Treatment

Below is a list of treatment options. Please choose the gender that you wish to learn more about.

Female

Ovulation Induction

clomiphene citrate (Clomid)

Advantages of clomiphene citrate are its low cost and a wealth of information regarding its effects—Clomid has been approved for ovulation induction by the FDA since 1967. This medication works to increase your own pituitary signal, follicle-stimulating hormone (FSH), to produce an egg. A follicle is simply a fluid-filled cyst that houses the developing egg in the ovary until ovulation occurs.

While Clomid can be an effective initial treatment, many women will need to move on to alternative therapies, usually due to minimal/partial response or marginal tolerance of the medication’s side effects.

letrozole (Femara)

Femara works through a slightly different mechanism than Clomid to increase the FSH signal from your pituitary and enhance follicular development. Its primary advantage is a shorter half-life than Clomid, which allows Femara to act primarily in the follicular phase, minimizing undesirable side effects. Additionally, this feature makes Femara an excellent medication to pair with the low-dose injectable FSH preparations detailed below for stronger ovulation induction protocols.

Despite its off-label use for many years, Femara has never been submitted to the FDA for approved use in ovulation induction cycles. There is reasonable supportive evidence from a large cohort of 911 infants born to mothers that took either Clomid or Femara in five Canadian centers demonstrating no increased risk of birth defects between these two medications (Tulandi T et al, Fertility and Sterility, June 2006). Please make sure that all your questions regarding the use of Femara have been answered by Dr. Moghadam before beginning your treatment cycle.

gonadotropins (Bravelle, Follistim, Gonal F, Menopur)

These are the medications most frequently prescribed for ovulation induction in a reproductive endocrinology practice. Whether these drugs are synthesized directly (Follistim, Gonal F) or purified (Bravelle, Menopur) in the laboratory, they are all follicle-stimulating hormone (FSH) preparations; Menopur consists of equal amounts of FSH and LH, which is useful in certain stimulation protocols. Since both FSH and LH are protein hormones that can be broken down with changes in temperature or pH, these preparations require refrigeration (once they are in a liquid form) and administration through subcutaneous injection.

Once these medications reach the ovaries, they are strong stimulators of follicular development. As a result, they can be used in lower doses for ovulation induction with timed intercourse/intrauterine insemination, or in higher doses for stimulations preceding in vitro fertilization (IVF) cycles.

Other Medications

metformin (Glucophage, Fortamet, Glumetza)

In certain medical conditions such as polycystic ovarian syndrome (PCOS), metformin may provide a useful addition to other fertility treatments. Women with PCOS often demonstrate increased production of insulin to maintain normal blood sugar (glucose) levels—this is one definition of ‘insulin resistance.’ Additionally, PCOS patients are at risk for developing diabetes mellitus, and this may even occur while they are in their reproductive years.

The best available evidence among women in the United States with PCOS not only demonstrates that administration of metformin results in significantly lower pregnancy rates than those observed with Clomid, but also that the combination of these two medications may or may not produce higher pregnancy rates than Clomid alone (Legro RS et al, New England Journal of Medicine, February 2007). Keep in mind that this well-designed research and other smaller studies supporting these findings are more indicative of results among a population of PCOS patients rather than individuals with the disorder. Therefore, we recommend blood testing for disorders of glucose metabolism (including diabetes) followed by tailoring the decision of whether or not to add/continue metformin to your individual clinical situation.

human chorionic gonadotropin or hCG (Ovidrel, Novarel)

When ultrasound measurements and/or hormone testing are indicative of mature follicles during a stimulation, we will instruct you to take hCG, more commonly known as the ‘pregnancy hormone,’ in order to simulate an LH surge followed by maturation/release of the egg(s) residing within the follicle(s).

Keep in mind that the egg and sperm typically unite in the last third of the fallopian tube and that the average time of ovulation is between 38 and 39 hours after hCG administration. Therefore, ovulation induction cycles in conjunction with intercourse or intrauterine insemination allow for more flexible hCG timing (24 to 48 hours before introduction of sperm) in comparison with IVF cycles (35 to 37 hours before egg retrieval).

Surgery

Laparoscopy

Information regarding laparoscopy is provided under our ‘diagnosis’ section. Dependent upon your symptoms, medical/surgical history, and/or prior fertility treatment, a laparoscopy may be recommended as an initial or subsequent step to enhance your chances of pregnancy. In addition to treatment of endometriosis, pelvic adhesions, and ovarian cysts, a procedure that is sometimes employed in conjunction with laparoscopy is ovarian diathermy. Specifically, for women with polycystic ovarian syndrome (PCOS) that have not responded to treatment with medications for ovulation induction (e.g. clomiphene), ovarian diathermy has been shown in some instances to produce a comparable pregnancy response to follicle-stimulating hormone (FSH) injections (Bayram N et al, British Medical Journal, January 2004)

Hysteroscopy

Information regarding hysteroscopy is provided under our ‘diagnosis’ section. If a woman has not had a reassuring assessment of her uterine cavity in the preceding year, a hysteroscopy may be done as a precursor to fertility treatment, particularly if she has a history or symptoms suggesting an abnormality of the uterus or cervix.

Microsurgical Tubal Ligation Reversal

As pregnancy rates with assisted reproductive technology have increased, patients are requesting tubal ligation reversal less frequently than IVF. Nonetheless, women with a strong desire to restore their fertility potential following tubal ligation can undergo a reversal procedure. Whether or not this is the best option is ultimately dependent upon a number of factors, including the nature of the previous sterilization procedure, age of the female partner, and fertility potential of the male partner.

Male

Intrauterine Insemination

Following intercourse, only a small proportion of the sperm ascend the female genital tract. The goal of intrauterine insemination (IUI) is to increase the quantity and quality of sperm that reach the fallopian tubes, thereby facilitating fertilization. Also known as artificial insemination, intrauterine insemination (IUI) can be performed in our office using your male partner’s sperm or, when indicated, donor sperm.

Before the IUI procedure, the sperm are washed and placed into a small volume of sterile medium. The process of sperm washing is performed to remove substances in the ejaculate that are not meant to reach the uterine cavity and concentrate the specimen into a small volume that will not leak out the cervix. The prepared sample is then injected directly into the uterus via a soft, thin catheter. This portion of the procedure is comparable in sensation to a Pap smear. The woman is able to resume normal activity immediately after intrauterine insemination.

For intrauterine insemination to be effective, the woman must have normal ovulation, open fallopian tubes, and a normal uterine cavity. Ovulation induction with fertility drugs may be indicated for women with ovulatory disorders. The sperm of the male partner, or donor, is analyzed beforehand to determine count, motility (movement) and morphology (shape and size).

IVF/Assisted Reproduction

In vitro Fertilization (IVF)

Overview

Although it was originally developed to assist women with tubal disease, in vitro fertilization (IVF) has evolved into the definitive treatment for nearly all types of infertility, especially for couples who have not experienced success with less complex treatment approaches. Suitable IVF candidates may include patients who have:

  • Blocked fallopian tubes
  • Pelvic adhesions
  • Endometriosis
  • Polycystic Ovarian Syndrome (PCOS)
  • Cervical abnormalities
  • Male factor infertility
  • Unexplained infertility
  • Genetic diseases suitable for screening through preimplantation genetic diagnosis (PGD)

Many of our patients will become pregnant through other treatments, but IVF is the most effective method for achieving pregnancy in a single cycle. We suggest reviewing the information presented on our website and scheduling a consultation with Dr. Moghadam before determining if IVF is the right option for you.

Preliminary Testing

Prior to undergoing IVF, our team will review your previous evaluation and/or fertility treatment—this is to ensure that we select a protocol that is not arbitrary (e.g. based upon age) but rather individualized to give you the best possible chance of success in a single cycle. Some of the testing that we will confirm includes:

Uterine Cavity Evaluation If you have not undergone a recent assessment of your uterus (e.g. hysteroscopy, saline-infusion sonogram, or hysterosalpingogram) or if you have a history of uterine abnormalities, we will often obtain repeat testing prior to IVF to rule out abnormalities that may interfere with successful implantation.
Genetic Disease Testing.

One example of this type of evaluation is carrier status screening of both partners for the pulmonary disease cystic fibrosis. Both the American College of Obstetricians and Gynecologists (ACOG) and the American Society for Reproductive Medicine (ASRM) recommend that all patients undergoing preconception counseling are offered cystic fibrosis testing. Although the population risk of having a child with this disease is less than 1 percent, obtaining this evaluation will allow our team to furnish you with the most complete counseling before beginning IVF. Testing for other genetic diseases may also be offered depending upon the background of male and female partners. We can also arrange for referral to a genetic counselor in the event of an abnormal result or for more detailed discussions regarding genetic disease risk.

Blood Borne Disease Screening

In certain instances, the Food and Drug Administration (FDA) requires that we obtain a specific panel of tests prior to embarking upon an IVF cycle. This is most often in cases involving third-party reproduction (e.g. donor egg). Among the majority of our patients utilizing their own eggs and sperm, we perform an abbreviated blood borne disease panel.

IVF Medications

Many of the medications we use in IVF are also used in other stimulation protocols. As previously mentioned, we will select a type/dose of medication and protocol that will optimize your response. Following a detailed injection teaching conference, you will be given a calendar that provides dates to start and stop each medication. Please keep in mind that the calendar is meant to serve as an estimate, since we frequently will need to adjust your doses and dates while we are monitoring your stimulation response. Finally, it is not uncommon for patients to need reassurance that they are taking their medicines correctly–we encourage you to call us anytime if you have questions.

Bravelle, Menopur (laboratory-purified gonadotropins)

These FSH preparations are packaged in a dried powder form that must be diluted with a small amount of saline before they are administered as a subcutaneous injection. Remember that Menopur contains both FSH and LH.

Follistim, Gonal F (laboratory-synthesized gonadotropins)

These FSH preparations are in a liquid form with cartridge/pen (Follistim) or pre-filled pen (Gonal F) delivery systems for subcutaneous injection.

Ganirelix (GnRH antagonist)

If ovulation occurs before we are ready to perform your egg retrieval procedure, your chances of getting pregnant will be adversely affected. Therefore, IVF requires that we not only stimulate your ovaries with one or more of the FSH regimens above but also include a medication that will block your LH surge until your egg retrieval. With protocols that involve Ganirelix, we will instruct you to add this medication as a daily subcutaneous injection beginning a few days into your stimulation, and continuing until the day of hCG administration.

Lupron (GnRH agonist)

Lupron is another medication that prevents early ovulation. Since it takes longer to work, Lupron-based protocols require that this subcutaneous injection is begun at variable intervals and doses before you begin your stimulation with FSH.

Novarel, Ovidrel (hCG)

As mentioned elsewhere on this website, both of the above medications are preparations of human chorionic gonadotropin (hCG), the ‘pregnancy hormone,’ which can be used in place of the LH surge prompting the eggs to mature within the follicle. This can be administered as an intramuscular (Novarel) or subcutaneous (Ovidrel) injection. Please keep in mind that because these medications are present in your bloodstream for 10 to 12 days after they are given, taking a pregnancy test in that time can produce a false positive result.

Progesterone

Women going through IVF are given progesterone supplementation as support for embryo implantation and early ongoing pregnancy. Progesterone is available in intramuscular and vaginal (gel or tablet) regimens that are begun from the day of retrieval and continued until the mid to late first trimester.

Antibiotics

Some evidence suggests that administration of antibiotics to both the male and female partners around the time of embryo transfer reduces bacterial growth at the catheter tip, and may improve pregnancy outcome.

Anti-inflammatory medications (steroids)

Similar to the thought process behind administration of antibiotics, the use of steroids (prednisone, dexamethasone, or methyl-prednisolone) around the time of embryo transfer may reduce inflammation at the site of implantation.

Stimulation

Following either an induced or spontaneous menstrual period, a typical stimulation is begun on the second or third day of your menstrual cycle and continues for 8 to 14 days before hCG is administered and the egg retrieval is performed. The goal is to use the fertility medications to promote the simultaneous maturation of multiple follicles. During this time period, a woman’s progress is monitored with several hormone testing and/or ultrasound assessments. Dependent upon the observed response, the medication doses are modified or continued until the follicle sizes and estrogen level indicate maturity.

Retrieval

When the stimulation has been completed, hCG is administered and the egg retrieval is scheduled approximately 36 hours after this injection. You will need to arrive at Austin Surgical Hospital at least an hour before your scheduled procedure time to allow for registration and nursing assessment prior to your procedure. Once you are in the procedure room, an anesthesiologist will administer 2 or 3 different medications intravenously that will remove any pain or memory during the egg retrieval.

Using a transvaginal ultrasound probe and a needle with attached tubing to a suction device, the eggs are aspirated through 2 puncture sites in the vaginal wall, meaning that there is no incision. The procedure lasts between 20 to 30 minutes.

Transfer

Following introduction of egg and sperm on the day of retrieval and several days of embryo culture, one or more embryos are transferred into the uterine cavity under ultrasound guidance using a thin plastic catheter. Since this is accomplished with a speculum in place and with a full bladder to assist in visualization of the uterus on ultrasound, patients report pressure but minimal pain during the embryo transfer.

Intracytoplasmic Sperm Injection (ICSI)

ICSI is a technique that has been available in conjunction with IVF since 1993. It is indicated for more moderate or severe cases of male factor infertility that are not responsive to treatment with intrauterine insemination (IUI).

After egg retrieval, mature eggs are identified by our embryologist. When the male partner has demonstrated a normal semen analysis, each egg is surrounded by tens of thousands of moving sperm to allow one to enter with early embryos observed the next day. This approach is insufficient, however, to achieve fertilization when sperm counts are low or the male partner has a low percentage of normal-shaped sperm (low morphology).

In these and other cases, we can employ ICSI to reduce the sperm requirement to a single injected sperm for each egg. The availability of ICSI also provides the opportunity to achieve fertilization with sperm that is surgically obtained by a urologist when the male partner has no sperm in his ejaculate (azoospermia).

Assisted Hatching

This technique involves removing a small portion of the zona or ‘shell’ around the embryo using a laser or a weak acid solution without harming the embryo. Since the embryo needs to expand and ultimately hatch from the zona before it can implant in the uterus, assisted hatching has been shown to improve pregnancy rates when the zona is observed to be thicker than normal or the female partner is 38 years of age or older.

Preimplantation Genetic Diagnosis (PGD)

For patients at risk of transmitting a genetic disease to their offspring, pre-implantation genetic diagnosis (PGD) can improve the chance that a healthy baby will be born. PGD, or pre-implantation genetic diagnosis, is a breakthrough technology that improves the likelihood of having a healthy baby. This process should be performed only by individuals with a high level of comfort and experience, such as our two scientists at Austin Fertility Institute.

IVF is required as a precursor to PGD, since it allows embryos to be readily available for assessment. Three days after egg retrieval, a majority of the embryos have usually grown to six to eight cells in size. One or two cells are removed from each embryo through embryo biopsy, and a genetic evaluation is performed on the DNA obtained from each of these cells. The results are available two days later, and embryos are selected for transfer based upon these findings.

Since PGD is not a routine part of IVF, there is an additional cost for the service that is variable dependent upon the type of genetic testing performed. Patients considering this procedure should undergo an in-depth consultation with both Dr. Moghadam and a genetic counselor before proceeding with treatment.

Due Date Calendar