100-56 Aberfoyle Cres. Etobicoke, ON, M8X 2W4 Tel: 416-231-4100 Fax: 416-231-0845
PATIENT INFORMATION / TREATMENT PROTOCOL
THE INFERTILITY EVALUATION
Infertility can be defined as the inability to conceive a child, having attempted to achieve a pregnancy for more than one year or the inability to carry a pregnancy to viability (recurrent pregnancy loss).
The standard tests and their order of succession, purpose and the procedures involved will be described later. Scheduling of tests will vary according to your individual circumstances, but the general rule of thumb is to proceed from the simple low-risk, low cost tests, to those tests which may be more invasive and expensive. It is absolutely necessary that both partners be investigated simultaneously.
“Infertility is a shared concern wherever the problem may reside. Limiting the evaluation to one member of a couple cannot be successful”. The aim of the infertility evaluation is to discover the reason for the couple’s infertility and to give a prognosis for future fertility. Both partners (if there is a partner) are asked at this time to have an initial consultation with Dr. E. Ryan or any of his associates.
A physical examination of the female partner will be conducted including a pelvic examination. The internal examination is beneficial in providing information about the size, shape and position of the reproductive organs uterus and ovaries. Special cultures are done from the endocervical canal (very much like a pap smear). Ultrasound assessment of the pelvic structures is done on the first visit. Assessment of the sperm for infection and quality and/or sperm washes assessment and/or sperm antibody testing will be arranged on an individual basis at this visit. Laboratory tests will be done at the time of the initial interview, including extensive hormonal profiles of both partners.
This is usually the first monitored cycle where we determine when and how well you ovulate and the response of your uterus (endometrium) to your hormone levels. This will not be done until about 4 to 6 weeks after the initial consultation to allow time to get all your blood and culture results back from the labs.
A semen analysis will be performed to detect if the infertility may be due to the male factor. The semen specimen is assessed for volume of ejaculate and sperm count per cc, percentage of motility, presence of white blood cells, debris, agglutination (sticking) of sperm (autosperm antibodies). We do appropriate cultures for different types of bacteria in the sperm sample. Early detection of male factor infertility may influence the further course of testing of the woman, or the male may undergo a more in-depth evaluation of his sperm (sperm wash assessment – see below), while the woman completes her tests. Abstinence of ejaculation should be no less than two days and no more than three days. Specific test for sperm antibodies are done when indicated. There is a fee for this antibody testing. This is done by appointment through our IVF centre called CREATE IVF @ 790 Bay St., 11th Floor andrology lab. A semen analysis is the single most important test in the evaluation of the male.
ENDOMETRIAL SAMPLING (E.S.)
An endometrial sampling MAY be done to see if there is an adequate biological response to progesterone from the lining of the uterus. On all patients who have tested positive for mycoplasma, we must do this test before we try to get you pregnant. There is a fee for this test.
SONOHYSTEROGRAPHY (Unlike HSG this test has no X-Ray exposure)
This ultrasound examination provides considerable information about your uterus and tubes without the use of X-rays. Indications for this test are numerous and may include: irregular vaginal bleeding, infertility, miscarriages, any suspected abnormalities of the uterus, or as a preliminary evaluation for in-vitro fertilization. You will have preliminary ultrasound scans of your pelvis before the test. The procedure itself takes from 5-15 minutes. A thin catheter is placed through the catheter in order to allow us to see the inside of the uterus and check the fallopian tubes. During the procedure you may feel some cramping as the saline is instilled, however most patients tolerate it quite easily. In summary the H.S.G. tells us more about the tubes and the sonohysterogram more about the uterine cavity.
Laparoscopy is an essential part of the infertility investigation in selected patients. In previous years we did laparoscopies on almost all women who had trouble conceiving, however over 90% of our patient now get pregnant without having had a laparoscopy done. A laparoscopy is a surgical procedure, which is performed under general anaesthetic as an out-patient at St. Joseph’s Health Centre. You will go home on the same day of the surgery. Through a small umbilical (belly button) incision a scope will be place into the abdomen to visualize the fallopian tubes, uterus, ovaries, pelvis and to assess other problems such as endometriosis, scar tissue or cysts.
If indicate, this procedure is done at the same time as the laparoscopy or may be done separately without Laparoscopy. The uterine cavity is directly visualized with an instrument similar to the laparoscope passed through the cervix. This test allows the doctor to look for tumours, adhesions or other abnormalities. We can also examine the fallopian tubes where they enter the uterine cavity. This would be done in CREATE IVF centre @ 790 Bay Street, 11th Floor.
Ovulation induction is a procedure by which a pharmacological hormone induces ovulation. These drugs can include the fertility tablet called Letrozole or Femara or injections of Menopur, Puregon, Gonal F, which are injectable drugs called Gonadotrophins. These drugs are essential to the successful development of ovarian follicles which contain the oocyte or “eggs” which are released at ovulation. Letrozole and all injectable drugs are dispensed by the doctor’s office staff, at the front desk for your convenience as many pharmacists do not routinely carry these medications. The injections begin on cycle day 3, 4 or 5 approx. of your cycle, are given intramuscularly or subcutaneously and continue daily until the follicles are mature for ovulation. HCG or Ovidrel or Lupron trigger, which are intramuscular/subcutaneous injections, are given at mid-cycle or when the ultrasound and blood hormone levels tell us that you are ready for ovulation. This drugs trigger ovulation (the expulsion of the egg(s) from the mature follicle(s)) and the final maturation of the eggs prior to fertilization. Progesterone suppositories, which are vaginal suppositories (may also be taken rectally with equal efficacy), containing the hormone progesterone, aid in sustaining a normal embryo in the uterine lining in the event fertilization and implantation takes place. These suppositories are started the night of the last insemination and continued for 14 days, as directed, until either pregnancy is confirmed or the menstrual flow has started. If you miss your period or are spotting lightly, you should continue to use suppositories until the office staff tells you to stop (based on your pregnancy test). If you have finished your supply, the nurse will give you more. In certain clinical situations we may also have you on intramuscular injections of progesterone for a few weeks.
Intrauterine Artificial Insemination (IUI): (PLEASE REFER TO LITERATURE UNDER INFORMATION PACKAGE FOR CYCLE MONITORING AND I.U.I.) is direct injection of washed sperm into the uterine cavity (uterus).
PLEASE REFER TO LITERATURE UNDER INFORMATION PACKAGE FOR CYCLE MONITORING AND I.U.I.
For those receiving the hMG (Menopur /Gonal-F/Puregon) injections and monitoring but not having artificial insemination, you should have intercourse the day after the HCG (or other trigger) injection and the next 2 to 3 days.
The pregnancy rate for C.O.H. with IUI is approximately 70-75% within 6 cycles of treatment, or 14 to 18% per cycle, depending on age and number of eggs produced in these cycles.
ARTIFICIAL INSEMINATION WITH DONOR SEMEN
Usually referred to as Therapeutic Donor Insemination or TDI, this treatment is indicated when a husband has:
*no sperm (azoospermia)
*when a sperm count is so low (oligospermia), that pregnancy is highly unlikely.
* for same sex couples (Female).
Other indications may include sterilization (i.e. vasectomy), a genetic defect, testicular injury, surgery or cancer therapy.
Donor semen is obtained from the sperm bank. The sperm from donors are anonymous, and are screened for medical and genetic diseases, all sexually transmitted diseases including AIDS (HIV-1/2, HTLV-l and 2) and Hepatitis A, B, and C.
Each semen specimen is quarantined for a minimum of six months (180 days), to ensure that the sperm donor is still negative for HIV-1/2, HTLV-l and 2, and Hepatitis. All sperm banks follow strict guidelines set forth by the American Association of Tissue Banks, the Canadian Fertility and Andrology Society, the American Fertility Society and the Society of Obstetricians and Gynaecologists of Canada. A consent form must be signed, if you are married or in a relationship. We recommend that your partner take part in the donor selection process. Your husband (if applicable) is required to sign the consent form agreeing to this method of treatment.
The sperm will be placed slowly into the cavity of the uterus. This procedure takes approximately 5 minutes, you will be asked to remain lying flat for 5 to 10 minutes, then you may get dressed and leave. We ask you to maintain a quiet and relaxed lifestyle for the next week or so, with no strenuous exercise. You may experience slight cramping after the insemination. This is normal. If your cramping is severe in nature, you may take plain Tylenol (without Codeine) or Ibuprofen (a mild anti-inflammatory). If you have high fevers and abdominal/pelvic pains, please call the office.
We have several psychologists who work with us and are available for consultation. To make an appointment, please call our office for further information. We always try to be available to discuss any feelings you may be having, questions you may have or for support in your time of crisis. Please do not hesitate to contact Dr. Ryan or his associates or their staff, to discuss freely any matters that concern you.
All payments are to be made prior to receiving medication and/or non-ohip procedures being performed. Payment can be made by: Visa, MasterCard, Interac, Debit, money orders, or cash.
OUR OFFICE HOURS ARE
Monday through Thursday: 6:30 am to 3:00 pm and Fridays 6:30 am to 2:00 pm
For weekends hours please call our office to arrange times for CREAT IVF @ 790 Bay street, 11th Floor.
If you have an emergency after office hours, please go to St. Joseph’s Health Centre Emergency Department or your nearest emergency department, or call our office and follow the instructions on the answering machine or to talk with the Fertility Dr. on call.