Fertility Frequently Asked Questions
Your first step in our office will be to complete a questionnaire describing past medical history and previous infertility evaluation and treatment. A copy of medical records relating to infertility, including doctor's notes, operative reports, and laboratory tests, is extremely helpful. A doctor then interviews the patient to assess their specific infertility needs.
During the evaluation and treatment of infertility, transvaginal ultrasounds may be performed to monitor ovulation. Ultrasounds are performed exclusively by the physicians of the Fertility Center at UT Health San Antonio, not by ultrasound technicians. A semen analysis will also be performed in our laboratory.
All IVF procedures are performed in-office. Minor outpatient procedures, such as hysteroscopy and tubal canalization, may also be performed in the office. If necessary, a hysterosalpingogram (x-ray of the uterus and fallopian tubes) may be performed by our physicians at the Medical Arts & Research Center - MARC. Surgery, if needed, may be done at the MARC Day Surgery Center, St. Luke’s Baptist Hospital, Methodist Ambulatory Surgical Center or University Hospital.
What is an Infertility Specialist?
The medical specialists that treat patients with infertility are known professionally as Reproductive Endocrinologists. Training in Reproductive Endocrinology requires a medical school degree. The physician must then complete a four-year residency in Obstetrics and Gynecology (OBGYN), during which they receive broad training in general Obstetrics and Gynecology. The final course of training is a two or three-year fellowship in Reproductive Endocrinology. Fellowship training focuses on the diagnosis and treatment of infertility and related disorders. This training includes experience in microsurgery, laparoscopic and hysteroscopic surgery, in vitro fertilization embryo transfer, sonography, and ovulation induction. In addition, the physician spends a significant amount of time performing clinical and/or laboratory research.
Upon completion of a Fellowship in Reproductive Endocrinology, specialists seek Board certification. Board certification is a multi-step process. To become Board certified in Reproductive Endocrinology, the physician must first obtain Board certification in Obstetrics and Gynecology. This requires successful completion of both a written and an oral examination. Board certification in Reproductive Endocrinology requires successful completion of additional written and oral examinations. The entire certification process takes several years to complete. Only those physicians who have successfully completed a Fellowship in Reproductive Endocrinology can become Board certified as an infertility specialist.
It is often quite difficult for a patient to determine whether or not their physician is an infertility specialist. Some physicians have gained skills through experience outside fellowship training, and some physicians successfully complete fellowship training and do not obtain Board certification. However, board certification is the only objective criteria by which patients can measure a physician's qualifications.
What are Assisted Reproductive Technologies (ART)?
Assisted Reproductive Technologies (ART) include in-vitro fertilization-embryo transfer (IVF-ET), frozen embryo transfer (FET) and includes the use of donor oocytes. Although ART has helped many people overcome their infertility, they are not the answer for every infertile couple. Most of the time we use ART only when less complex and less expensive methods of treatment have failed. However, in certain circumstances (such as advanced age or severe male factor) we may recommend ART as first-line therapy.
During IVF-ET, the oocytes and sperm are combined in a culture dish in the laboratory. Fertilization and very early embryo development occur outside the body, rather than in the fallopian tube. Once early embryo development is recognized, the embryos are transferred into the uterus (IVF-ET) or frozen for future frozen embryo transfer. Your physician will discuss each of these procedures with you so that the most appropriate procedure for your individual situation will be used.
Couples who are considering ART should realize that it is an intensely emotional, physically arduous, and expensive procedure. Most couples find it difficult to consider the chances for success realistically without dampening the drive that allows them to undertake these procedures. Above all, couples should explore plans for the future, whether or not their attempts at ART are successful.
Am I a candidate for ART?
Every patient should have completed a basic infertility evaluation. Because of the physical, emotional, and financial demands of ART, these procedures generally are used in patients who have tried less complex and less expensive methods of correcting their infertility. The majority of patients in ART programs suffer from tubal factor, male factor, or unexplained infertility. ART candidates who will be using their own eggs should be under 46 years of age and must have
- No evidence of premature menopause
- At least one accessible ovary, and
- A normal uterus
Menopause and ovarian function are irrelevant for candidates using donor eggs. Donor egg recipients must be under 50 years of age and have a normal uterus. All ART candidates should be in good health and have no medical conditions that would pose a serious health risk to themselves or the child they would carry.
Participation in an ART program can be stressful and emotional. We encourage couples considering or pursuing ART therapy to attend group support sessions such as those offered by RESOLVE, a national infertility support group. We can also refer you to private counselors for individualized care.
ART Financial Information
A cost estimate for an ART cycle is difficult to provide because some costs vary considerably between patients. In particular, the number of ultrasounds and estradiol measurements, and the amount of stimulation medications can significantly change the total cost of the procedure. However, we have attempted to offer affordable ART by providing a bundle package that includes the cost of one basic IVF cycle within this bundle, excluding the costs of medications and additional procedures such as freezing of embryos and intracytoplasmic sperm injection (ICSI). Because the ART procedures involve multiple steps, any patient who does not proceed to a further step is usually charged only for the cost of the completed procedures. Before initiating ART, you should discuss financial arrangements with our billing personnel.
Additional expenses to consider may include loss of wages from time missed at work, as well as, expenses incurred by travel and accommodations for our out-of-town patients. In addition, the medications employed in ART procedures (hCG and GnRH analogs) are very expensive. All of these factors must be considered in ascertaining the financial feasibility of participation in an ART program.
We are sensitive to the tremendous financial investment that couples make to participate in this program. We continuously strive to keep our costs manageable and we seek funded research protocols in which ART costs for the participants may be defrayed. In addition, through the efforts of our professional organizations, we are actively lobbying both at the state and national levels for insurance coverage for ART.
What are my chances for success?
One of the first questions that most people ask is "What is the chance for success?" The initial hope of achieving a pregnancy by ART is often dampened by the answer to this question. In 2013 in our program, liveborn infants occurred in approximately 46.4 percent of cases in women 35 and younger and in which women had embryos derived from their own eggs transferred to the uterus. The 2013 nationwide "take home baby rate," was 40.1 percent for these same women. We believe that the delivery rate or "take home baby rate" is the only real measure of success. Patients should be aware, however, that some clinics define "success" as any positive pregnancy test, or any pregnancy, even if miscarried or ectopic. These "successes" are irrelevant to patients desiring a baby.
Success varies with many factors. One very important factor is the age of the woman. Over age 37, ART success rates decline dramatically. Another factor that affects ART success is the number of embryos that are transferred. Presently, the collection of oocytes, fertilization, and early embryo growth, are accomplished with a high degree of efficiency. The major hurdles to success are implantation after embryo transfer and early pregnancy loss. The rate of early pregnancy loss is slightly higher with ART compared to spontaneous conception. The risk of early pregnancy loss increases with age of the female partner. There is, however, no evidence that the risk of birth defects or chromosome abnormalities (such as Down's syndrome) is any different with ART. Pregnancy complications tend to be higher with ART pregnancies, primarily because of the much higher rate of multiple pregnancy. Twins occur in about 25 percent of ART pregnancies versus 1-2 percent of spontaneous pregnancies. The risk of more than a twin pregnancy is about 1 percent nationally in women < 40 years old.
To put these figures into perspective, studies have shown that the rate of successful pregnancy in couples with proven fertility in the past is approximately 20 percent per cycle. Therefore, although a figure of 46.4 percent may sound low, it is much greater than the chance that a fertile couple will conceive in any given cycle.
We advise that patients plan at the onset to make several ART attempts. There is no absolute restriction on the number of times that a couple can attempt ART. Although cumulative pregnancy rates increase through a total of six attempts, the success rate for any given cycle remains constant. A rest period between attempts is sometimes recommended which is usually an interval of one normal menstrual cycle. Couples who have achieved an ART pregnancy in the past have an increased likelihood of ART-related conception in the future.
Before starting ART therapy, we perform certain tests to ensure that conditions for a successful pregnancy are optimal.
You should have a complete physical exam, including breast exam and Pap smear per American College of Obstetrician and Gynecologist’s guidelines. You should also start taking prenatal vitamins containing folic acid, which has been shown to reduce the risk of birth defects of the spine. Women over 40 should consider having a mammogram prior to ART therapy.
We confirm the woman’s blood type, and screen for antibodies that could affect the health of a fetus. We also perform a test for syphilis (a venereal disease that can affect the fetus). Documentation of immunity to rubella (German measles) may also require a blood test. Rubella during pregnancy can cause serious harm to the fetus. We require blood tests for hepatitis and HIV (AIDS) for both the patient and her partner. We may recommend a blood test for FSH (a hormone that regulates ovarian function). This must be performed on the second, third or fourth day of the menstrual cycle. We may also order a test called antimullerian hormone (AMH). These tests can reveal abnormalities in ovarian function (ovarian reserve) that can affect the success of ART therapy, especially in women over 35 years of age.
A semen analysis should be performed within one year of ART. Changes in sperm quality may occur over time, which could affect the success of ART therapy. In some cases, we may recommend additional semen testing. For example, we may test for the presence of anti-sperm antibodies. Sperm antibodies are proteins in the semen that can impair sperm function. These antibodies can also be found in the woman’s bloodstream. Sperm antibodies can impair fertilization, even in vitro. If we detect anti-sperm antibodies, we may prescribe special therapy before or during the ART procedure.
We recommend evaluating the anatomy of the uterus prior to ART. We may suggest an x-ray procedure (hysterosalpingogram, HSG), ultrasound procedure (saline infusion sonohysterogram, SIS or SHG), or hysteroscopy. An HSG is performed by injecting a special liquid (X-ray contrast) through the cervix into the uterus. The liquid is visible on x-ray films and outlines the anatomy of the uterus and tubes. This is performed in a radiology suite and requires no anesthesia. An SHG is performed by injecting sterile saline into the uterus during transvaginal sonography. This procedure is performed in the office without anesthesia. Hysteroscopy involves insertion of a small telescope and light source through the cervix into the uterus to look for abnormalities. We may also perform this procedure in the office using local anesthesia.
Prior to or during the IVF/ET, we also perform a uterine measurement. The purpose of this procedure is to determine the length and curvature of the uterine cavity. This enables us to guide the embryo transfer catheter into the proper position during the actual embryo transfer. Uterine measurement is similar to a pelvic exam or intrauterine insemination. Your physician will place a speculum in the vagina, and insert a thin, flexible plastic catheter through the cervix into the uterus. You may experience a small amount of cramping when the catheter goes through the cervix and again when the tip of the catheter touches the top of the uterine cavity. This cramping, which is similar to a mild menstrual cramp, should resolve within 30-60 seconds.
Minimal Stimulation IVF-ET
The first ever IVF-ET baby, Louise Brown, was born in 1978, and was conceived without the benefit of any fertility drugs. In the years that followed her birth, the experience of most clinics was that the success of IVF-ET was improved by administering injectable fertility drugs to the woman. Thus, the use of injectable fertility drugs became the routine in IVF-ET. One disadvantage of injectable drugs is that they substantially increase the cost of IVF-ET. Not only are the injectable drugs themselves expensive; their use necessitates more office visits and testing in the days preceding oocyte retrieval, and more work for the IVF-ET laboratory personnel after retrieval to care for the resultant greatly increased number of oocytes. In order to give some chance of pregnancy to infertile couples who simply cannot afford conventional IVF-ET with injectable drugs, some clinics have continued to offer IVF-ET without injectable drugs, which significantly decreases the total costs of the procedure.
There are two slightly different ways in which IVF-ET can be performed without the use of injectable gonadotropins. One is "minimal stimulation IVF-ET," in which the woman takes the relatively inexpensive oral fertility drug clomiphene citrate (Serophene® or Clomid®) early in her cycle. This is the method our Program uses. The other way is to take no fertility stimulants whatsoever, and simply aim to retrieve the oocyte produced in the woman's natural cycle. The maximum "take home baby" rate (chance of having an actual living child) of minimal stimulation IVF-ET is generally believed to be 10-15 percent. In the U.S.A. in 1994, the most recent year for which figures are available, the "take home baby" rate of natural cycle IVF-ET in women less than 40 years old was 4.5 percent per cycle started, and 10 percent per oocyte retrieval procedure. The particularly low success rate of natural cycle IVF-ET may reflect a selection bias. That is, physicians may recommend natural cycle IVF-ET to patients who have previously demonstrated poor responsiveness to fertility drugs (thinking the fertility drugs will be of no benefit to them), thereby effectively selecting patients for natural cycle (IVF-ET) who have a particularly poor chance of becoming pregnant. Even if this is the case, it is unreasonable to expect any more than a 10-15 percent take home baby rate from minimal stimulation IVF-ET with current technology and methods.
The process of minimal stimulation IVF-ET begins with treatment with birth control pills in the cycle before stimulation. We will perform a baseline ultrasound around the time of your expected period after the pills. If that ultrasound is normal, you will take clomiphene citrate (50 mg), two tablets by mouth daily, cycle days three through seven. The next ultrasound will be performed on cycle day eight. Several more ultrasounds will be performed in subsequent days, the exact number and frequency depending on the rate of growth of the oocyte-containing structures (follicles). Usually, no blood work is needed for monitoring for couples undergoing minimal stimulation IVF-ET. On the date that the ultrasound indicates that the largest follicle has an average diameter of 18-20 mm, human chorionic gonadotropin (hCG) 10,000 units intramuscularly will be injected in the evening. Oocyte retrieval will be performed 35 hours after the hCG injection.
The basic techniques of oocyte retrieval, insemination, embryo culture, embryo transfer, progesterone supplementation after embryo transfer, and pregnancy testing after embryo transfer are very similar or identical to those used in conventional IVF-ET and are discussed elsewhere. Because patients undergoing minimal stimulation or natural cycle IVF-ET have only very few or one follicle(s), it may be possible to perform the oocyte retrieval procedure without the services of the anesthesiologist. Your physician can provide some medications for pain relief during the procedure, and most patients do well with this approach. You should discuss this matter with your physician before making a final decision. Not all patients will be candidates for minimal stimulation IVF.
Advances in microscopic equipment and knowledge about oocytes, sperm and embryos have led to the development of new techniques in ART. Micromanipulation refers to the microscopic treatment of individual oocytes, sperm, or embryos in an effort to improve fertilization and/or pregnancy rates. These techniques require specialized equipment and personnel. The most common micromanipulation techniques used currently are intracytoplasmic sperm injection (ICSI), which is used to assist fertilization in cases of severe male factor infertility, and assisted hatching which is used in some cases in an effort to facilitate implantation of the embryos.
Intracytoplasmic Sperm Injection (ICSI)
The ICSI technique has been developed over the past 15 years to treat cases of severe male factor infertility. Candidates for ICSI may include patients with severe reductions in sperm number or motility, regardless of cause and patients with a history of failure of fertilization in conventional in-vitro fertilization-embryo transfer (IVF-ET). The ICSI technique may also be used to achieve fertilization using surgically extracted sperm from patients with anatomic or surgical conditions (such as vasectomy) which prevent sperm from entering the ejaculate. In all these cases, donor sperm or ICSI may provide the only options for conception.
The ICSI technique attempts to achieve fertilization by the direct injection of a single sperm into the cytoplasm (interior) of the egg. This is accomplished in the following manner: Mature eggs are freed of surrounding cells by a combination of enzyme treatment and microdissection. Using special micromanipulation equipment, the eggs are individually injected with a single sperm. Injected eggs are returned to the laboratory incubator and are treated thereafter as in conventional IVF-ET.
The mechanical placement of a sperm into the egg bypasses all the normal processes of sperm-egg interaction that occur naturally as well as in conventional IVFET. These processes normally lead to the selection of the single fertilizing sperm based on its ability to pass through the many layers of cells surrounding the egg, to contact and bind to the egg coating (zona), to penetrate this coating, to contact and merge with the egg cell membrane and ultimately to be drawn into the egg where the genetic material in the sperm joins that of the egg. These interactions help assure that a normal sperm is selected by the egg for fertilization. Even when conventional IVF-ET is performed, the egg is exposed to tens of thousands of sperm from which to choose. In sperm injection, it is the laboratory that chooses. We rely on the size, shape, and motility of sperm to choose the ones for injection. While these characteristics are useful, they do not guarantee that the sperm selected for injection is normal.
The potential consequences of injecting a normal appearing sperm that is in fact abnormal include the development of a genetically abnormal embryo. Previous experience suggests that most abnormal conceptions do not implant or develop in the uterus. The incidence of congenital abnormalities (birth defects) following ICSI appears to be no higher than that of the general population. This observation is based on the experience of several thousand babies born worldwide following ICSI. Despite this reassurance, it is prudent to regard ICSI as an experimental technique not without risk since long term follow-up of offspring (regarding, for example their fertility is unavailable). Recent evidence suggests that some forms of severe male factor infertility are genetic and may be passed on to children through the ICSI procedure. In addition, you must realize that within the normal human population a certain percentage (approximately 4%) of children are born with physical or mental defects, and that the occurrence of such defects is beyond the control of physicians.
Apart from the possible genetic consequences of selecting an abnormal sperm for injection, the physical trauma to the egg resulting from sperm injection can lead to degeneration of the egg, decreased fertilization rate, poor or arrested embryo development following fertilization, and reduced chance of a successful pregnancy outcome.
The benefit of ICSI is that it provides a way to treat extreme cases of male factor infertility which otherwise would remain untreatable. Experience shows that fertilization in vitro requires a minimum number of motile, normal shaped sperm. The chance for fertilization in vitro becomes very low when this minimum number of sperm is not available. Theoretically, only a few sperm are necessary to undertake ICSI. To date, however, the successful outcome of sperm injection is neither predictable nor consistent for all patients.. One other option is the use of donor sperm. Use of donor sperm normalizes the success of conventional IVF-ET in couples with severe male factor infertility. In cases where male factor is the only diagnosis, pregnancies with donor sperm can be achieved through timed insemination, a treatment far less expensive and complicated than IVF-ET.
There is no guarantee that these inseminations will result in fertilization or a pregnancy. The likelihood of conception can be decreased by coexisting female fertility problems. In general, the results of intracytoplasmic sperm injection decline with increasing age of the female partner. This probably reflects the progressive decline in oocyte quality with age of the patient and the egg's inability to survive the invasiveness of sperm injection.
A separate consent form and an additional charge is required for ICSI.
Normally, embryos are transferred to the uterus three to five days after retrieval. Usually, the embryos consist of eight cells at three days of age. After a day three transfer, the embryo must continue to develop to the blastocyst stage (a hollow ball of about 100 cells) before implantation can occur. This development takes several days. Immediately before implantation, the blastocyst must "hatch" from the zona coating which originally enveloped the oocyte. An alternative is to wait until day 5 to perform the embryo transfer to select the best embryo that has progressed to the blastocyst stage. The progression of the embryos in culture will determine what day the transfer will be recommended. To assist the hatching process, we sometimes micro manipulate the embryos immediately before embryo transfer. This involves using a laser to make a slight defect in the zona pallucida (egg coating). This must be performed under the microscope by trained personnel using special micro tools. There is a small risk of damage to the embryos from the procedure. It is not clear which patients are the best candidates for assisted hatching, but we may consider it for patients with repeated unexplained treatment failures or for women 38 years of age or older or for frozen embryos. An additional charge is required for assisted hatching.
Embryo cryopreservation is another important part of successful ART programs. Cryopreservation affords patients several advantages. Couples can cryopreserve embryos in excess of the ones that are usually transferred during an ART cycle. These embryos provide a second or even third opportunity for pregnancy without undergoing another ovarian stimulation and retrieval.
Those embryos that meet developmental criteria for appearance and rate of growth can be frozen at any of several stages in their development. The freezing process is computer controlled and employs special solutions to protect the fertilized eggs from damage. Frozen embryos are stored at 196°C (or approximately 400°F) below zero. Prior to ART, you and your partner must sign a consent form indicating what we should do with any additional embryos. Current choices are disposal or cryopreservation for your future use. We will store your embryos for a maximum of three years. During that time you must keep us informed of your current address at least annually. Social, ethical, and legal principles related to various aspects of ART have not yet been established. For this reason, you should discuss the implications of cryopreservation with your physician and with an attorney before proceeding with ART. Issues to consider include the disposition of embryos in the event of divorce or the death of either you or your partner. Our current policy is to dispose of cryopreserved material if both of the original partners to the agreement die.
As with cryopreserved semen, some embryos do not survive cryopreservation and thawing. Those that do may function less well than fresh embryos, that is, they may implant and produce ongoing pregnancies at a somewhat lower rate than fresh embryos. Despite this we have established a very successful frozen embryo transfer (FET) program. Additionally, recent national data suggests that fresh and frozen embryo transfer success rates are equivalent. This is probably because of the use of modern freezing techniques such as vitrification and possibly from the greater use of preimplantation genetic screening of embryos. The number of embryos transferred with a frozen embryo is based upon the quality of the embryos after undergoing thawing and the female partner’s age. Embryos can be transferred successfully during either a natural cycle or an artificial cycle in which you take estrogen and progesterone. There is no consensus regarding which approach is "best."
Preimplantation Genetic Testing ( Preimplantation Genetic Diagnosis or Preimplantation Genetic Screening)
Preimplantation Genetic Testing is offered in our center utilizing the latest technological advances and techniques. Preimplantation genetic diagnosis (PGD) is offered for those individuals who have or are carriers of specific genetic disorders. Embryos that are found to not be affected with the genetic disorder are selected for embryo transfer. Embryos can also be tested to determine the presence of normal chromosomes before they are transferred into the uterus. This is called preimplantation genetic screening (PGS). For both of these procedures, one or more cells are biopsied and removed from the embryo (commonly on day five of embryo development in our center) and sent for genetic analysis. Chromosomally abnormal embryos will not implant or will result in a miscarriage or in an abnormal pregnancy. The percentage of chromosomally normal embryos will vary from patient to patient and can be affected by many factors including age and the health history of both parents. The embryos that are tested and show normal chromosomes will be transferred either on Day six after retrieval or cryopreserved and transferred at a later date as described for embryo cryopreservation. The indications for PGS are evolving but may include someone with recurrent miscarriages, someone who is older or has diminished ovarian function or someone with multiple failed ART cycles. Some couples may choose PGS for personal reasons. An additional charge is required for preimplantation genetic testing.