General Terms

Azoospermia is the complete absence of sperm in the semen and has many causes. Obstructive azoospermia implies that there is a blockage in the genital tract, yet there is normal testicular production of sperm. Other causes of azoospermia are non-obstructive, meaning that there is a significant diminution in sperm production within the testicle. Obstructive azoospermia accounts for about 40% of all cases of azoospermia. Obstruction may be either congenital or acquired. Vasectomy is a common form of male contraception in that the vas deferens is cut and sealed on each side forming an acquired obstruction. Vasectomy is the most common cause of obstruction. Another common cause of obstruction is a prior infection that created scarring of the ductal structures. Congenital obstruction can be due to either a malformation or the absence of the vas deferens and may be associated with the presence of cystic fibrosis mutations.

Finding the cause of the obstructive azoospermia is important to determine treatment options to help achieve pregnancy.

If there is a major medical or genetic disorder underlying the azoospermia, it may be important to identify these disorders and determine if it may be passed onto your children.

A Blastocyst is an embryo that has developed two different cell types and also contains a central fluid-filled cavity. The outer cells, called the trophectoderm, will become the placenta, and the inner cells will become the fetus. Blastocyst formation in the human usually occurs on the 5th day after fertilization. By the end of the sixth day, healthy blastocyst should hatch from its outer shell (the zona pellucida), and within another 24 hours the hatched blastocyst begins to implant in the lining of the mother's uterus.

Over the first two decades of experience with in vitro fertilization (IVF), embryos were routinely cultured for two to three days in the laboratory, and then transferred to the uterus. This is quite different than when embryos normally enter the uterus from the fallopian tube (day 5 or 6). During a natural cycle, 2-3 days after conception, embryos are typically found in the fallopian tubes and may not be ready to enter the uterus. Recently, laboratory culture conditions have been improved so that embryos resulting from an in vitro fertilization cycle can develop to the blastocyst stage in the laboratory, and therefore be replaced into the uterus at the more "natural" time, Day 5 or 6 after fertilization.

The additional benefit of waiting longer to transfer embryos is reducing the number of embryos needing to be transferred to result in a viable pregnancy. While extended culture of embryos will not improve the quality of an abnormal or poor quality embryo, by culturing embryos to the blastocyst stage there is more opportunity to choose the healthiest ones for transfer, thereby reducing the number transferred with the result of limiting the risk of a multiple gestation pregnancy

CBAVD is a genetic abnormality whereby the male is born without the vas deferens and results in azoospermia, or absence of sperm in the ejaculate. About two-thirds of men who have CBAVD have a genetic mutation that can cause cystic fibrosis if they initiate a pregnancy with a woman who has the same genetic mutation. Therefore, a male diagnosed with CBAVD should seek genetic testing and counseling during the infertility treatment process. Treatment options for couples where the male has CBAVD include microsurgical reconstruction, TESE, and use of donor sperm.

Two to three percent of all pregnancies occur outside of the uterus and are known as an ectopic pregnancy. The majority of ectopic pregnancies occur in the Fallopian tubes, and can be life threatening if not treated. Historically, treatment of an ectopic pregnancy was surgical removal of the entire fallopian tube, which decreased the possibility of future natural conception. Advances in treatment of tubal pregnancies focus on preserving the fallopian tube and treatment options include laparoscopic surgery or usage of an injectable medication (Methotrexate).

Early warning signs of an ectopic pregnancy include abnormal bleeding and pelvic pain. An ultrasound will help confirm the diagnosis of an ectopic pregnancy.

Ejaculatory dysfunction may take the form of complete failure to emission and/or retrograde ejaculation. Causes of ejaculatory dysfunction include spinal-cord injury, diabetes mellitus, retroperitoneal surgery, multiple sclerosis, bladder-neck and prostate surgery, psychogenic, and idiopathic. Treatment options for ejaculatory dysfunction include oral medications, vibratory stimulation, electroejaculation, and testicular sperm extraction (TESA) procedures.

Electroejaculation is a procedure that is performed when a medical or psychological condition prevents a male from ejaculating. During an electroejaculation procedure, the doctor inserts an electrical stimulation probe into the rectum. The doctor controls the amount of electrical stimulation delivered so that an ejaculation occurs. This can be done either in the office or in the operating room with anesthesia, depending on the sensory status of the patient. Alternative methods of sperm retrieval, including testicular sperm extraction, are recommended when penile vibratory stimulation and rectal probe ejaculation are unsuccessful or unavailable.

Also known as “embryo freezing,” embryo cryopreservation is a method used to preserve embryos where they are stored at very low temperatures. Embryo cryopreservation allows the use of a woman’s own embryos for subsequent treatment cycles. A frozen embryo transfer cycle does not require use of follicle stimulating hormones and egg retrieval is not needed, thereby significant reducing the cost and invasive care as compared to an in vitro fertilization cycle using newly created embryos. Embryos may be stored indefinitely and there appears to be no increase risk of birth defects from cryopreserved embryos. However, embryo cryopreservation is not without risks, as almost 40 percent of cryopreserved embryos do not survive the freezing and thawing process. The pregnancy rates associated with frozen embryo transfer cycles are slightly lower than with fresh transfer. This may be caused by additional stress placed on the embryo during the cryopreservation and thawing process or simply by the selection of the most promising embryos for fresh transfer.

Endometrial polyps are overgrowths of the uterine lining.

Endometrial polyps can be associated with irregular menstrual bleeding, but in many cases there may not be any additional symptoms associated with the polyp(s). Polyps can be diagnosed by transvaginal ultrasound, saline sonogram, or hysterosalpingogram (HSG). There is some evidence that polyps can contribute to difficulties conceiving by interfering with implantation. On rare occasions, polyps can be malignant.

Removal of the polyp(s) via a hysteroscopic polypectomy is performed by a qualified surgeon and is a relatively quick out patient procedure. After the patient is sedated, a gynecological surgeon removes the polyp using a fiber optic scope called a hysteroscope. After removal, the polyp is sent to a pathologist for examination. The majority of patients undergoing this procedure are discharged home within hours of the procedure.

Patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again 2 weeks after the procedure (with her next period).

Side effects of a polypectomy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling vaginal discharge, she should consult her physician immediately.

Endometriosis is a condition in which there is a growth of uterine or endometrial tissue outside of the uterus. This disease affects an estimated 10 million women in the US, and it is one of the leading causes of infertility in women. Though there are many effective treatments, there is no known cure. The diagnosis is confirmed when uterine or endometrial cells are identified outside their usual location inside the uterus.

Endometriosis may be found on the outside of the uterus, inside and outside the ovaries, or implanted upon the fallopian tubes, bowel, urinary tract, and anywhere in the abdomen. When a woman gets her period the endometriosis often responds to the menstrual cycle's hormonal signals. When the endometriosis bleeds, the woman may have sensations of deep pain or cramping. The body responds to the bleeding by surrounding it with inflammation often causing adhesions and leaving scar tissue. Endometriosis is estimated to be present in 15% of all reproductive age women, but as many as 30-40% of all infertile women. The exact way in which endometriosis affects infertility is not fully understood. Scar tissue and adhesions are known to interfere with the path the egg and sperm must travel to unite and become fertilized and implanted. In some women, endometriomas (a special type of ovarian cyst that contain endometrial cells that grow and bleed during menstruation) may form inside the ovaries causing enlargement of the ovaries, therefore interfering with normal ovarian functions such as ovulation. There also may be links between endometriosis and hormonal imbalances or immune system abnormalities that can also interfere with fertility. Some women with endometriosis experience severe pain during their menstrual cycle or during intercourse, excessive or irregular bleeding during menstruation, or urinary or bowel problems in conjunction with menstruation.

Other symptoms may include fatigue; painful bowel movements with periods; lower back pain with periods; diarrhea and/or constipation and other intestinal upset with periods. The amount of pain is not necessarily related to the extent or size of growths. Other women experience no symptoms, and their endometriosis goes undiagnosed until they seek medical help to explain their inability to conceive. Because endometriosis is progressive, the key to preserving fertility in women who have endometriosis is early diagnosis and treatment of the symptoms that interfere with conception and pregnancy.

Ultrasound scans may detect the presence of endometriomas in the ovaries, while laparoscopy is typically the definitive way endometriosis is diagnosed. Laparoscopy is typically performed as an outpatient surgical procedure in which a fiber optic telescope is inserted into a female's abdomen below the navel to look for endometriosis, scarring, and adhesions. While there is no known cure for this disease, effective treatment of the symptoms is available. In general, surgery and hormonal treatments may be helpful for the treatment of pain related to endometriosis. For infertility, there may be a need for other types of treatment following surgery to increase the number of eggs ovulated in a given month. Endometriosis in the Fallopian tubes may interfere with movement of egg from the ovary or embryo to the uterus. In this situation, in vitro fertilization may be needed to bypass the scarred Fallopian tubes.

Uterine fibroids are benign (non-cancerous) tumors of the uterus that can cause infertility, heavy periods, severe menstrual cramps, and pelvic pressure. These abnormal growths are among the most common causes of infertility in women. There are no known causes for uterine fibroids, though it is suspected that there is an absence of a signal to turn off division of the muscle cells that make up the walls of the uterus. While traditionally hysterectomy was the recommended treatment for women with fibroids, women with fibroid tumors are now being offered more conservative treatments such as myomectomies. A myomectomy is a surgical procedure in which the fibroid tumor is removed, yet the uterus is left in place. Reconstruction of the uterus is a vital part of this procedure. Specialists who perform myomectomies are often able to save a woman from needing a hysterectomy, enabling her to retain her childbearing ability. For some fibroids, the myomectomy can be done on an outpatient basis (laparoscopically or hysteroscopically). Medications are another option for treating fibroid tumors in some women. These medications shrink the size of the fibroid and lessen heavy bleeding and pain. These medications require careful monitoring by a physician should only be used for a limited period of time.

Doctors will often perform an operative hysteroscopy if a uterine abnormality is suspected.

Use of a thin telescope called a “hysteroscope” enables the physician to insert operating tools, such as a scalpel or scissors, cautery devices or a laser fiber, into the uterus with precision and accuracy. The hysteroscope is also valuable in treating some forms of tubal occlusion, which is a blockage at the junction of the uterus and fallopian tube. Operative hysteroscopy is usually performed in the first part of the menstrual cycle so that the build-up of the endometrium does not block or obscure the physician’s view of the uterus.

Patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again two weeks after the procedure (with her next period).

Side effects of a hysteroscopy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling vaginal discharge, she should consult her physician immediately.

In vitro fertilization (IVF) is the process of retrieving eggs and sperm and manually fertilizing them in a laboratory dish outside the womb. Healthy embryos are then transferred back into the uterus with the goal of implantation and further embryo development. IVF is performed by physicians who specialize in reproductive medicine and have received additional education and training in the evaluation and treatment of male-factor and female-factor infertility.

IVF was originally developed in the early 1970’s to treat infertility caused by blocked or damaged fallopian tubes. Louise Brown, born in the United Kingdom in 1978, was the first baby conceived with the help of IVF. She made headlines again in 2006 when she went on to naturally conceive a healthy baby of her own. The technology of IVF and advanced reproductive technologies has improved markedly since then; and over 3 million babies have been born since Louise Brown with the help of IVF.

IVF involves four steps:

Stage I: Ovarian Stimulation and Monitoring - In order to maximize the patient's chances for successful fertilization, a patient undergoing IVF usually take hormones in the form of injections to increase the number of eggs produced in a given month. Frequent monitoring is performed to continuously follow a woman's ovarian response, allowing the physician to adjust and time medication dosage appropriately.
Stage II: Egg (Ovum) Retrieval - Under sedation, the reproductive specialist extracts mature eggs via ultrasound guidance. Egg retrieval is a minimally invasive procedure that normally takes less than 15 minutes. Patients typically can resume normal activity within the next day.
Stage III: Culture and Fertilization - Embryologists use high-power microscopes and steady precision to fertilize the eggs with sperm in the embryology laboratory. At times, the sperm are released on top of the oocyte to fertilize it. In other cases, especially when there are less than one million living sperm, intracytoplasmic sperm injection (ICSI) is used where a single sperm is microinjected directly into the cytoplasm of the ovum.
Stage IV: Embryo Transfer - A fertility specialist will transfer the minimum number of healthy and mature embryo(s) back into the uterus, with the goal of implantation in the uterine wall. This procedure usually does not involve any sedation. The physician will use ultrasound to guide a small catheter through the cervix and deposit the embryo(s) in the uterus. The embryo transfer procedure takes only a few minutes and recovery time is less than a day. Remaining viable embryos can be cryopreserved and used for subsequent transfer cycles. A pregnancy test is performed 11 days after the embryo transfer to evaluate whether implantation successfully occurred.

Infertility is the failure to conceive after one year of having regular, unprotected sexual intercourse. In women over the age of 35, it is often prudent to begin an evaluation after only 6 months. Approximately 12% of the population in the United States is impacted by infertility, according to the Centers For Disease Control. There is a natural decline in fertility that comes with aging; this decline occurs more quickly for females after age 30, and markedly increases after age 35. Primary infertility describes a couple who has never conceived, while secondary infertility refers to a couple who has achieved a pregnancy in the past but is unable to do so again. Diagnosis of the cause of infertility can be female factor, male factor, or of unknown origin. The occurrence of each of these diagnostic categories is roughly similar.

Intracytoplasmic sperm injection (ICSI) is a type of in vitro fertilization procedure in which a single sperm is injected directly into the egg. It is a revolutionary technique that provides effective treatment options for situations where few sperm are available for treatment or there are concerns about fertilization. Because some male factor infertility issues may be caused by chromosomal abnormalities in the male partner, it is important for those diagnosed with male factor infertility to have a thorough examination with a reproductive endocrinologist or urologist specializing in infertility.

Intrauterine insemination (IUI), also known as artificial insemination, can often be used as part of the treatment protocol for couples experiencing male-factor infertility. A well-timed IUI performed during ovulation utilizing a sample with good count and motility can be an effective treatment. In a laboratory, the sperm can be separated from the seminal fluid and re-suspended in a very small volume of sterile medium that will keep the sperm alive and actively mobile. Often, preparation involves a "swim-up" procedure, in which only the fastest swimmers are selected for insemination. The insemination is performed by passing a sterile catheter through the cervical canal into the uterine cavity and then injecting the sperm suspension directly into the uterine cavity. Usually the insemination itself causes little if any discomfort and the procedure is performed in just a couple minutes.

While an IUI can be very effective, some women may experience mild side effects. These include:

• Cramping
• Discomfort during the actual procedure
• Reaction to the medication(s) used to induce ovulation

In a laparoscopy, a fiber optic telescope called a laparoscope is inserted into the Female's abdomen below the navel to look for endometriosis, scarring, adhesions, and other pelvic disease and is used in place of a more invasive abdominal procedure. At times, the procedure is performed to look for the cause of pelvic pain or infertility, and is called a "diagnostic" laparoscopy. Once disease is identified, however, the surgeon should be capable of performing an "operative" laparoscopy, and actually treat the disease. Instruments such as laser can be useful in some cases to treat adhesions and endometriosis. The primary advantages of laparoscopy include rapid patient recovery and decreased cost attributed to the extremely small incision and the fact that the patient nearly always goes home the same day. Aside from the treatment of extremely large fibroids, most pelvic surgery can be performed laparoscopically.

Side effects of a laparoscopy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling discharge from the vagina or surgical site, she should consult her physician immediately.

The term multiple gestation refers to a pregnancy with more than one fetus. Higher order multiples is used to describe a pregnancy with three or more fetuses. Any multiple gestation pregnancy, whether spontaneous conceived or the result of infertility treatment, puts the mother at risk of pre-term labor, pregnancy-induced hypertension, and diabetes.

Pregnancies resulting from infertility care have a higher rate of multiple gestation pregnancies than through spontaneous conception. Early diagnosis is vital in order to provide appropriate care to the expectant mother, and explore all medical options, including fetal reduction, which is most often discussed in cases of higher order multiple gestations.

If seeking infertility care, the physician should work closely with the patient to discuss the risk of multiples associated with each treatment option. Closely monitoring patients receiving fertility drugs, and minimizing the number of embryos transferred in patients undergoing in vitro fertilization, may help reduce the chance of a multiple gestation pregnancy.

Myomectomy is a surgical intervention to remove uterine fibroids. If fibroids are small or are located within the cavity of the uterus (submucous), they can often be removed using a small fiber optic scope called a hysteroscope. In these cases, the procedure is a relatively quick outpatient procedure, and patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again 2 weeks after the procedure (with her next period).

If fibroids are larger or are located within the wall of the uterus (intramural), then removal is usually performed abdominal through a bikini incision in a procedure called an abdominal myomectomy. In these cases, the procedure may require 2 nights of hospitalization and recovery and two to three months prior to attempted conception.

As the female fetus develops, the uterus forms from the fusion of two identical structures called Müllerian ducts. Incomplete fusion or improper development of the endometrial cavity can result in an abnormally shaped uterus, which can lead to difficulty with reproduction. The various abnormalities have a wide-ranging spectrum; those that are clinically significant may contribute to menstrual disorders, endometriosis, infertility, miscarriages, and preterm labor. A classification system for the basic types of observed abnormalities exists, but the major types are:

• Uterine agenesis or uterine hypoplasia: Complete or partial failure in formation of one or both Mullerian ducts.
• Unicornuate uterus: Complete or partial failure in formation of one Mullerian duct, leading to the formation of a "hemi" uterus with a small cavity, sometimes associated with an obstructed hemi-uterus that is not connected to the cervix.
• Bicornuate uterus: Failure of the two ducts to fuse completely in the midline, leading to two separate, small uterine cavities with a single cervix.
• Septated uterus: The cavity is subdivided by a band of tissue; the septum can be small or, at its extreme, can divide the cavity into two distinct halves.
• Other uterine anomaly associated with Diethylstilbestrol-induced (DES) exposure: DES is a synthetic estrogen compound that was widely prescribed as a treatment for recurrent miscarriages from 1938-1971. Physicians ceased to prescribe DES when it was discovered that it damaged the reproductive systems of female fetuses, leading to Mullerian duct abnormalities. Mullerian duct abnormalities are typically characterized by a constricted or abnormally shaped uterine cavity.

Oocyte cryopreservation is a new and exciting experimental procedure that may help a woman preserve her reproductive potential. Women who may benefit from this procedure include

1) Those women who are at risk of becoming sterile due to chemotherapy, radiotherapy or removal of their ovaries;
2) Women who are choosing to delay reproduction, for personal or career reasons, while attempting to maintain their reproductive potential;
3) Women who have a family history of endometriosis, early menopause or premature ovarian failure

Oocyte cryopreservation involves the extraction of a woman’s unfertilized eggs from her uterus. The process is the same as stage I and II of an in vitro fertilization cycle whereby the patient takes injectable hormones to increase oocyte production in order to obtain a number of eggs during the retrieval phase [see also In Vitro Fertilization]. The retrieved oocytes are then slowly cooled to a freeze and stored at extremely low temperatures. When the woman becomes ready to attempt pregnancy, a fertility specialist team will thaw the stored oocytes, attempt to fertilize the eggs and transfer subsequent embryos.

More than 150,000 women in the United States are unable to conceive children because of ovarian problems. Many women do not produce eggs, or have had their ovaries removed, have had radiation therapy or chemotherapy for cancer that destroyed their ovarian function, or have dysfunctional ovaries, and are no longer producing high quality eggs. Other women have deferred pregnancy until their late thirties or forties. Since the ovaries age at such dramatically different rates in different women, while some conceive quickly, others are no longer able to conceive using their own eggs and require donated eggs to conceive. Egg donation is a treatment that involves receiving from an appropriate donor. The donated eggs are then fertilized using male partner sperm or donor sperm, and results in the embryos being then transferred into the female recipient’s uterus.

Egg donors are typically healthy women between ages 21 and 32 who have been thoroughly screened to ensure they are physically healthy and fully aware of the donation process. Egg donors take injectable hormones for eight to ten days to increase their egg production. The eggs are retrieved transvaginally, using an ultrasound to guide the procedure. The recipient of the donated eggs usually takes hormones to synchronize her cycle with the donor's cycle and to prepare her uterus to receive the embryos, and thus enhance the likelihood of implantation occurring. In some programs, more than half of women undergoing ovum donation conceive and deliver.

Pelvic pain is a common complaint. Its nature and intensity may fluctuate, and its cause is often obscure and in some cases no disease can be shown. Pelvic pain may originate from common sites such as the uterus, tubes, and ovaries, or in less common sites. At times, the pain may be psychogenic, or at least related to emotional states. To diagnosis the causes of, and prescribe treatment for pelvic pain, physicians conduct a thorough personal and medical history, with special attention to: type of discomfort, distribution and radiation of pain, duration of pain, associated symptoms, and relation to urination, bowel movements, and sexual intercourse. Particularly important is the relationship to the menstrual cycle. Pelvic pain may have multiple causes, including inflammation or direct irritation of nerves caused by adhesions or scar tissue. Appropriate management of pelvic pain ranges from conservative or medical management (including hormonal treatments and pain killers) to surgical management (often including laparoscopy). A thorough evaluation and directed treatment by a trained physician will relieve pain in over 80% of women.

Laparoscopy, hysteroscopy, laparotomy, and other surgeries used to evaluate and treat diseases of the female reproductive tract.

Certain diseases require surgery for correction. Often times, the treatment of abnormalities of the uterus, ovaries, and fallopian tubes can be performed safely as an outpatient or "same-day" surgical procedure. It is important that your physician have advanced training and extensive experience in performing laparoscopic and hysteroscopic surgery to make your surgery safe, convenient, and minimally invasive. Other pelvic surgeries such as myomectomies, laparoscopically assisted vaginal hysterectomies, and endometrial ablations also require significant surgical expertise.

Polycystic ovary syndrome (PCOS) is a condition in which the ovaries accumulate tiny benign cysts (little follicles two to five millimeters in diameter, each of which contains an egg). In a normal menstrual cycle, follicles continue to grow; eventually the largest, most mature follicle will release an egg. Ovulation is almost exclusively of a single egg in a natural cycle. In the case of PCOS, the follicles stop growing and release male hormones into the blood. Ovulation in women with PCOS can be rare without the help of medications. In some women, there will be a long history of irregular periods and, perhaps, an increase in facial and body hair caused by more than the normal amount of male hormone in the blood. There are estimates that about 20 percent of all women have mild polycystic ovaries (PCO). It is probably genetic - often coming down the male side of the family. When a woman is not trying to get pregnant, oral contraceptive pills are good treatments: they stop follicles and male-hormone-producing tissue from accumulating, stop complications such as abnormal hair growth from taking place, give regular periods, provide contraception, and protect future fertility.

Women with PCOS may require assistance in stimulating ovulation. See Treatment options for additional information on fertility medications.

Traditional methods used to identify genetic disease require prenatal diagnosis through chorionic villus sampling (CVS) or amniocentesis, followed by potential termination of the pregnancy if the fetus is found to be affected. Recent scientific advances now allow the diagnosis of some genetic disorders before pregnancy is established using a technique known as pre-implantation genetic diagnosis (PGD). PGD combines the technology of in-vitro fertilization (IVF) with new molecular biology techniques.

A single cell is removed from an eight cell embryo in a procedure called an "embryo biopsy." This single cell is sent to a lab that specializes in detecting genetic abnormalities. If the embryo is found not to contain the genetic disorder being tested for, the embryo may be considered for transfer.

It is important to speak to both a genetic counselor and the treating physician to fully understand the accuracy rate of PGD.

Prolactin is a hormone that can be overproduced by the brain, interfering with normal reproductive function.

Hyperprolactinemia

Prolactin is a hormone secreted by the pituitary gland (located at the base of the brain). Normally, prolactin is present in the blood stream in low levels in non-pregnant women. During pregnancy, prolactin levels increase approximately ten-fold and stimulate milk formation. Hyperprolactinemia is a condition where the brain secretes too much prolactin in a woman who is not pregnant. Hyperprolactinemia can produce a variety of reproductive dysfunctions including inadequate progesterone production during the luteal phase after ovulation, irregular ovulation and menstruation, absence of menstruation, and galactorrhea (breast milk production by a woman who is not nursing). Prolactin levels should be measured in women who experience these conditions. Hyperprolactinemia is a common problem found in up to one-third of patients with absence of menstruation and in up to 90 percent of women with galactorrhea.

Prolactin secretion may increase mildly with sleep, stress, intercourse, exercise, nipple stimulation, ingestion of certain foods and drugs, and pregnancy. If a woman's prolactin level is elevated the first time it is tested, a second sample should be checked when she is fasting and non-stressed. If the prolactin level continues to be markedly elevated, it is important to look for a cause.

Confirmed elevations of prolactin need to be evaluated. In some cases, magnetic resonance imaging (MRI) or computerized tomography (CT) of the brain will be performed to look for small tumors. Low thyroid hormone production is a common medical condition that can cause hyperprolactinemia. In approximately 30 percent of cases, the hyperprolactinemia is unexplained.

Observation and expectant management is appropriate for some of affected women, and medical management is highly successful in others. Parlodel® and Dostinex® are the two drugs commonly used to treat prolactin excess. They both work by suppressing prolactin production. Ovulation and menstruation generally return within six weeks of normalizing prolactin levels. However, galactorrhea, may take more time to resolve.

The side effects of these medications (including lightheadedness, nausea, and headache) usually resolve within the first month of use.

Miscarriage occurs in 15 to 25% of pregnancies, though losses may be so early that the female was not yet aware of the pregnancy. The rate of miscarriage risk increases markedly when a woman passes the age of 40, approaching 50% probability in some studies. Most miscarriages are due to chromosomal abnormalities, but other causes may be related to anatomic, hormonal, infectious, or immunological abnormalities. Spontaneous abortion is the technical name for miscarriage. Recurrent pregnancy loss is defined by the American Society for Reproductive Medicine (ASRM) as two or more failed pregnancies. ASRM recommends seeking medical evaluation for recurrent pregnancy loss after three or more losses, which impacts approximately 1% of all women who have been pregnant.

When evaluating recurrent pregnancy loss, the physician attempts to identify any abnormalities that may be causing the frequent losses. A direct cause is found less than half the time these evaluations are performed. Fortunately, couples with such unexplained recurrent miscarriage usually have a high chance of a successful subsequent pregnancy. If the woman does get treated for recurrent miscarriage and subsequently gets pregnant, it is difficult to know whether the treatment was responsible for the pregnancy's success. Unfortunately, few studies have been well done on this subject, and many of the suggested treatments are expensive and experimental.

Common tests performed for recurrent pregnancy loss include checking chromosomes of each partner (karyotypes), checking a woman's uterine anatomy (hysterosalpingogram), evaluating common hormonal problems (thyroid, prolactin, glucose), checking for infections (chlamydia and mycoplasma), and checking for common immunologic problems (antibody testing). Treatment can vary in complexity, ranging from taking a baby aspirin each day or undergoing an outpatient surgical procedure to remove a fibroid (hysteroscopic myomectomy) to undergoing complicated immunotherapy.

The testicular sperm aspiration/extraction (TESA) involves the direct removal of sperm from the testicles. Because comparatively few sperm are discovered during a TESA procedure compared to normal male ejaculate, it is required that IVF with ICSI be utilized in conjunction with the TESA procedure. TESA procedures are preformed either percutaneously or microscopically.

Percutaneous testicular sperm retrieval
When dealing with obstructive azoospermia (a blockage and normal sperm production is present), a simple percutaneous extraction of sperm is recommended. This procedure is performed under anesthesia (local or general) whereby a biopsy needle is utilized to extract a very small amount of testicular tissue. A laboratory expert will isolate sperm from the testicular tissue, which will be used in conjunction with ICSI during the IVF procedure. The wound is closed with a few small absorbable stitches.

Microscopic testicular sperm retrieval
In clinical scenarios in which the testes are not producing adequate amounts of sperm, also called non-obstructive azoospermia, microsurgical testicular sperm extraction is performed. Non-obstructive azoospermia may be the result of testicular atrophy, Y deletions, Kleinfelter’s cases, or post-chemotherapy/radiation. In this scenario, under general anesthesia, the TESA is performed using an operating microscope to search for testicular tubules that appear more developed and contain mature sperm. A microscopic TESA may take several hours. The tissue is removed and a laboratory expert will search the tissue for sperm which, if found, will be used in conjunction with ICSI during the IVF procedure.

A patient may return to normal activities 1-2 days after a percutaneous TESA procedure, and may resume intercourse within 1 week. A patient may return to normal activities 7 days after a microscopic TESA procedure, and may resume intercourse within 2 weeks.

Side effects of a TESA procedure may include hematoma, infection, and hydrocele.

Varicoceles describe a condition where the veins located in the scrotum surrounding the testes are dilated and enlarged. Approximately 15% of all men have varicoceles and, for most men, they do not seem to impair testicular function. However, about 40% of all men with infertility have varicoceles and it is generally believed that the presence of a varicocele impairs sperm production. Although the exact effect a varicocele has on sperm production is not known, it is suspected that an increase in testicular temperature may occur, which does not allow for sperm to mature properly. Most infertile men with varicoceles have improvement of semen quality after varicocele repair, and some infertile men with varicoceles are able to achieve a conception after varicocele repair. Varicoceles are found during a physical examination. Upon detection, the physician will also order a semen analyses to determine if the varicocele may be impacting sperm production and maturation. For varicoceles that are suspected to be interfering with fertility, surgical repair may be recommended. Surgical repair of a varicocele is done in an outpatient surgical center with general or local anesthesia. The surgeon will ligate, or tie off, the dilated veins during the procedure that lasts approximately one hour. Many urologists will perform this procedure using microscopic techniques, as the higher magnification allows for increased precision. Surgical intervention is successful in 90% of cases in that the dilation of veins is corrected and does not recur; approximately 60-80% of men have improved sperm count and motility after repair of the varicocele. About 40% of couples will subsequently initiate a pregnancy following a varicocele repair.

A patient may return to normal activities 2-3 days after a varicocele repair, including resumption of intercourse after 1 week of abstinence. Attempts to achieve a pregnancy can occur upon resumption of intercourse.

Side effects of a surgery for varicocele repair may include an infection, hydrocele, hematoma, or recurrence, though these side effects are diminished by the use of microsurgical techniques.

Microsurgical reconstruction of the male reproductive tract is often a successful treatment used when an obstruction exists in the vas deferens or to reverse a vasectomy. A vasovasotomy is the operation most frequently performed for a vasectomy reversal and involves connecting the severed ends of the vas deferens. However, if following a vasectomy an obstruction has occurred in the epididymis, a vasoepididymostomy must be performed which involves connecting the vas deferens to the section of the epididymis that contains mature and motile sperm. After vasectomy reversal, sperm return to the semen in about 70 to 95% of men and pregnancy without assisted reproductive technology occurs in 30-75% of couples.

The chance for pregnancy following reconstructive surgery depends on many factors, most importantly the age and fertility status of the female partner and the number of years between the vasectomy and its reversal. The longer the period of time between vasectomy and reversal, the lower the chances for successful reversal.

Microsurgical reconstruction is a two to four hour operation and can be performed as an out patient procedure. Successful microsurgical reconstruction may allow couples to have subsequent children without resorting to invasive and expensive IVF treatments. However, a physician will consider the age and medical history of both partners to determine the optimal treatments to achieve a pregnancy.

It is important to understand that after a successful microsurgical vasectomy reversal, the average interval until pregnancy is about one year.

A patient may return to normal activities 7 days after a microsurgical reconstruction, including resumption of intercourse after 4 weeks of abstinence. Attempts to achieve a pregnancy can occur upon resumption of intercourse.

Side effects of a surgery for microsurgical reconstruction may include swelling, hematoma, or infection at the surgical site

Vitrification is a specialized laboratory technique that is used to cryopreserve, or freeze, human eggs (oocytes) or embryos. This is a rapid freezing technique that prevents formation of water crystals during the freezing process. Water crystals are a major cause of cell damage during the cryopreservation process. Vitrification also minimizes chemical toxicity by exposing the eggs or embryos to the cryoprotectants for a much shorter duration than what has been known as a "slow freeze" technique. While more IVF clinics are moving towards use of vitrification, it is important to note that any eggs or embryos frozen using a slow freeze technique can continue to be stored and thawed for future use.