Treatments & Procedures for achieving a pregnancy depends upon the specific cause of infertility

The more aggressive level of ovulation induction is called superovulation. This treatment uses gonadotropins or sometimes a combination of clomiphene and gonadotropins to stimulate the production of multiple eggs. Patients undergoing superovulation must be closely monitored by blood tests and ultrasounds. Monitoring ensures that the patient does not hyperstimulate and also helps the physician administer the correct dosage of medication so that only a few follicles develop. This is a critical step to keeping the multiple pregnancy rates low. At the end of the superovulation treatment process, a low dose HCG (human chorionic gonadotropin) may be prescribed to stimulate ovulation. Ovulation will occur between 24-36 hours after HCG. The patient is instructed to either have intercourse during this time or to come in for an intrauterine insemination. Depending on the cause of infertility, the success rate per superovulation treatment varies based on the woman's age.

Intrauterine insemination (IUI) is a procedure in which sperm are placed directly into the uterine cavity through a catheter near the time of ovulation. This procedure is most commonly performed when there are problems with the sperm, such as low count or low motility, or an incompatibility between the sperm and the cervical mucus. It can also be performed to overcome problems associated with a man's inability to ejaculate inside the woman's vagina due to impotence, premature ejaculation or other medical conditions. IUI increases the chances of pregnancy because the sperm are placed directly in the uterus, bypassing the cervix and improving the delivery of the sperm to the egg.

IUI's can be performed either with the partner's sperm or with donor sperm. It is recommended that the patient abstain from sexual intercourse for two to three days before the procedure. In some cases, it may be necessary for the female to take medication to induce ovulation prior to IUI, if her cycles are not regular. The male will provide a semen sample one to two hours before the procedure is to be performed. The semen will be washed, a procedure in which the sperm is separated from the seminal fluid, the more active sperm are concentrated and the quality of the sperm is analyzed. Following the wash, it is time for the insemination procedure, which only takes a few minutes and does not cause much, if any, discomfort for the female. The doctor will insert a small catheter into the uterine cavity through the cervix and iinstill sperm directly into the uterus. The patient is able to resume normal activity immediately following the IUI procedure.

When semen quality is too low for IUI to be successful, in vitro fertilization (IVF) or intracytoplasmic sperm injection (ICSI) may still be successful. Low sperm counts, depending on severity, are treated first by correcting infection. In severe cases, the male partner is first referred to a urologist. If the Urologist determines that no further improvement in sperm count is to be expected then and only then is IVF and ICSI suggested.

In its simplest term, IVF is simply the uniting of egg and sperm in vitro (in the lab) to form an embryo. Subsequently, the

embryos are transferred into the uterus through the cervix and pregnancy is allowed to begin. IVF was the first of the ART (Advanced Reproductive Technology) techniques to be developed. The first birth was in 1978 in England. The procedure was pioneered by a Gynecologist and a Ph.D. (Drs. Steptoe and Edwards).

Since multiple oocytes are required in order to enhance the likelihood of pregnancy, stimulation with injectable gonadotropins is usually required. Frequent monitoring is necessary with sonograms and blood tests. When these diagnostic methods indicate that the time is appropriate, a hCG injection is given to mature the eggs. The eggs are retrieved from the ovary just before they are ready to be released. This usually occurs about 36 hours after the hCG injection. Immediately following the egg retrieval, a semen sample is processed in the IVF laboratory. The sperm and eggs are placed in a dish and fertilization takes place (in vitro) outside the patient's body in the laboratory. The fertilization process takes approximately 10-20 hours. Embryos are then cultured for 3-5 days before being replaced back in the uterus by a simple technique much like intrauterine insemination.

Embryo transfer occurs on day 3 or 5 following the egg retrieval. Embryos are carefully placed into a special catheter and inserted into the uterine cavity. Generally, 2-3 embryos are transferred back into the uterus depending on the patient's age, embryo quality and physician recommendation.

Intracytoplasmic Sperm Injection (ICSI) enables men with poor sperm quality to father children. ICSI is used when the male has very low sperm count. Even in men with no sperm seen at the time of semen analysis, there may be sperm within the testes. This sperm can be removed by aspiration from the epididymis or testes in procedures called TESE (testicular sperm extraction) or MESA (microscopic epididymal sperm aspiration). TESE and MESA procedures combined with ICSI allow many men, previously considered sterile, to produce children .

In the ICSI procedure, a microscopic hole is placed in the egg membrane with an instrument that resembles a syringe. A single sperm from the father is drawn into the "syringe" and inserted into the egg. There is now broad, successful, clinical experience with hundreds of ICSI patients and their children. Embryologists receive advanced training to enable them to perform this delicate procedure.

Two weeks later a pregnancy test can be obtained. Three weeks after the pregnancy test, an ultrasound can be performed and the fetal heart beat can be seen. If more embryos are generated than can be transferred, freezing (cryopreservation) can save these additional embryos. Frozen embryos can be stored for future replacement at much lower cost than the original IVF cycle.

Egg donation is a process by which eggs (oocytes) from another person, the donor (usually between the ages of 20 to 30) are fertilized with sperm. The embryo is then transferred into the uterus of the recipient patient who is trying to conceive. The egg donation process is usually considered for women with advanced maternal age over 42 years, in patients with poor ovarian reserve, premature ovarian failure, prior surgical removal of the ovaries and Turner syndrome.

The recipient may choose a known donor (family member or friend) or pick an anonymous egg donor (most often from an egg donor agency). The donor agency usually handles the details of the donor matching process. Prior to egg donation, both the recipient and the donor will need to be screened. Evaluation of the recipient's uterine cavity which includes a sonohystogram and a trial transfer is a prerequisite. This is done to ensure a normal uterine environment for an embryo to implant. The egg donor should be between 20 to 30 years of age. They are informed about the medications, surgery, risks, side effects, lifestyle limitations, and time demands of the procedures. Donors are required to undergo several screening tests including infectious disease screening, psychological screening, drug screening, ovarian reserve screening and a complete history and physical as well as a pelvic ultrasound exam. The male partner or sperm donor will also need to have the infectious disease tests completed.

When the requisite tests have been completed, the egg donation procedure can begin. The process is similar to IVF except that it involves two women, the donor and the recipient. Both the recipient and the egg donor will be placed on medications- an injectable gonadotropin (Lupron) and/or birth control pills to coordinate and synchronize their menstrual cycles. At the appropriate time, the egg donor will start injectable fertility drugs while the recipient will take oral estrogen tablets to prepare her uterine lining for implantation. While the egg donor is being stimulated and monitored for follicle growth with hormonal blood levels and ultrasound exams, the recipient's cycle is adjusted in order to coordinate it with the donor's cycle. Monitoring is followed at the appropriate time by the hCG trigger injection. Approximately 36-37 hours later, the egg retrieval is scheduled. Eggs are retrieved under ultrasound guidance and handed over to the embryologist to handle. At the time of egg retrieval, the recipient's partner or sperm donor will provide a sperm sample. The embryologist will prepare the sperm sample for insemination of the eggs in the laboratory. Fertilization occurs and the eggs are allowed to grow for 3 to 5 days. Meanwhile, the recipient will continue oral estrogen and will be started on progesterone supplementation. The healthy embryos will be transferred into the recipient, at the appropriate time, 3-5 days after the egg retrieval. If embryos are produced in excess of need, they can be cryopreserved for future use. After the embryo transfer, the recipient is asked to curtail excessive physical activity for a few days. Detailed post- transfer instructions will be provided. A pregnancy test will be performed 14-15 days after the embryo transfer.

A gestational carrier is a woman who has an embryo transferred into her uterus, becomes pregnant, carries the fetus throughout the pregnancy and delivers the child for another couple. The ovum and sperm of the couple (natural father and natural mother) are used to create the embryos or alternatively, donor eggs and sperm from the natural father may be used to create the embryo. In both these situations, the gestational carrier has no genetic link to the fetus.

The term gestational surrogate refers to a woman who carries the pregnancy for and delivers the baby for another couple, and uses her own egg to create the embryo. Therefore, the fetus is genetically linked to the gestational surrogate.

Women who should consider a gestational carrier to fulfill their dreams of parenthood include those who lack a uterus because of previous surgery (hysterectomy), or congenital absence of the uterus, those who have a deformed uterus incapable of carrying a healthy pregnancy to full term and women who are advised against undertaking a pregnancy because of chronic ill health or physical disability.

Once a couple had decided to use a third person (gestational carrier) to help them have a baby, they have to go through the process of finding a suitable gestational carrier. Some couples may elect to use either a relative or close friend while others choose to use an agency to help them with the process. It is recommended but not required that the gestational carrier be a woman in excellent health, under the age of 35, with a good obstetric history and with at least one healthy, living child. She should be highly committed to fulfill her obligations as a gestational carrier. Using a gestational carrier is an emotionally intense and legally complex arrangement that warrants psychological evaluation and counseling of the carrier as well as legal counsel with signing of a legal contract. Dr. Pinto will provide assistance in this process and support the patient every step of the way.

Once the gestational carrier / gestational surrogate have been selected she needs to undergo a thorough screening. This includes a careful medical and family history, a thorough physical examination, a psychological evaluation, specific blood tests to exclude HIV, hepatitis B and C, and other sexually transmitted diseases, cervical cultures for organisms such as chlamydia and ureaplasma that might interfere with a successful outcome ,an evaluation of the uterus by hysteroscopy (where a thin, telescope-like instrument is introduced into the uterus) to look for anything that might interfere with implantation and blood tests for prolactin and thyroid stimulating hormone. Additionally, the carrier's partner will be tested for HIV, hepatitis, and other sexually transmitted diseases

When all evaluations are completed, the treatment cycle can begin. The process is similar to IVF except that it involves two women, the egg donor / intended mother and the gestational carrier. Both the gestational carrier and the egg donor will begin medications for synchronization of cycles and preparation for embryo transfer. The egg donor / intended mother will take fertility medication to stimulate her ovaries to produce more than one egg while the carrier / surrogate simultaneously takes medication to prepare her uterine lining for implantation. Monitoring of the egg donor / intended mother is followed at the appropriate time by the hCG trigger injection. Approximately 36-37 hours later, the egg retrieval is scheduled. Eggs are retrieved under vaginal ultrasound guidance and handed over to the embryologist to handle. At the time of egg retrieval, the partner will provide a sperm sample. The embryologist will prepare the sperm sample with washing and centrifugation, for insemination of the eggs in the laboratory. Fertilization occurs and the eggs are allowed to grow for 3 to 5 days. Meanwhile, the carrier / surrogate will continue oral estrogen and will be started on progesterone supplementation. The healthy embryos will be transferred into the carrier / surrogate, at the appropriate time, 3-5 days after the egg retrieval. If embryos are produced in excess of need, they can be cryopreserved for future use. After the embryo transfer, the carrier / surrogate is asked to curtail excessive physical activity for a few days. Detailed post- transfer instructions will be provided. A pregnancy test will be performed 14-15 days after the embryo transfer. If it is positive, it indicates that implantation has taken place. In such an event, the hormone support will be continued for an additional 8 weeks. The first ultrasound examination to evaluate the pregnancy is scheduled approximately 4 weeks after the transfer. If the pregnancy test is negative, all treatment is discontinued and menstruation usually begins within three to ten days.

Preimplantation genetic diagnosis (PGD), also termed embryo biopsy, is a procedure that can identify some genetic defects within an embryo before it is transferred into the uterus. The patient undergoes the normal IVF process until egg retrieval. These eggs are fertilized by a procedure called Intracytoplasmic Sperm Injection (ICSI) where one sperm fertilizes each egg. All embryos are biopsied on Day 3, by removing a single cell from each embryo. Each cell is then treated with probes for genetic abnormalities and the DNA is evaluated to determine if the inheritance of the gene is present. Those embryos without the genetic defect are transferred into the uterus. Preimplantation genetic diagnosis enables couples that carry genetic disorders to try for a biological normal child of their own. PGD minimizes the risk of passing genetic defects on to future generations.

PGD is a new and innovative technique made possible by recent advances in medical technology. Not every practice offers this procedure. RFC is proud to offer our patients the most modern techniques.

Laparoscopy is a minimally invasive surgical procedure that allows for a complete examination and evaluation of a woman's pelvic and abdominal structures.

It is an outpatient surgical procedure performed under general anesthesia in the operating room in a day care surgical center. It is not uncommon to discover abnormalities that may prevent pregnancy, yet may not be readily identified on physical exam or with blood tests or on ultrasound exam.

Most abnormal findings discovered at diagnostic laparoscopy can be corrected in the same sitting. Various energy sources such as laser, ultrasound and electro surgical instruments are utilized to excise adhesions, open blocked tubes, and correct most anatomical defects. Operative laparoscopy also allows for removal of ovarian cysts, effectively treating extensive pelvic endometriosis, removal and reconstruction of uterine fibroids, and treating ectopic pregnancy. Pictures are taken before, during and after the surgery. Most patients are discharged home following the procedure. Normal activities can usually be resumed within a few days.

Hysteroscopy is an outpatient surgical procedure performed under general anesthesia in the operating room in a day care surgical center. Using several operating tools such as grasping forceps, operating scissors, other fine

instruments, and electro surgical instruments the abnormalities discovered when performing a diagnostic hysteroscopy can be corrected at the same sitting. Following operative hysteroscopy an intrauterine device may be placed inside the uterus to prevent the uterine walls from fusing together and forming scar tissue. Hormonal medication such as estrogens may be prescribed to stimulate the endometrial lining. Recovery time following the surgery is usually around 2 hours. Most patients are discharged home following the procedure. Normal activities can usually be resumed within a few days. Some vaginal discharge and cramping may be experienced for several days following the procedure. Sexual intercourse should be avoided for a few days or for as long as bleeding occurs.