Many women who have difficulty becoming pregnant can conceive with medical assistance. One form of treatment is ovulation induction,
which is usually the first step in infertility treatment. In this treatment, medications are given to induce ovulation in women who
have irregular periods. The medications can also be given to stimulate the production of multiple eggs in women who ovulate monthly,
thus enhancing their ability to conceive. The medications come in two forms: oral and injectable.
Intrauterine Insemination (IUI)
Intrauterine insemination (IUI) is a process in which sperm are obtained from ejaculate, washed and
placed into a woman's uterus. Often, IUI is performed in conjunction with ovulation induction. Number
of eggs available for fertilization is increased by stimulating the ovaries. IUI is performed for men with
normal and low sperm counts. This will enhance the ability of sperm to fertilize the egg.
Intrauterine insemination (IUI), a form of artificial insemination, is a relatively simple procedure that
enables conception by directing sperm to the right place at the right time. In this process, a thin tube
called a catheter is placed directly into the cervix and a carefully prepared sperm sample is injected directly
through the catheter into the uterus.
IUI increases a woman's chances of becoming pregnant by injecting an optimal sperm sample
directly into the uterus at a time when the woman is most fertile. Studies have shown that pregnancy
is more likely to occur if the timing of exposure to sperm is controlled in this way and if sperm is placed
in higher numbers closer to the egg or eggs.
In order to determine the best treatment plan, a physician may recommend some or all of the following tests before
moving forward with artificial insemination:
When is IUI recommended?
IUI is often recommended for women or couples who:
Have ovulation problems and are undergoing ovulation induction, especially when timed
intercourse has not succeeded.
Are unable to have appropriately timed intercourse due to travel problems or in cases of sexual dysfunction.
Have mild male factor infertility.
Have unexplained infertility.
Have been unsuccessful with infertility medication alone or with other treatments.
Preparing for an IUI procedure
In order to determine the best treatment plan, a physician may recommend some or all of the following
tests before moving forward with artificial insemination:
A hysterosalpingogram, wherein a small amount of fluid is delivered into the
uterus and tubes and an X-ray is taken, outlining the uterine cavity and fallopian tubes.
FSH and estradiol blood level tests to determine ovarian function, egg production and quality.
A semen analysis to determine volume, quality and motility (normal forward movement) of the male sperm.
Prior to the IUI procedure, the male partner is recommended to abstain from ejaculation for 1 to 3 days (however,
abstaining for more than 5 days can result in decreased motility).
IUI with Fertility Medication
IUI is usually performed with the use of 'ovary-stimulating' fertility medication. Studies have demonstrated that IUI in combination with medications that stimulate egg production can significantly increase a woman's chances of conception. These medications include Clomid, (clomiphene citrate), Puregon or Gonal-f.
Fertility medication is often recommended for those diagnosed with age-related sub-fertility, endometriosis, unexplained infertility or male factor infertility.
What to expect from the IUI procedure?
Prior to the artificial insemination procedure, the male partner collects sperm through masturbation,
either at home or in our clinic. Sperm is then sent to our laboratory where it is separated from the
seminal fluid which can irritate the uterine lining. The most active, motile (normal, forward moving)
and healthy sperm are extracted and then placed into the uterus via a catheter. The entire procedure
takes no more than 5 minutes. In rare cases, there may be mild cramping following the procedure, but
this is normally mild and short-lived. Our patients can resume normal activity immediately. Their doctor
may recommend that the patient have intercourse on the day or evening of artificial insemination to further
increase chances of conception.
Does IUI pose any risks?
There is less than a one percent chance of pelvic infection with IUI.
If using fertility medications, there may be possible side effects to consider, including
ovarian hyperstimulation syndrome, in which ovaries become swollen and painful.
How many artificial insemination cycles might be recommended?
Even natural fertility results in pregnancy just 20% of the time in any given month. Studies indicate that
the possibility of conception using IUI is highest in food that signals that premier follicle to grow. Minimal concentrations are present so that there is only enough stimulation for one follicle, while the remaining follicles simply dissolve away. When the body is supplemented with FSH as an injectable medication, a few more of the 400 oocytes present can compete for the stimulatory source. In these instances, the better oocytes are spared from destruction and can be cultivated in the hope that they will generate a fertilizable oocyte and the potential for a good embryo and resultant baby.
In Vitro Fertilization (IVF & ICSI)
Beginning an IVF cycle is an exciting and anxious time for a couple. Our Center provides couples with
the maximum amount of clinical, emotional and administrative support they will need to complete
their cycle successfully whether it results in a pregnancy or not.
The following explanation is meant to simplify what occurs during various stages of IVF:
Ovarian Follicle Development through Controlled Ovarian Stimulation
Al-Manar Fertility and Endoscopy Center uses fertility drugs that simulate the female partner,
natural hormones to develop several normal follicles in the ovaries. These medications are
Clomiphene Citrate also called Siphene® or Ovofar® Menogon (hMG), a 50:50 mixture of FSH
and LH hormonal administered intramuscularly Puregon® (PoFSH) administered subcutaneously
or Gonal-F (RecFSH). Any excess oocytes that fertilize and develop into embryos at fertilization
may later be stored through cryopreservation.
Follicular growth, development and maturity are evaluated through frequent hormone monitoring and by ultrasounds. Typically,
the hormones estradiol, luteinizing hormone and progesterone are measured through blood tests to evaluate ovarian response.
Ultrasound is used several times during a cycle to measure accurately follicular growth and size.
These steps allow the physician team to modify the treatment in some cases and to stop the cycle
if the response to stimulation is not satisfactory. Once follicular maturation is achieved,
the patient receives an intramuscular injection of human chorionic gonadotropin (hCG), which
triggers oocyte maturation and ovulation. Oocyte retrieval is performed approximately 34 hours
Oocyte Retrieval through Puncture/Aspiration
If the last hormone blood test and ultrasound evaluation indicates healthy growth
of follicles, then aspiration of mature follicles takes place. This entire procedure
takes approximately 20 minutes performed under short general anesthesia. The physician
locates each follicle through ultrasonic guidance and carefully aspirates them. The contents
of the follicles are immediately taken to the IVF lab. Patients usually recover for one to two
hours following oocyte retrieval and are then discharged. Progesterone supplementation is initiated
from the day of the retrieval.
Oocyte Culture, Insemination and Fertilization
In the IVF laboratory, follicular fluid is examined under a microscope to locate all eggs, which are
then incubated in special media. Generally, semen collection occurs at about the time of the egg retrieval
but, in some cases, may be several hours later. The sperms are then added to the eggs in culture here fertilization occurs.
Any resulting embryos are stored in the incubator and maintained in culture until the time of embryo transfer and/or
Usually, the transfer of the embryos takes place on day two or three post retrieval. The embryos are examined under
the microscope and carefully aspirated to a thin transfer catheter. The loaded catheter is introduced under
transabdominal ultrasound guidance through the cervix into the uterus where the embryos are placed. This procedure
takes a few minutes and does not require anesthesia.
After the transfer, the patient rests for two hours prior to discharge. Twelve days after the embryo transfer, a serum based
pregnancy test is taken. During this period, patients are advised to perform light activity and remain in contact with the Center.
If pregnancy does not occur, our team reviews the IVF cycle and makes specific recommendations for follow-up. The patient will speak
with the clinical staff to review and if necessary discuss other options.
Embryos of sufficient quality that are not transferred can be cryopreserved. The embryologist will select
embryos that are suitable for freezing. Embryos that are ideal for freezing have blastomeres of equal size
and display minimal or no fragmentation.
Intracytoplasmic Sperm Injection (ICSI)
Intra Cytoplasmic Sperm Injection (ICSI) is a laboratory procedure developed to help infertile couples undergoing
In Vitro Fertilization (IVF) due to severe male factor infertility. ICSI involves the insertion of a single sperm
directly into the cytoplasm of a mature egg (oocyte) using a special microinjection pipette (glass needle).
After sperm injection into the egg, further culture and embryo transfer is as with the IVF cases. For patients
with subfertile semen, this procedure is preferable to IVF.
ICSI can facilitate fertilization by sperm that will not bind to or penetrate an egg.
It can also be used to treat men with extremely low numbers of sperm. However, ICSI is
generally unsuccessful when used to treat fertilization failures that are primarily due to
poor egg quality.
Indications for Intra Cytoplasmic Sperm Injection
Oligospermia - very low sperm counts.
Asthenozoospermia - poor sperm motility.
Teratozoospermia - too many abnormal sperms.
Problems with sperm binding to and penetrating the egg.
Antisperm antibodies (immune or protective proteins which attach and destroy sperm)
of sufficient quality to prevent fertilization.
Prior or repeated fertilization failure with standard IVF culture and fertilization methods.
Frozen sperm collected prior to cancer treatment that may be limited in number and quality.
Azoospermia with obstructive pathology - absence of sperm secondary to blockage or
abnormality of the ejaculatory ducts that allow sperm to move from the testes.
In this situation, sperms are obtained from the epididymis by a procedure called
microsurgical epididymal sperm aspiration (MESA) or from the testes by testicular
sperm extraction (TESE).
Thus very few azoospermic men need to resort to a sperm bank now with the availability of ICSI.
ICSI is not a perfect technique. Some eggs will be damaged by the ICSI process. Some eggs
have plasma membranes that are difficult to pierce. In other instances, the fertilized
egg may fail to divide, or the embryo may arrest at an early stage of development.
Perinatal outcome studies in Europe suggest that although multiple pregnancies are common with ICSI,
no evidence of increased incidence of congenital malformations or abnormal karyotype. There
is no evidence that abnormalities may arise later in life to babies born as a result of ICSI,
although there is also no guarantee that all babies will be normal.
Hystero-Salpingography (HSG) is a radiologic procedure to investigate the shape of the
uterine cavity and the shape and patency of the fallopian tubes. It entails the injection of
a radio-opaque material into the cervical canal and usually fluoroscopy with image intensification.
A normal result shows the filling of the uterine cavity and the bilateral filling of the fallopian
tube with the injection material. To demonstrate tubal rupture, spillage of the material into the
peritoneal cavity needs to be observed. A synonym to hystero-Salpingography is uterosalpingography.
The procedure involves x-rays. It should be done in the follicular phase of the cycle. It is contraindicated
in pregnancy. It is useful to diagnose uterine malformations, Asherman's syndrome, tubal occlusion and used extensively
in the work-up of infertile women. It has been claimed that pregnancy rates are increased in a cycle when an HSG has been
performed.  Using catheters, an interventional radiologist can open tubes that are proximally occluded.
The test is usually done with radiographic contrast medium (dye) injected into the uterine cavity through the
vagina and cervix. If the fallopian tubes are open the contrast medium will fill the tubes and spill out into
the abdominal cavity. It can be determined whether the fallopian tubes are open or blocked and whether the
blockage is located at the junction of the tube and the uterus (proximal) or whether it is at the end of the
fallopian tube (distal).
The HSG can be painful, so analgesics may be administered before and/or after the procedure to reduce
pain. Many doctors will also prescribe an antibiotic prior to the procedure to reduce the risk of
Minimally Invasive Ultrasound Procedures
Ultrasound technology has made dramatic advances in recent years. Ultrasound now offers infertile patients newer treatment
options not available before. Modern surgical techniques have progressively become less and less invasive - all for the
patient's benefit! From laparotomy to laparoscopy and now to ultrasound guided procedures, we are witnessing a change
in the gynecologist's armamentarium from the knife to the endoscope to the guided needle!
The benefits to the patient are many and include: reduced costs, reduced hospitalization, reduced
risk of complications and better preservation of fertility, with increased chance of conception
for the future.
Ultrasound-guided procedures can be used to treat a variety of problems seen in the infertile woman.
Egg Pickup for IVF
The use of vaginal ultrasound for egg pickup has made egg retrieval a short, simple and inexpensive procedure,
which can be performed in a day-care unit, under sedation and local anesthesia. The ovaries are normally present
in the Pouch of Douglas and are very accessible transvaginally. Moreover, the presence of adhesions does not
interfere with egg collection.
Ovarian Cyst Aspiration
An ovarian cyst is a very common condition in which fluid collects in the ovary. However,
cysts that are more than 5 cm in size need to be treated as they can cause problems
(e.g. twisting and rupture). Normally, surgery had to be done to remove these cysts
and often this damaged the surrounding normal ovary as well. With ultrasound-guidance,
we can stick a needle from the vagina into the cyst and empty the contents
(usually clear fluid) by sucking it out. This empties the cyst, which often does not recur.
Treatment of Ectopic Pregnancy
With technological advances (ultrasound and beta-HCG blood tests) the diagnosis of tubal pregnancy can be made very early, usually before rupture. It can be treated by injecting a toxic chemical, Methotrexate, into the sac, which causes the tissue to die and then get reabsorbed, without any surgery whatsoever. In more advanced tubal pregnancies, potassium chloride can be injected directly into the heart of the baby in the ectopic gestational sac, thus killing it and preventing it from growing.
Ultrasound-Guided Tubal Embryo and Gamete Transfer for IVF and GIFT techniques
Techniques have been devised to pass a special tube into the fallopian tubes through the
vagina under ultrasound guidance, so as to place the embryos and /or the gametes in the
fallopian tube. Since the tube offers a better environment for the gametes and embryos than
the uterine cavity, it is believed that this will improve pregnancy rates.
Pre-implantation Genetics Diagnosis
Pre-implantation genetics diagnosis (PGD) is a technique aimed at eliminating embryos which have
abnormal chromosomes or carrying serious genetic disease before pregnancy is established. One of the most important application areas of the PGD technique is to identify embryos that
can have defects in their chromosomes despite the absence of diseases. These structural or numerical
defects in the embryo can be seen more often in older pregnant women, especially those over 35. This
situation may result in infertility because it reduces the chance of implantation and also causes
unwanted miscarriages. As a matter of fact, 40 out of 100 pregnancies in women aged 39 and over will
result in problems related to structural or numerical chromosomal defects.
In addition to older women, PGD is used in female patients who have experienced repeated
miscarriages or cannot conceive despite having tried IVF twice or more. In spite of all its benefits,
cases in which this technique will be used must be selected carefully. It should be remembered that a
PGD procedure requires a cell to be extracted from the embryo via a biopsy. So there is chance of harming
the embryo and this procedure has a 10 percent margin of error. Therefore, it is thought to do more harm
than good when performed needlessly.
Why should someone undergo this procedure?
The risk of miscarriage during a normal pregnancy drops from 23 to 9 percent.
The probability of the embryo attaching to the womb nearly doubles.
The chances of a clinical pregnancy and going home with a baby increase.
The rate of multiple pregnancy decreases.
How is a PGD procedure performed?
The patient's suitability for PGD is evaluated by a doctor who specializes in the related disease.
Next, the couple is prepared for the IVF procedure.
The egg taken from the mother is fertilized with the father's sperm in a laboratory environment.
Embryologists extract one or two blastomeric cells from the removed embryos via a biopsy.
Cells extracted via a biopsy are subjected to a special dyeing technique (FISH), which allows chromosomes to be examined under a microscope, following a fixation process.
Embryos with structural or quantitative chromosomal defects are selected and removed. The healthy embryos are then transferred into the mother's womb.
Causes of infertility in Female
A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual
intercourse in the absence of any known cause of infertility, should be offered further clinical
assessment and investigation along with her partner. It is recommended that a consultation with a
fertility specialist should be made earlier if the woman is aged 36 years or over, or there is a known
clinical cause of infertility or a history of predisposing factors for infertility.
Damage to fallopian tubes
Damage to the fallopian tubes (which carry the eggs from the ovaries to the uterus) can prevent contact between the egg and sperm. Pelvic infections, endometriosis and pelvic surgeries may lead to scar formation and fallopian tube damage.
Some women have problems with ovulation. Synchronized hormonal changes leading to the release of an egg from the ovary and the thickening of the endometrium (lining of the uterus) in preparation for the fertilized egg do not occur. These problems may be detected using basal body temperature charts, ovulation predictor kits and blood tests to detect hormone levels.
A small group of women may have a cervical condition in which the sperm cannot pass through the cervical canal. Whether due to abnormal mucus production or a prior cervical surgical procedure, this problem may be treated with intrauterine inseminations.
Abnormal anatomy of the uterus, the presence of polyps and fibroids.
The cause of infertility in approximately 20% of couples will not be determined using the currently available methods of investigation.
Minor Male Infertility & Endoscopy Procedure
Just like varicose veins in the legs, the scrotum is also subject to dilated veins. What happens is that the veins become
dilated when blood doesn't drain properly from them. This extra blood pools in the scrotum and it negatively impacts sperm
production. The positive news is that this is the most common reversible cause of male infertility and may be corrected by
minor outpatient surgery.
Most doctors perform this surgery microscopically to preserve the arterial supply and lymphatic. An incision is
made about one inch above the penis (it's called a subinguinal incision) avoiding the abdominal muscles, which
means less post-operative pain.
Seminal Fluid Abnormalities
This occurs when the semen is very thick, making it difficult for the sperm to move into the woman's
reproductive tract. An attempt is made to separate the moving sperm from the dead sperm and
surrounding debris, process it and place it directly into the uterus with a small tube. This
is called intrauterine insemination (IUI).
Ductal System Problems
Some of these are sperm carrying ducts that may be missing or blocked. An absence of both sides of the vas deferens
since birth obstructions at the point where the delicate tubular structure drains the testes or higher up in the more
muscular vas deferens or blockage that occurred during hernia or hydrocele repairs or from scar tissue from due to an
The mechanics of the situation are that sperm must travel through the ejaculatory ducts as they go from seminal vesicles to the urethra. If these ducts are blocked, the sperm can't get through.
Options here include repairing or unblocking the ducts, or if that's not possible, the sperm can be harvested so they can go through the man's reproductive tract. In cases like this, sperm is obtained in low numbers, so this procedure must be used in conjunction with advanced reproductive techniques to attempt a pregnancy.
In the past several decades the technology of cryopreservation, or maintaining life in a frozen state,
has advanced considerably. With the use of modern techniques, cryopreservation of
sperm to preserve an individual's ability to reproduce has become successful, safe,
and widely available.
Who needs to freeze semen?
Some common reasons why you may choose to store a semen sample include:
Prior to Artificial Insemination: One common cause of male infertility is a low concentration of sperm in the ejaculate. For some, the collection of one or more samples to be cryopreserved and later combined with a fresh sample and used for artificial insemination may be helpful in achieving a pregnancy.
Prior to the absence of the partner: For couples going through cycles of artificial insemination or in vitro fertilization (IVF), it can be frustrating when responsibilities or obligations require a spouse to be absent. If it is anticipated that the male partner will be unavailable during the optimal time for the procedure, it is possible to cryopreserve a semen sample prior to his departure as a backup in the event he is prevented from providing a sample at the time of the procedure. While this may not be optimal, it can often keep the time and finances invested in a procedure from being wasted due to unforeseen circumstances.
Vasectomy: The majority of men who choose a vasectomy as a form of birth control see it as a permanent decision.
However, unexpected changes in a patient's life such as a new marriage or death of a child or
spouse can give rise to the desire to have more children. Vasectomies can be surgically reversed
but success is widely variable and the surgery is expensive and invasive. Additionally, after an
initially successful reversal, the ducts through which the sperm travel often develop scar tissue
and become obstructed. As most individuals plan for a vasectomy well in advance, cryopreservation
prior to having a vasectomy provides an effective form of insurance against a change in future plans.
Treatment for malignant disease: Hodgkin's disease, leukemia, testicular cancer and other malignancies often occur in juveniles, young adults and others who haven't started or completed their families. Fortunately, early detection and improved therapies have dramatically increased the survival rate for these diseases. Unfortunately, the chemotherapeutic agents and radiation therapy used to treat these diseases affect the production of sperm.
The response to treatment varies considerably, depending on how far the disease has progressed prior to treatment, the type and quantity of agents used and the specific individual's reaction to the treatment. While many patients who have undergone chemotherapy will eventually have a return of sperm production to varying degrees, some therapies, such as treatment with platinum based agents, result in a high probability of sterility. Even though the time between diagnosis and initiation of treatment is short, there is often a window of several days in which a patient can cryopreserve his semen.
How is the semen cryopreserved?
After a semen sample has been collected, it is placed on a warming block maintained at 37°C, until
the sample, which is highly viscous directly after collection, has become liquefied. At this time the
semen sample is washed as in IUI and is mixed with a freezing medium that allows the semen sample to
survive the freezing and storage process. The freezing medium used contains cyroprotectants.
Cryoprotectants are salts or chemicals that help remove water from the cells being frozen. If the
water is not removed from the sperm, ice crystals will form inside of the cell and break up it up,
resulting in cell death.
Semen samples are slowly frozen in liquid nitrogen vapors. Once the semen samples have been frozen in the liquid nitrogen vapors
they are placed on canes or in special containers where they are stored in the liquid nitrogen until they are needed.
Liquid nitrogen has a temperature of -196°C, compared with a temperature of -20°C found in the average home freezer. The very low
temperature essentially halts all metabolic activity in the cell, allowing them to be frozen and stored for very long periods.
When a sample is thawed, it is removed from the liquid nitrogen and placed in water until it has reached a liquid state. Once liquid, it
is placed on a 37°C block and allowed to warm to that temperature prior to being prepared for use. By thawing the sample in stages,
the sperm are protected from thawing too quickly, which results in the sperm heads swelling and rupturing as water moves back into the cells.
Use of Cryopreserved Sperm to achieve pregnancy
Cryopreserved sperm are generally used in two different ways to achieve pregnancy. The first way is with artificial insemination.
When artificial insemination is used the female partner, working with a fertility specialist,
determines when she will be ovulating. At the appropriate time, an appointment is scheduled with
the Andrology laboratory and one of the cryopreserved samples is prepared by carefully thawing and
washing the semen sample. The washing procedure removes the cryoprotectants and seminal fluid,
and concentrates the sperm into a volume appropriate for insemination. Depending on the quality
of the sample, the doctor may have more than one vial prepared at each attempt. Once the sample
is prepared, the patients will take it to their care provider to have the insemination performed.
The physician performing the procedure uses a small catheter that is inserted into the uterus and
deposits the sperm.
If there is known female factor infertility, or sperm are not available in sufficient quantity or quality,
In vitro fertilization (IVF) can be another option. With this technique the female partner, working with
a reproductive endocrinologist receives hormone injections that stimulate her ovaries to produce
several follicles containing mature eggs. When the follicles have matured sufficiently, the eggs
are retrieved and the cryopreserved sperm is prepared and used to fertilize the eggs. Advantages
to this procedure include a much higher pregnancy rate and the ability to use semen samples with a
very low concentration or poor motility.
FAQs about Sperm Freezing:
How long can sperm be stored?
There is no practical limit to the length of time sperm, correctly maintained in liquid nitrogen, can be stored.
Is freezing harmful to the sperm?
A percentage of the sperm will not survive the freezing process. The survival rate varies greatly between individuals. There may be some loss of fertilization potential in the sperm that do survive. Freezing itself does not cause DNA damage to the sperm. Again, the effects of cryopreservation are variable between samples and patients.
How is the semen specimen collected?
A single ejaculate is collected into a sterile container by masturbation. A private room is available specifically for the purpose of semen collection.
How many samples should be frozen?
A minimum of two samples is recommended for storage prior to surgery and/or therapy, however it's the patient's choice as to how
many samples he will freeze. The patient should discuss his future plans during the initial consult and establish a plan based
on time constraints and future need. The number of samples needed for adequate storage is different for each situation and varies
with the quality of the sample once it is thawed.
What if the initial semen quality is poor, or the concentration is very low?
Many cryopreserved samples may not be of sufficient quality for use with artificial insemination. However, advanced procedures used in association with ICSI are regularly performed with sample of very poor quality or concentration. Any sample containing sperm, regardless of concentration or quality, is routinely frozen. If there is a concern at the time of processing the sample for cryopreservation the laboratory director or your care provider will be contacted.
How long should the abstinence period be between collections?
Optimal abstinence time is from two to five days.
How can I be sure my semen sample is not contaminated with another sample or mislabeled?
The specimen container used to collect the sample is labeled and verified by the patient prior to collection. Once the sample is received
it is handled with extreme caution. All materials used in the process are labeled with the patient's
name, the current date and a visit number unique to the patient and the sample collected.
Each sample is assigned a physically isolated workstation. All tools and solutions used in
preparing the sample for cryopreservation are sterile and single use. This and the use of
trained, certified Andrology technicians will ensure there is no confusion in the handling of
Freezing extra embryos increases the opportunity to achieve a pregnancy as a result of a single egg retrieval procedure.
If a pregnancy does not occur in "fresh" IVF cycle, the patient can return at a later time for transfer of the remaining
embryos. An ultrasound assessment of the uterine lining is performed before the embryos are thawed, to make sure an adequate
uterine environment is present. Usually about 75% of the frozen embryos survive the thawing process, but it can vary depending
on the stage at which the embryos are frozen.
After the transfer after completing the transfer you will be repositioned very gently so your legs are together and
slightly elevated. This position is recommended for a short period of time following transfer. It is important during
this time that you remain relatively relaxed and comfortable. Usually you will remain at rest for 15 to 30 minutes
after the transfer.
The lining of the uterus is uniquely designed to enhance the process of embryo implantation.
Special secretions of nutrients and cell adhesion molecules assist the embryo in the process
of continuing development, attaching to the uterine wall and burrowing the placental cells into
the uterus. The embryos are now safely housed within the walls of the uterus. For better or worse,
there is very little you can do at this point to affect the chances of successful implantation.
Whether or not the embryo or embryos implant in the uterus is primarily dependent on the health
of the embryo.
When you go home, be a couch potato for 6 - 8 hours after the transfer. Have a good book ready
to read and move between bed, the bathroom and the couch. If you have small children you avoid
lifting them. After 8 hours, you may increase your activity but don't do vigorous aerobics or running.
Your ovaries will still be full of fluid from the effects of the stimulation and you may feel
some bloating or pelvic discomfort at this time. It is okay to take the stairs slowly and walk
short distances, less than a half mile. Avoid any vaginal creams, lubricants, or spermicides. Take showers instead of tub baths and don't go swimming. Avoid vaginal intercourse or orgasm for
about a week after your transfer. If you have to travel, give yourself twice as much time as usual
and minimize stress.
Testicular Sperm Aspiration Or Extraction
TESE (testicular sperm extraction)
Sperm is produced in the testicles and carried to the penis through the tubes which are known as the epididymis and the vas deferens.
When it is not possible for the sperm to travel beyond the testicles to reach the penis for ejaculation,
then sperm can be retrieved by two different methods: TESE (testicular sperm extraction) and PESA
(percutaneous epididymal sperm aspiration).
PESA(percutaneous epididymal sperm aspiration) PESA is a minimally invasive technique which is used to
extract sperm from the epididymis under local anaesthesia with a fine needle. If sperm cannot be retrieved using this
method then the patient may have to proceed to TESE which is also a minimally invasive procedure performed under
local or general anaesthesia and is used to extract sperm from the testicles.
Lack of sperm in the ejaculate can occur as a result of various circumstances, for example,
when a man is born without a vas deferens, if the ducts are blocked by scarring from a previous infection,
or if the man has undergone vasectomy in the past and reversal has failed.
Sperm obtained from either the testicles or the epididymis will usually have poor motility. Therefore,
in order to improve the chances of fertilisation the sperm are usually microinjected into each egg by ICSI.
Hysteroscopy Dignostic & Operative
The inside of a woman's uterus has a special lining called the endometrium. That lining
is unique because it responds to the hormones produced monthly. There are a number of
conditions that disrupt the endometrium and can lead to heavy or irregular periods or infertility.
Operative hysteroscopy refers to a minimally invasive technique whereby such conditions
can be treated on an outpatient (day surgery) basis. Conditions treated hysteroscopically
include endometrial polyps or fibroids that can be removed to enhance fertility. Hysteroscopy
is used for conditions below:
A couple may not be able to achieve pregnancy for a number of reasons. Sometimes the cause of female infertility is related to the defect in the shape or size of the uterus. One example of this is a seperate uterus (a thin sheet of tissue divides the inside of the uterus into two sections). Hysteroscopy may find and help treat these problems.
Sometimes benign growths, such as polyps and fibroids, can be diagnosed with the hysteroscope. Hysteroscopy
might help a doctor to biopsy a growth in the uterus to find out whether it may be cancer or may become cancer.
These structures can be removed with operative hysteroscopy in 20 minutes.
Abnormal Uterine Bleeding
A woman has this condition if she has heavier or longer periods than usual between periods or has any bleeding after her periods have stopped at menopause. Hysteroscopy may help the doctor and find the cause of abnormal bleeding that other methods have not found. It may be used to take a biopsy.
Some women experience consecutive pregnancy losses before 20 weeks. Hysteroscopy can be used to identify the reason of recurrent losses. Adhesions and uterine abnormalities may result in this problem and can be fixed by hysteroscopy.
Bands of scar tissue or adhesions may form inside of the uterus. This is so called Asherman's syndrome. These adhesions may cause infertility and changes in menstrual flow. Hysteroscopy may help dissect adhesions.
An intrauterine device (IUD) is a small plastic device inserted into the uterus to prevent pregnancy. In some cases, it moves out of its proper position inside the uterus. It then embeds itself in the uterine wall or the tissue around it. It can be found and removed hysteroscopically.
Hysteroscopy is a safe and simple approach. Problems such as injury to the cervix or the uterus, infection, heavy bleeding, or side effects of the anesthesia occur in less than 1% of the cases.
Hysteroscopy is best done during the first week after the menstrual period. This allows a better view of the inside of the uterus. With general anesthesia, you breathe a mixture of gases through a mask and you will not be conscious during the surgery.
Before a hysteroscopy, the opening of your cervix may need to be dilated (made wider) with a special device. The hysteroscope then is inserted through the cervix and into the uterus.
A liquid may be released through the hysteroscope to expand the uterus so that the inside can be seen better. A light shone through the device allows the doctor to view the inside of the uterus and the openings of the fallopian tubes into the uterine.
You may feel faint or sick or you may have slight vaginal bleeding and cramps for a day or two. get in touch with your doctor if you have fever, severe abdominal pain, heavy vaginal bleeding or discharge.
Laparoscopy Dignostic & Operative
A woman's reproductive organs lie in her pelvis. There are a number of conditions that
can affect the fallopian tubes, ovaries and uterus and that can be treated surgically.
Operative laparoscopy refers to a minimally invasive technique done on an outpatient basis.
This procedure is helpful in treating many debilitating or infertility-causing conditions,
including endometriosis, uterine fibroids, damage from infection, tubal disease and pelvic
Some women are evaluated with a laparoscopy, while more complex laparoscopy can restore a woman's
pelvic anatomy to enhance fertility. Conditions such as endometriosis are usually diagnosed and treated
A laparoscope is a small telescope that is inserted into the abdomen through a small incision(cut).
It brings light into the abdomen so the doctor can see inside. Laproscopy is usually done on an outpatient
basis you don't have to stay in the hospital overnight.
Tissue like endometrium (the lining of the uterus) some times grows in places outside of the uterus. The tissue bleeds every month, as with a menstrual cycle. This condition is called endometriosis. It can cause pain, scar tissue and infertility. One way to be certain that endometriosis is present is by laproscopy.
Sometimes tissues in the abdomen stick together and form scar tissue called adhesions.This can happen because of infection, endometriosis, or
surgery. Adhesions can cause pain. They often can be separated during the laproscopy.
Fibroids are growths that form on the inside, outside, or within the wall of the uterus. Laparoscopy can diagnose fibroids especially located outside of the uterus. These fibroids can be removed by operative laparoscopy.
Ovaries sometimes develop cysts (fluid-filled scas). These cysts may be harmless, causing only mild pain. Some cause infertility or menstrual disorders. Some ovarian cysts may disappear after a short time. If they don't, these cysts may be taken out during laparoscopy.
Uterus can be removed by laparoscopy with the assistance of the developed instruments. Laparoscopy can also assist in the removal of the ovaries. Uterus can be taken out of the body through vagina or cut in the abdomen and through the cuts on the skin.
When a woman has pain in her lower abdomen during early pregnancy, the doctor may suspect an ectopic pregnancy, An ectopic pregnancy is one that may be located in the tube instead of the uterus. It may rupture the tube and cause abdominal bleeding that may require emergency surgery. The doctor can perform a laparoscopy to diagnose and often treat an ectopic pregnancy.
Advantages of laparoscopy
In the past, most surgery involving reproductive organs was performed by laparotomy (making an incision in the abdomen).
Now, many of these same procedures are done through the laparoscope easily. There are many benefits of laparoscopy such as a shorter hospital stay, smaller incisions and a shorter recovery.
After the anesthesia is given, small cut is made below or inside the navel. A gas, carbon
dioxide is usually put into the abdomen. The gas swells the abdomen so the pelvic reproductive
organs can be seen more clearly. The laparoscope is placed through the cut. Another cut is
often made above the pubic region. Through this cut , an instrument is used to move the organs into view. Usually, the laparoscope projects images of
the surgery onto a television screen. This makes the image larger and easier for the doctor to see. These images can be photographed for later viewing.
After the procedure, the instruments are removed and the gas released. The cuts are then closed, usually with stitches that dissolve. In a few hours you can go home. You should plan to have some with you at home, at least for a day.
Although problems seldom occur with laproscopy, there some complications. You may have some bleeding, reactions to the anesthesia, or injury to the other organs. The most common organs injured during the procedure are the blood vessels, bowel and the urinary tract. A follow-up laparotomy may be needed, which will require you be admitted to the hospital. There is also a minimal risk of infection after the procedure.
More common problems include:
2. Pain around the cuts made in your abdomen
3. Scatchy throat if a breathing tube was used during general anesthesia
4. Abdominal cramps
5. Discharge(like your period) that lasts a few days
6. Swollen abdomen
7. Shoulder pain
Minor Gyneacolocal Procedures in Female
Colposcopy - Colposcopy is a diagnostic tool used for further evaluation of abnormal Pap
smears. This procedure provides a non-surgical way for your physician to visualize your cervix.
One of the most frightening times in a woman's life is when the gynecologist calls and says that her Pap smear results are abnormal.
Although you might think an abnormal Pap smear means that you have cervical cancer, the fact is that the majority of abnormal
Pap smears are not caused by cervical cancer. The more likely cause of abnormal Pap smear results is inflammation or a vaginal infection.
Because the Pap smear can only screen for potential problems, not diagnose them, your gynecologist may want to take
a closer look at your cervix to determine the cause of your abnormal Pap smear results. He will perform an examination
called a colposcopy. Your doctor may order this procedure if you have Pap smear results that:
indicate cervical dysplasia or cervical cancer.show evidence of HPV.show first-time or repeat a typical squamous cells of undetermined significance(ASCUS).
Your gynecologist may also order a colposcopy if your cervix appears abnormal during your
pelvic exam and Pap smear, or if you have a history of prenatal DES exposure.
Colposcopy is a simple, 10 to 15 minute procedure that is painless and performed in a gynecologist'
s office. You are positioned on the examination table like you are for a Pap smear and an
acetic acid (such as common table vinegar) is placed on the cervix.
Your physician will use a colposcope a large, electric microscope that is positioned approximately 30 cm from the vagina to view your cervix.
A bright light at the end of the colposcope lets the gynecologist clearly see the cervix.
Cyrosurgery - Cervical cryosurgery or cryotherapy is a gynecological treatment that freezes a section
of the cervix. Cryosurgery destroys abnormal cervical cells that show changes that
may lead to cancer. These changes are called precancerous cells. Your gynecologist may use the
term cervical dysplasia to describe your condition.
Cryosurgery of the cervix is most often done to destroy abnormal cervical cells that show changes that may
lead to cancer. These changes are called precancerous cells. Your gynecologist will probably use the term
Cryosurgery is done only after a colposcopy confirms the presence of abnormal cervical cells.
Cyrotherapy is also used for the treatment of cervicitis or inflammation of the cervix. Cryosurgery is not a treatment for cervical cancer.
What happens during cryosurgery?
Cryosurgery is performed in your doctor's office while you are awake. It is similar to a pelvic exam:
you will be asked to undress from the waist down.
lie on an exam table with your feet in stirrups.
A speculum is inserted into your vagina to hold the vaginal canal open so that your cervix
can be seen.
However, that's where the similarity ends.
Cryotherapy uses special instruments called cryo probes.
During cryosurgery the cyro probes are inserted into your vagina until they firmly cover the abnormal areas of cervical tissue.
Next, liquid nitrogen begins to flow through the cryo probes at a temperature of approximately -50 degrees Celsius.
This causes the metal cryo probes to freeze and destroy superficial abnormal cervical tissue.
The most effective treatment result is obtained by freezing for three minutes, letting the cervix thaw and repeating the treatment for three more minutes.
LEEP Procedure - The loop electrosurgical excision procedure (LEEP) is used when there is
an indication of abnormal cells on the surface of the cervix If your doctor has told you that
you need to have a LEEP procedure, it's because your annual Pap smear indicated the presence
of abnormal cervical cells, or cervical dysplasia. While the loop electrosurgical excision
procedure, or LEEP procedure, may make you wonder if your doctor wants you to jump. The LEEP
procedure has nothing to do with jumping. The LEEP procedure is one of several procedures your
doctor has available to help diagnose and treat abnormal cervical cells. Other procedures your
doctor may want you to have either before or during the LEEP procedure include, a colposcopy and /
or a cone biopsy.
LEEP uses a thin wire loop electrode which is attached to an electrosurgical generator.
The generator transmits a painless electrical current that quickly cuts away the affected cervical tissue
in the immediate area of the loop wire. This causes the abnormal cells to rapidly heat and burst and separates
the tissue as the loop wire moves through the cervix.
This technique allows your physician to send the excised tissue to the lab for further evaluation which insures
that the lesion was completely removed, as well as allowing for a more accurate assessment of the abnormal area.
You may want to ask your doctor if it's OK to take an over-the-counter pain reliever such as
ibuprofen before your procedure to help minimize any pain. Never take any drug before
any medical procedure without explicitly asking your doctor about it. Always follow your
doctor's instructions for preparation for the LEEP.
What happens during the LEEP procedure?
The LEEP procedure takes about 20-30 minutes and is usually performed in your physician's office.
In some ways it may seem much like a normal pelvic exam because you will lie on the exam table
with your feet in the stirrups. A colposcope will be used to guide your doctor to the abnormal
area. Unlike a normal colposcopy, a tube will be attached to the speculum to remove the small
amount of smoke caused by the procedure.
An electrosurgical dispersive pad will be placed on your thigh. The pad is a gel-covered adhesive
electrode which provides a safe return path for the electrosurgical current. A single-use, disposable
loop electrode will be attached to the generator hand piece by your physician. Your cervix will be
prepared with acetic acid and iodine solutions that enable your physician to more easily see the
extent of the abnormal area. Next a local anesthetic will be injected into the cervix. The electroloop
will be generated and the wire loop will pass through the surface of your cervix.
After the lesion is removed your physician will use a ball electrode to stop any bleeding that
occurs. He may also use a topical solution to prevent further bleeding. You can leave your
physician's office soon after the procedure.
Hysteroscopy - Hysteroscopy provides a way for your physician to look inside your uterus. A hysteroscope is a thin, telescope like instrument that is inserted into the uterus through the vagina and cervix. This tool often helps a physician diagnose or treat a uterine problem.
Pelvic laparoscopy - Laparoscopy is usually performed under general anesthesia however, it can be
performed with other types of anesthesia that permit the patient to remain awake. The typical
pelvic laparoscopy involves a small (1/2" to 3/4") incision in the belly button or lower abdomen.
Laparoscopy is a minimally invasive surgical technique used in procedures such as tubal ligation,
gallbladder removal or hiatal hernia repair. It is normally performed in the Al-Manar Fertility
and Endoscopy Center l. In most cases, patients can return home a few hours after a laproscopic procedure.
What happens during laparoscopy?
Laparoscopy is usually performed under general anesthesia; however it can be performed with other
types of anesthesia that permit the patient to remain awake.
The typical pelvic laparoscopy involves a small (1/2" to 3/4") incision in the belly button or
lower abdomen. The abdominal cavity is filled with carbon dioxide. Carbon dioxide causes the abdomen
to swell, which lifts the abdominal wall away from the internal organs. That way, the doctor has more
room to work.
Next, a laparoscope (a one-half inch fiber-optic rod with a light source and video camera) is inserted
through the belly button. The video camera permits the surgeon to see inside the abdominal area on video
monitors located in the operating room.
Depending on the reason for the laparoscopy, the physician may perform surgery through the
laparoscope by inserting various instruments into the laparoscope while using the video
monitor as a guide. The video camera also allows the surgeon to take pictures of any problem
areas he discovers.
In some cases, the physician may discover that he is unable to accomplish the goal of surgery through the laparoscope and
a full abdominal incision will be made. However, if this is a possibility in your case, your physician will
discuss this with you prior to surgery and the surgical consent form will include this possibility.
D & C - Often used to diagnose or treat abnormal uterine bleeding, the D&C is one of the
most common GYN operative procedures. Dilation and Curettage also provides important information
about whether uterine cancer is present.
Before you can understand D&C you need to know a little about the uterus and cervix. The uterus is a pear-shaped,
muscular organ that sits in the lower abdomen. The top of the uterus is wide and it narrows like the neck of a
bottle at the bottom. The lower third portion of the uterus is its neck which is called the cervix.
The cervix is round and has a small opening called the OS. During your GYN exam your physician can see the
cervix by using a speculum an instrument used to separate the walls of the vagina.
The inner wall of the uterus is lined by endometrial tissues. The endometrial tissues thicken
during the first part of your menstrual cycle. Once ovulation occurs progesterone acts to stop
this thickening and changes the endometrial lining so that it is ready to accept a pregnancy
should it occur. If pregnancy doesn't occur, hormone production ceases and the endometrium breaks
up and is shed as menstrual blood.
Who Needs A D&C?
A D&C may be required to diagnose and/or treat a problem such as heavy or prolonged
menstruation, as well as unexplained bleeding between periods. The are many possible causes for
these menstrual abnormalities, one of the most common being a hormonal imbalance. Hormonal
imbalance causes a thickening of the endometrium which sometimes causes irregular or prolonged
menstrual cycles. Although this can happen at any age it most commonly occurs in young women
just starting menstruation and in older pre-menopausal women.
Abnormal uterine bleeding is also a warning of various types of growths, which are most often non-cancerous.
One of these benign growths are polyps which attach either by a stem or a stalk most often to the lining of the uterus or
the cervix. Polyps inside the uterus can usually be removed by D&C. Fibroid tumors are another common benign growth that
occurs in the uterus. Fibroids can be silent causing no symptoms, or they can cause heavy bleeding and painful cramping.
Although fibroid tumors are sometimes detected during dilation and curettage, another surgical procedure is necessary to
Abnormal bleeding is sometimes a sign of endometrial cancer, particularly in women over 40. Women over 40,
especially those past menopause, may have a D&C or another procedure called an endometrial biopsy.
Occasionally a hysteroscopy is performed at the same time as a D&C, allowing the doctor a better view
of inside the cervix, vagina and uterus.
Dialation and curettage are also commonly performed following miscarriage or abortion in cases where the uterus fails
to fully empty its content. Abortions induced before the 12th week of pregnancy are performed in a manner which is
similar to the D&C.
Ovarian Cyst Aspiration - An ovarian cyst is a very common condition in which fluid collects in the ovary. However,
cysts that are more than 5 cm in size need to be treated as they can cause problems (e.g. twisting and rupture). Normally,
surgery had to be done to remove these cysts and often this damaged the surrounding normal ovary as well. With ultrasound-guidance,
we can stick a needle from the vagina into the cyst and empty the contents (usually clear fluid) by sucking it out. This empties the cyst,
which often does not recur.
Causes of Male Infertility
Reproduction (or making a baby) is a simple and natural experience for most couples. However, for some
couples it is very difficult to conceive. Male infertility is diagnosed when, after testing of both partners,
reproductive problems have been found in the male partner.
How common is male infertility?
Infertility is a widespread problem. For about one in five infertile couples the problem lies solely
in the male partner (male infertility).
Are there any signs or symptoms of male infertility?
In most cases, there are no obvious signs of an infertility problem. Intercourse, erections and ejaculation will
usually happen without difficulty. The quantity and appearance of the ejaculated semen generally appears normal
to the naked eye.
How does the male reproductive system work?
The male reproductive tract is made up of the testes, a system of ducts (tubes) and other glands opening into the ducts.
The testes (testis: singular) are a pair of egg shaped glands that sit in the scrotum next to the base of the penis on the outside of the body.
Each normal testis is 15ml to 35ml in volume in adult men. The testes are needed for the male reproductive system to function normally.
The testes have two related but separate roles:
production of sperm.
production of the male sex hormone, testosterone.
What causes male infertility?
Male infertility can be caused by problems that affect sperm production or the sperm transport process. With the results of medical tests,
the doctor may be able to find a cause of the problem.
Known causes of male infertility can be:
Sperm production problems: The most common cause of male infertility is due to a problem in the sperm
production process in the testes. Low numbers of sperm are made and/or the sperm that are made do not work properly.
About two thirds of infertile men have sperm production problems.
Blockage of sperm transport: Blockages (often referred to as obstructions) in the tubes leading
sperm away from the testes to the penis can cause a complete lack of sperm in the ejaculated semen.
This is the second most common cause of male infertility and affects about one in every five infertile men,
including men who have had a vasectomy but now wish to have more children.
Sperm antibodies: In some men, substances in the semen and/or blood called sperm antibodies can develop which can
reduce sperm movement and block egg binding (where the sperm attaches to the egg) as is needed for fertilisation.
About one in every 16 infertile men has sperm antibodies.
Sexual problems: Difficulties with sexual intercourse, such as erection or ejaculation problems, can also
stop couples from becoming pregnant. Sexual problems are not a common cause of infertility.
Hormonal problems: Sometimes the pituitary gland does not send the right hormonal messages to the
testes. This can cause both low testosterone levels and a failure of the testes to produce sperm.
Hormonal causes are uncommon and affect less than one in 100 infertile men. Unfortunately,
medical scientists do not yet understand all the details of sperm production and the fertilisation process.
As a result, for many men with a sperm production problem, the cause cannot be identified.