugs used and the anesthesia needed for the retrieval. Due to the availability of multiple eggs, however, the pregnancy rate is much improved compared to natural cycle IVF.
At the MacLeod Laboratory, assisted reproductive technology is offered only if other remedies are exhausted in reversing the infertility condition.
To the top of the page | Semen Analysis | Hysterosalpingogram | Laparoscopy | Postcoital Test | Transvaginal Ultrasonography | Artificial Insemination | Fertility Drug Stimulation | Antisperm Antibody Determinations | Hormonal Evaluation | Donor Program | In Vitro Fertilization | Antibiotic Therapy | Contact Us
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