Infertility program

Our office provides basic infertility work-up and treatments for couples having difficulty achieving pregnancy. Services we provide include infertility evaluation tests and ovulation stimulation with or without artificial insemination. We do not provide IVF (in-vitro fertilization) or complex ovarian stimulation services. In women of advanced maternal age, usually 40, we are more likely to quickly refer to those who perform IVF, realizing that the biological clock is the most important key player in these patients.

Infertility is a challenging process for everyone involved. Couples often come to me frustrated and anxious, fearful that they will not be able to conceive. Happily, we have much to offer and we usually see successful outcomes to treatment. When success is not achieved in a timely manner, I do not hesitate to refer patients for “high tech” procedures performed by reproductive endocrinologists that yield success in the majority of couples.

When you come into the office for initial evaluation (usually after you and your husband have been trying to conceive for at least a year), we will sit down with you and review your past history to try to identify factors which may contribute to infertility. You will also be asked to fill out a questionnaire geared toward identifying contributing factors.

Next we will recommend specific tests. These may include blood tests, semen analysis, and ultrasound or other radiologic tests. Here’s a general description of the tests and why they may be recommended:

• Day 21 Serum Progesterone. A blood test which is the only way to definitely determine whether or not you have ovulated. Basal body temperature testing, thin stringy cervical fluid mid cycle, and ovulation predictor testing all give PRESUMPTIVE evidence that ovulation has taken place. But only an elevated progesterone on the 21st day gives definitive evidence that ovulation has indeed taken place. Results are usually available in 2-3 days.
• Thyroid Panel. An elevated Thyroid Stimulating Hormone (TSH) indicates a low functioning thyroid gland which may interfere with the hormones that produce ovulation. Replacement with thyroid hormone will usually restore the normal interval of ovulation. Results are usually available in 2-3 days.
• Prolactin. A hormone produced in the pituitary gland in the brain usually involved with lactation. Sometimes, a small benign micro-tumor in this area may produce elevated levels of the hormone Prolactin, which may also interfere with ovulation. If it is elevated, we will order an MRI of the brain to make sure no tumor exists. If no tumor exists in the face of elevated prolactin, we usually treat with a specific steroid which lowers the level and restores normal ovulation. Results are usually available in 2-3 days.
• Follicle Stimulating Hormone and Estradiol. These are drawn on the third day of menstrual bleeding, and gives us an idea of the “fertilizability” of the eggs your body produces once a month. An elevated FSH is concerning and predicts that the “low tech” method of infertility treatments will be no more successful than what a couple can achieve on their own with no treatment. In situations where the FSH is elevated, we refer couples for IVF. FSH and Estradiol tests are recommended for patients younger than 35 years old. Results are usually available in 2-3 days.
• Clomid Challenge Test. This test is slightly more involved than the FSH/Estradiol. It is reserved for women over 35. An FSH and Estradiol are drawn on Day 3 of menstrual bleeding. The ovulation inducing medicine Clomid is given daily from the 5th to the 9th day of a woman’s cycle. On the tenth day, the FSH is drawn again. The results are then analyzed and again, if elevated, predict poor success with basic infertility treatment. Results are usually available 2-3 days after the labs are drawn on the 10th day.
• Semen Analysis. This is all the husband has to contribute in the infertility workup. More than 30% of infertility is related to the male partner. We’d be foolish to do a compete workup on the wife and not examine the husband’s semen. If results are normal, that’s great. If abnormal, we generally recommend antibiotic therapy (to clear an asymptomatic prostate infection) followed by a repeat semen analysis. If results are still abnormal, we can provide treatment based on the findings. Generally, we look for the overall number of sperm, how motile the sperm are (swimming straight and fast as opposed to sluggishly in circles), and the morphology, or how normal the sperm look under the microscope. Results are usually available in 3-7 days.
• Post-Coital Test. This test is performed midcycle during ovulation. Shortly after having intercourse at home with your husband, we would ask you to come into the office. We will aspirate cervical mucous with a small catheter and place it on a glass slide, where we will examine it under a microscope. If we see thin stretchy egg-white consistency cervical mucous and a multitude of fast moving sperm, the test is considered normal. If either the cervical mucous is thick and tenacious or there are a lack of abundant fast moving sperm, the test is considered abnormal. In this way we are able to diagnose the so-called “hostile cervical mucous” and provide treatment to bypass the mucous altogether. We are able to do this by performing intrauterine insemination. Since we do this test in the office, results are available during the same visit.
• Hysterosalpingogram (HSG). This is a test done at a radiology facility. It is able to evaluate the presence of uterine abnormalities such as endometrial polyps or fibroids, both which can interfere with implantation of a fertilized egg. It also evaluates fallopian tube patency. If the fallopian tubes are blocked, the sperm will never meet up with the egg. Obviously, that’s a major problem which can either be remedied by laparoscopic tubal surgery or in-vitro fertilization. This test can be uncomfortable and usually requires prophylactic pain medication (Alleve, Motrin, or sometimes Vicodin). Additionally, if you are allergic to iodine or shellfish, you will need to let the radiologist know. To set up this test, we will ask you to call the radiology department at John Muir Medical Center on the 1st day of your menses. The test should be done between day 6 and day 10 of your cycle. Results of the test can be available in 2-3 days.

Once we have results from all of the tests, we would like to have you come back in to review results and establish an appropriate plan. Treatment regimens are usually aimed at correcting a problem identified during the investigation of infertility. In the absence of isolating the factor responsible, we utilize regimens that are known to produce results in a significant number of couples.

Since every patient may have different thoughts on how aggressive they would like to be in treatment, our goal is to provide options that are effective and yield high likelihood of success. Once we decide together on a treatment regimen, we will give you handouts with instructions to minimize confusion for you (it can be very confusing at first). The instructions should make the program clear, but certainly call us with any questions.

I am forthright in my recommendations for treatment. If I think that a plan is unlikely to be successful, I’ll let you know. I am not interested in treating patients that I know have a low chance of success and when I know that they would be better served in the hands of an infertility specialist that performs “advanced reproductive technology” such as super ovarian stimulation or in-vitro-fertilization. I look forward toward to providing prenatal care to those patients who have come to me with infertility problems. If another physician helps a patient of mine become pregnant, it’s a success for everyone.

The following is a brief explanation of the programs we offer:

• Clomid stimulation cycle with use of Ovulation Predictor Kits
• Involves a visit to the office during on one of the 1st five days of the menstrual cycle for a “clomid check”. The couple is then instructed to have intercourse following a positive surge on an “over-the-counter” ovulation predictor kit.
• Clomid stimulation cycle with Ovulation Predictor Kits and Artificial Insemination (Intrauterine Insemination, or “IUI”)
• Involves a visit to the office during on one of the 1st five days of the menstrual cycle for a “clomid check”. The couple is then instructed to return to the office for artificial insemination following a positive surge on an “over-the-counter” ovulation predictor test.
• Clomid stimulation cycle with Follicle Scanning, Human Chorionic Gonadotropin (HCG)injections, and Artificial Insemination
• Involves a visit to the office during on one of the 1st five days of the menstrual cycle for a “clomid check”. The couple is then instructed to return to the office on or around day 12 of the cycle for an ultrasound of the ovaries. If the follicles within the ovaries are of sufficient size, then the patient is given an injection of HCG to encourage controlled ovulation and asked to return the next day for artificial insemination.
• Ovulation Predictor Kit timed Artificial Insemination
• When the patient has a positive surge with an ovulation predictor test, she calls for an appointment the next day and comes in for artificial insemination.

Some physicians prescribe Clomid freely, without monitoring ovaries prior to the start of the medication. We do not do that. We have our patients come in for an examination at the start of each Clomid cycle. We do not usually make exceptions to this practice.

Once we have determined a treatment plan, we will encourage you to stay with the plan until completion (i.e., pregnancy, or until we have exhausted the number of cycles planned). Busy schedules and frequent business trips will certainly decrease the likelihood of success, and if multiple cycles are canceled as a result, we will likely recommend advanced reproductive technologies or taking a break. Infertility treatment is rarely convenient

Should you have any questions along the way, please ask. My Nurse Practitioners have been doing this as well for a very long time, so if I am not immediately available, feel comfortable in asking them your questions.

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