Frequently Asked Questions
Inability to conceive after one year with regular unprotected intercourse. Un-protected means intercourse without the use of birth control pills or condoms, weather you meant to get pregnant or not. For women older than 35 years infertility testing should be started at 6 months as the incidence of infertility and low egg reserve increases.
Age is the most important factor impacting fertility. Age is associated with reduction in egg number and egg quality.
The number of eggs remaining in the ovary constantly diminishes from approximately 300,000 at birth to 1,000 at the age of menopause.
For example by the age 35 the number of eggs remaining in the ovary is half those present at age 25. Hence it is important for women to seek consultation as early as possible.
In addition to reduced egg numbers, the quality of the eggs is also lower with advanced age. The most important aspect of egg quality is the chromosomal complement of the eggs. Abnormal eggs carry or lack a chromosome or piece of chromosome. For not well understood reasons, the number of abnormal eggs increases with advance in age.
Diminished in the number of quality eggs with age reduces the chance for natural conception, prolongs the time to achieve pregnancy and increases the risk for miscarriages, ectopic pregnancy and abnormal pregnancy outcomes.
Fertility treatment is less successful with advance in age even when IVF is employed. Age is also associated with increased risk for miscarriage after IVF. Success of egg freezing is also reduced when performed later in life >38-40 years.
Couples are encouraged to seek fertility evaluation and possibly treatment following one year of regular unprotected intercourse. Unprotected means relation without any method of birth control (pills, condom or others). Women 35 years or older should consider a consultation earlier e.g after 6 months. Couples or women should also seek care in the presence of a known infertility factor
Recurrent pregnancy loss is one of the toughest spots for women that require extensive support and counseling. We start by asking the couple not to attempt pregnancy and use a birth control method till the workup is completed. We run both partners’ chromosomes, antiphospholipid antibodies and tests for excessive clotting (thrombophilia). We also investigate the shape of the uterus and exclude any abnormalities in its cavity. We refrain from ordering tests or recommending treatment of anecdotal or no proven relation to recurrent miscarriage.
After testing is completed with convene with the couple to discuss 1. Test results and how to address any abnormality and 2. The odds for a delivery of a healthy newborn.
Women with specific abnormality e.g. clotting problems are treated with aspirin and heparin. Women with abnormalities in the uterus require surgical correction, mostly through hysteroscopy not major surgery. Women or men carrying a chromosomal abnormality as translocation are offered IVF with embryo biopsy followed by chromosomal analysis of the embryos and transfer of normal ones.
For women with no abnormalities, there is a 70% chance of delivering a viable baby if they continue to try using intercourse, IUI or IVF cycle.
The odds for successful pregnancy depend on age and ovarian reserve. Moreover, the choice of treatment is dependent on many additional factors e.g. risk for multiple pregnancy.
The odds after ovarian stimulation and IUI are 10 to 15% for each treatment cycle.
The odds after IVF is 45 to 50% per treatment cycle in women 35 years or younger. The odds drop in older women, proportionate to age.
In women using donor oocytes the odds for pregnancy is 50 to 70% per treatment cycle. The chance for pregnancy is even higher if frozen embryos are considered.
For women freezing their eggs for later use, the potential for pregnancy is 5 to 10% for each thawed oocyte. Women younger than 38 and producing > 8 oocytes may achieve a pregnancy rate close to 40-45%.
Inability to conceive after one year with regular unprotected intercourse. Un-protected means intercourse without the use of birth control pills or condoms, weather you meant to get pregnant or not. For women older than 35 years infertility testing should be started at 6 months as the incidence of infertility and low egg reserve increases.
Age is the most important factor impacting fertility. Age is associated with reduction in egg number and egg quality.
The number of eggs remaining in the ovary constantly diminishes from approximately 300,000 at birth to 1,000 at the age of menopause.
For example by the age 35 the number of eggs remaining in the ovary is half those present at age 25. Hence it is important for women to seek consultation as early as possible.
In addition to reduced egg numbers, the quality of the eggs is also lower with advanced age. The most important aspect of egg quality is the chromosomal complement of the eggs. Abnormal eggs carry or lack a chromosome or piece of chromosome. For not well understood reasons, the number of abnormal eggs increases with advance in age.
Diminished in the number of quality eggs with age reduces the chance for natural conception, prolongs the time to achieve pregnancy and increases the risk for miscarriages, ectopic pregnancy and abnormal pregnancy outcomes.
Fertility treatment is less successful with advance in age even when IVF is employed. Age is also associated with increased risk for miscarriage after IVF. Success of egg freezing is also reduced when performed later in life >38-40 years.
Couples are encouraged to seek fertility evaluation and possibly treatment following one year of regular unprotected intercourse. Unprotected means relation without any method of birth control (pills, condom or others). Women 35 years or older should consider a consultation earlier e.g after 6 months. Couples or women should also seek care in the presence of a known infertility factor
Recurrent pregnancy loss is one of the toughest spots for women that require extensive support and counseling. We start by asking the couple not to attempt pregnancy and use a birth control method till the workup is completed. We run both partners’ chromosomes, antiphospholipid antibodies and tests for excessive clotting (thrombophilia). We also investigate the shape of the uterus and exclude any abnormalities in its cavity. We refrain from ordering tests or recommending treatment of anecdotal or no proven relation to recurrent miscarriage.
After testing is completed with convene with the couple to discuss 1. Test results and how to address any abnormality and 2. The odds for a delivery of a healthy newborn.
Women with specific abnormality e.g. clotting problems are treated with aspirin and heparin. Women with abnormalities in the uterus require surgical correction, mostly through hysteroscopy not major surgery. Women or men carrying a chromosomal abnormality as translocation are offered IVF with embryo biopsy followed by chromosomal analysis of the embryos and transfer of normal ones.
For women with no abnormalities, there is a 70% chance of delivering a viable baby if they continue to try using intercourse, IUI or IVF cycle.
The odds for successful pregnancy depend on age and ovarian reserve. Moreover, the choice of treatment is dependent on many additional factors e.g. risk for multiple pregnancy.
The odds after ovarian stimulation and IUI are 10 to 15% for each treatment cycle.
The odds after IVF is 45 to 50% per treatment cycle in women 35 years or younger. The odds drop in older women, proportionate to age.
In women using donor oocytes the odds for pregnancy is 50 to 70% per treatment cycle. The chance for pregnancy is even higher if frozen embryos are considered.
For women freezing their eggs for later use, the potential for pregnancy is 5 to 10% for each thawed oocyte. Women younger than 38 and producing > 8 oocytes may achieve a pregnancy rate close to 40-45%.
Modern treatment of male factor infertility depends on results of initial evaluation. Men with 10 million motile sperms in their ejaculate can attempt ovarian stimulation and IUI. Men with less sperm or with multiple sperm abnormalities: reduced number, count and motility should undergo IVF sometimes with ICSI where a single sperm is injected in each egg. Men with no ejaculated sperm (azospermia) should be evaluated for surgical retrieval of sperm from the testes.
Men with severe male factor are at an increased risk for genetic abnormalities and this should be considered prior to treatment.
Men with erectile dysfunction can be assisted through medical treatment or vibratory devices and sperm can be used for IUI or IVF.
Once few normal sperm are obtained, successful pregnancy depends on ovarian reserve of female partner. Thus it is important to evaluate male and female partners prior to any procedures in any of them.
There is no strong evidence that repair of varicocele or medical treatment improves the odds for pregnancy in partners of men with male factor infertility.
Sometimes women do not conceive after multiple IVF attempts. These challenging situations require careful evaluation of past treatment. These include the specifics of ovarian stimulation protocol and ultrasound and hormone levels in every stimulation day. It also requires evaluation of the state of eggs and embryos after each cycle. Prior difficulty in embryo transfers is also investigated. Additional tests may be required such as Karyotype (Chromosome analysis of both partners), saline sonography to detect any abnormalities in the uterine cavity, endometrial biopsy to detect inflammation of the lining of the uterus and other tests. Review of ultrasound and hysterosalpingogram (HSG) may indicate a dilated fallopian tube (hydrosalpinx) that should be excised before treatment. We address any abnormality detected before initiating further treatment.
Our approach to repeat IVF failure in women with low ovarian reserve or advanced reproductive age is Modification of stimulation protocol: reduce dose, change timing of hCG injection. Many times modification of the way stimulation is done improves the number and quality of eggs. This may include pretreatment with estradiol and antagonist in the preceding cycle just before starting stimulation, the addition of oral agents e.g clomid or letrozole, reduced dose of gonadotropin and earlier administration of hCG injection.
Genetic testing of the embryos: This approach is may be feasible in women producing large number of eggs and embryos but fail to achieve pregnancy. Genetic testing enables selection of the chromosomally normal embryos for transfer or for women and men with abnormal chromosome configuration.
If prior IVF failure takes place in women with high ovarian reserve with the production of many eggs but no pregnancy after transfer of good quality embryos changing the stimulation protocol may reduce the number of eggs produced, increase egg maturity and embryo quality. Mild stimulation protocols and adding an oral agent commonly achieve that goal and yield a successful pregnancy.
There are many steps you can take but by far the most important is early consultation with a qualified reproductive endocrinologist. This step allows for the study of various fertility factors especially ovarian reserve and directs you to the most successful plan of action.
Encourage your partner to seek care and advice from a urologist and a reproductive endocrinologist. Explain that he is not the only factor and there are always multiple factors cooperating together.
