The first step toward understanding your fertility and its relationship with your body, is to closely review the material outlined in this handbook. The following chapters provide an overview for basic reproductive health. They will help you understand common terms used by your Personal Care Team, the staff members which are assigned to assist you. All key terms are referred to in the glossary.
Also, you may find it helpful to note any questions you wish to discuss with your team on the note pages provided at the end of each chapter.
Founded in 2004 by Dr. John Zhang, New Hope Fertility Center is located in Manhattan and specializes in low-dose and minimal-stimulation assisted reproduction techniques and fertility preservation. New Hope Fertility is the only U.S. fertility center focusing on Mini-IVF™, a gentler approach which combines with cutting-edge IVF technology to help patients achieve pregnancy with fewer drugs, reduced side effects and less stress compared to conventional IVF methods. New Hope Fertility also provides a full range of both male and female assisted reproduction services including fertility diagnosis, genetic testing, embryo and egg banking, donor and surrogate services, vitrification and reproductive repair surgeries and treatments. For a full list of services, please visit New Hope Fertility Center online.
Dr. John Zhang founded New Hope Fertility Center in 2004. As a visionary leader in the field of reproductive medicine, Dr. Zhang is proud to have pioneered gentler and more affordable fertility treatments options here in the United States. His Minimal Stimulation (Mini-IVF™), Natural Cycle, and Conventional IVF protocols, all customized to each individual patient, continue to help many couples realize their dreams of having a family. Read more about Dr. John Zhang.
Dr. Lyndon Chang has been with New Hope Fertility Center since 2006. As a quick study, he went through an accelerated program and graduated with his medical degree at the age of 23. He is passionate about the Minimal Stimulation protocols at New Hope Fertility and is happy to be working at a facility that has the state-of-the-art technology to make cutting edge procedures possible. Read more about Dr. Lyndon Chang.
Dr. Mingxue Yang has received extensive medical training both in China and in the US and has been recognized for his achievements with the National Faculty Award for Excellence in Resident Education 2006 by the Council on Resident Education in Obstetrics and Gynecology and an award for Special Excellence in Endoscopic Procedures by American Association of Gynecologic Laparoscopists. Read more about Dr. Mingxue Yang.
Dr. Samuel Wong has been with New Hope Fertility Center since 2010. He excelled as a student, graduating from Cornell University with Honors and Distinction and receiving the Berlex Best Resident Teaching Award and the Award for Excellence in Laparoscopic Surgery from New York University's School of Medicine. Read more about Dr. Samuel Wong.
Dr. Sherman Silber is a world leader in Male Infertility care specilalizing in IVF, sperm retrieval, ICSI (Intracytoplasmic Sperm Injection), vasectomy reversal, and tubal ligation reversal. He has authored several medical textbooks and is widely published for work in fertility and infertility and travels the world, sharing his skills and knowledge. Read more about Dr. Sherman Silber.
Dr. Alejandro Chavez-Badiola became Medical Director and Founder of New Hope Fertility Center Mexico in 2009. Inspired by Dr. Zhang's results with Mini-IVF™, Dr. Chavez-Badiola decided to take the opportunity to learn IVF™ from Dr. Zhang, and ever since, has been committed to performing natural cycle IVF and Mini-IVF™ for his own patients, which have achieved great results. Read more about Dr. Alejandro Chavez-Badiola.
Dr. Allison Rosen has been practicing clinical psychology for over 30 years, and specializes in helping people with the emotional hurdles that they face, particularly when they are struggling to overcome infertility. In addition to her practice with patients, she is at the forefront of research and hopes to help develop methods to preserve fertility and help cancer patients. Read more about Dr. Allison Rosen.
This chapter provides an introduction to reproductive health of the female and male anatomy, it also reviews many of the common causes of infertility. As you begin your treatment, this chapter will be a useful reference in understanding your body and your treatment protocol.
The female reproductive system is a complex system of several organs that produces egg cells and nourishes and protects the developing embryo. Using the diagram below as a guide, familiarize yourself with the main parts of the female reproductive system discussed below.
Figure 1.1 The Female Reproductive System
Figure 1.2 Structure of the egg: The monthly
"dominant follicle" ruptures releasing a single egg.
The menstrual cycle is a female body's monthly pattern of preparing for a possible pregnancy. The average menstrual cycle is 28 days, though some women may experience shorter or longer cycles. During one menstrual cycle one of the ovaries releases an egg and the uterus grows new endometrium. If the egg is not fertilized by sperm, the endometrium sheds from the uterus in form of a menstrual period through the cervix and vagina.
The different systems communicate by hormones – a group of different substances that carry the information from one cell to another. The hormonal system involves: release of hormones by the pituitary gland, the brain and the ovaries.
Use Figure 1.3 to guide you through the phases of the menstrual cycle discussed below.
Figure 1.3 The Menstrual Cycle
During this phase, the pituitary gland releases follicle stimulating hormone (FSH) which stimulates the growth and development of follicles in the ovaries. As the follicles mature estrogen levels will start to rise and this will have various effects. Ultimately, estrogen will limit itself by signaling the pituitary gland to inhibit FSH production and begin production of luteinizing hormone (LH). In addition to reducing FSH production, estrogen also causes the endometrium to thicken and later be ready of embryo implantation. The spike of LH will trigger the ovulation, which occurs mid-cycle.
As LH and FSH spike, the "dominant follicle" ruptures and releases a single egg known as an oocyte. The egg leaves behind the ruptured follicle that shortly thereafter gets filled with blood and forms another functional structure called corpus luteum. The corpus luteum secretes progesterone, which encourages the transformation of the endometrium in preparation for implantation. Meanwhile, the egg travels in one of the fallopian tubes toward the uterus. While in the fallopian tube, the egg may be fertilized by sperm, if sexual intercourse occurred and an adequate amount of sperm is available in the vagina. Once the egg is fertilized, it will continue moving toward the uterus in the form of an embryo and eventually attach to the endometrium.
The corpus luteum lasts only 12-14 days, unless it begins to receive human chorionic gonadotropin (hCG) from the implanted embryo, in which case it remains active for 10 weeks. If pregnancy does not occur, the corpus luteum breaks down, progesterone levels decrease, and the endometrium, which is no longer needed, is expelled through the cervix and vagina. The corpus luteum is replaced by a scar called the corpus albicans.
Pregnancy can occur only if the egg encounters sperm within 24 hours of ovulation. After ejaculation, sperm swim from the vagina up through the cervix into the uterus. From the uterus, they make their ascent into both of the fallopian tubes, propelled by their tails and by the contractions of the uterine walls. If ovulation has not occurred when they arrive at the fallopian tubes, they can survive up to three days waiting to encounter and fertilize an egg.
When egg and sperm interact, many sperm attempt to burrow through the outer membrane of the egg called the zona pellucida (see Figure 1.4). When the first sperm is successful, fertilization occurs. The sperm fuses with the egg, transferring its genetic material. The egg then becomes impenetrable to other sperm.
Figure 1.4 Fertilization: Sperm burrowing
through the zona pellucida.
The fertilized egg, now known as an embryo, travels to the uterus and cell division occurs over the course of four days. On day five, the embryo rearranges itself into a hollow ball of cells called a blastocyst. Pregnancy may occurs once the blastocyst or embryo has attached to the endometrium (see Figure 1.5).
Figure 1.5 Pregnancy: Embryo implantation.
The most common causes of female infertility include gynecological factors, hormonal dysregulation, sexually transmitted diseases, diet and lifestyle.
While the male reproductive system is also influenced by hormonal changes, it differs from the female reproductive system in many ways. Unlike women, men produce their sex cells, called sperm, throughout sexual maturity. Additionally, male reproductive organs are both internal and external. Using the diagram (Figure 1.6) as a guide, familiarize yourself with the main parts of the male reproductive system.
Figure 1.6 Male Reproductive System: The male reproductive
system is composed of both external and internal organs.
Figure 1.7 Structure of Sperm: The male
sex cell is produced throughout sexual maturity.
A number of factors can contribute to male infertility. These include conditions affecting sperm function, production and delivery, hormonal dysregulation, sexually transmitted diseases, general health and lifestyle factors.
Figure 1.8 Normal and abnormal sperm cells.
In the previous chapter, we reviewed the male and female anatomy and common causes of infertility. Currently, an array of advanced procedures and diagnostic tools are available to help correct even the most difficult infertility cases, preserve embryos for future transfer and determine the genetic health of embryos. The following sections will help you become familiar with many of these infertility treatments and procedures.
Over the course of your menstrual cycle, your core body temperature dips slightly. Your core body temperature is lower during the follicular phase compared to the luteal phase of your cycle, and a sustained shift in temperature (0.4 to 0.6 degrees Fahrenheit) indicates ovulation has occurred. Planning intercourse to sync with this sustained shift in body temperature (when you are most fertile) is called timed intercourse. This can be accomplished by charting your basal body temperature (BBT) which is taken at the same time each morning before getting out of bed.
Your expected ovulation may also be monitored in two to four office visits. These visits consist of hormone levels and sonograms. When ovulation is expected, you will be instructed on the ideal days to engage in sexual intercourse.
Intrauterine insemination (IUI), also known as artificial insemination, uses a catheter to place a number of washed sperm directly into the uterus. The purpose is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization. IUI is often selected by couples who have been trying to conceive for at least one year but who have no known reasons for their infertility. It may also be selected for conditions such as low sperm count, decreased sperm mobility, requirement of donor sperm, a hostile cervical condition (such as cervical mucus that is too thick), or sexual dysfunction. Although IUI still requires the sperm to reach and fertilize the egg on its own, it is important to make sure that the sperm is healthy and mobile. IUI provides the sperm an advantage by giving it a head start, but it still has to seek out the egg on its own.
For patients with tubal blockages or damage, ovarian failure, menopause and severe male factor infertility, IUI is not suitable.
The procedure involves stimulating ovulation with medication to encourage multiple egg development, and timing insemination to coincide with ovulation. Semen is collected for insemination after two to three days of abstinence from ejaculation and then "washed" in the laboratory (separating sperm from the naturally accompanying seminal plasma). Washed sperm is then placed into a very thin sterile flexible catheter, which is inserted through the women's cervix and then injected into the uterine cavity (see Figure 2.1).
Figure 2.1 Intrauterine Insemination: Washed
sperm is injected into the uterine cavity.
IVF is an assisted reproduction technique in which an egg fertilized outside of a woman's body is transferred into her body. Many IVF treatments involve administering fertility medications to a woman to mature more than one egg in each cycle. Immediately before ovulation, a doctor retrieves the eggs and unites them in the laboratory with sperm either from the patient's partner or a donor. The resulting embryo is then transferred to the woman's uterus for implantation. If successful, pregnancy is confirmed two weeks later with a pregnancy test.
Below is a brief overview of common IVF protocols and their distinguishing features.
Conventional IVF protocols are designed to produce a high quantity of eggs by treating patients with multiple daily injections and higher doses of medication as compared to Minimal Stimulation IVF and Natural Cycle IVF.
Mini-IVF™ stimulates the ovaries with minimal medication, uses a uniquely thin, flexible needle to retrieve the eggs resulting in briefer, less painful egg retrievals. Also, Mini-IVF™ uses a nasal spray trigger (Synarel) for ovulation induction instead of hCG (human chorionic gonadotropin) which has fewer side effects compared to conventional IVF.
Natural Cycle IVF is a drug and chemical-free protocol. It avoids fertility drugs that would otherwise stimulate your ovaries to produce multiple eggs. The underlying principal of this procedure is to capture the single egg your body naturally produces each month during your menstrual cycle.
If your egg or your partner's sperm is not viable for pregnancy, donor eggs and sperm offer an alternative route to having a baby. Donor Egg IVF cycles generally use conventional IVF treatments to maximize the number of eggs that the donor can provide each cycle. Most donor sperm is purchased from frozen sperm banks.
In cases where a surrogate carries your genetically matched child, gestational surrogacy, surrogate IVF is available to retrieve your eggs and fertilize them with sperm from your partner or a donor. The embryos are then implanted into your surrogate's uterus.
Vitrification is an innovative flash-freezing technique for oocytes, embryos and ovarian tissue. This fertility preservation procedure, which has a 98% survival rate, allows you to store surplus embryos created in one cycle for later use.
Numerous diseases and disorders classified as chromosomal disorders, single gene defects and sex-linked disorders can be tested for through a technique called pre-implantation genetic diagnosis (PGD).
PGD involves the removal and biopsy of several cells from the embryo when the embryo has reached the blastocyst stage. At the day 3 stage, when the embryo consists of just six to eight cells, a single cell is removed. Biopsies taken at the day 5 stage, when the embryo has about 100 cells, are more indicative. At the day 5 stage, your doctor will remove three or four cells from the trophectoderm, the part of the blastocyst that will become the placenta.
PGD is performed for all single gene defects where the specific mutation is identifiable. Analysis of the cells occurs by fluorescent in situ hybridization (FISH), a diagnostic method used to show the number and arrangement of chromosomes. PGD is an early screening technique and it does not entirely rule out the chance of a defect being present. For this reason, PGD should be followed up with first-trimester screenings.
As discussed in the previous chapter, infertility can result from a number of mechanical and structural problems with the reproductive system that surgery may be able to correct. Detailed below are some common procedures; a full listing of surgical treatments available at New Hope can be found in the Appendix.
This radiology procedure is used to examine the inside of the uterus and fallopian tubes and their surrounding environment. A dye is inserted in a thin tube through vagina and into the uterus. Images are taken using a fluoroscope as the dye passes through the uterus and fallopian tubes. The resulting images are used to find any injuries, blockages or anatomical abnormalities.
A hysteroscopy is a procedure used to look at the inside of the uterus. A camera called a hysteroscope is inserted through the vagina into the neck of the uterus and attached to a light source for visualization. This surgical technique allows doctors to view the internal structures of the uterus without the need for an abdominal incision.
A myomectomy is performed to remove uterine fibroids and reconstruct the uterus. Since the uterus is not removed in its entirety, this presents an alternative to a hysterectomy when suitable.
If you are unable to produce viable eggs, ovarian tissue transfer is one donor option you might consider. Tissue transfer involves removing the ovary of one woman, microsurgically dissecting the tissue, and subsequently transplanting it into another woman. It can be a preferable alternative to egg donation because ovarian tissue has potentially thousands of eggs, and the tissue continues to function as a normal healthy ovary in your body long after the transfer.
Testicular transplant is a novel technique for men who have suffered the loss of a testicle. This donor procedure may help restore reproductive capacity. The resulting sperm will have the genetic traits of the donor.
Intracytoplasmic sperm injection is a micromanipulation technique used in cases of male factor infertility where normal sperm quantity and motility is impaired. With ICSI, a single sperm is selected on the basis of its shape and size and then injected into the cytoplasm of a mature egg to achieve fertilization (see Figure 2.2).
Figure 2.2 Intracytoplasmic Sperm Injection: Sperm is
injected into cytoplasm of mature egg.
Testicular Biopsy may be helpful to determine the cause of male infertility. The procedure involves examining a tissue sample that contains seminiferous tubules that produce sperm under a microscope. The results may indicate correctable problems with the testis. If the testis is normal, there must be other sources for the infertility. During the procedure, the patient is under local anesthesia.
These two procedures are used to retrieve sperm directly from different areas of the testicle. Both procedures are performed under local anesthesia. The sperm can then be used in conjunction with IVF and Intracytoplasmic Sperm Injection (ICSI).
This method is used when infertility is caused by blockage. Using an operating microscope, reproductive specialists isolate the epididymis and then retrieve fluid from an epididymal tubule. The fluid obtained is then processed in the laboratory to ensure that sperm are present. Afterwards, the tubules are closed microsurgically. The sperm can then be used immediately or frozen for later use.
This method involves removing a small piece of testicular tissue through an incision in the testes. The tissue is then processed to extract sperm in the laboratory. As opposed to MESA, this process usually results in fewer specimens since they are more difficult to work with and do not freeze as well. TESE is only used in severe cases where it is the only method to deal with poor sperm.
The reasons for infertility are varied and sometimes complex, but can often be addressed with the help of an expert team. This chapter provides a step-by-step overview of your Mini-IVF™ treatment starting with the initial consultation. You may find the question and answer section at the end of this chapter helpful, as it reviews common patient questions.
During the initial consultation, you will meet with your personal care team to discuss your medical history, family goals and design a treatment plan tailored to your needs.
Your comprehensive fertility evaluation begins with a blood test to determine your FSH, estradiol, LH and progesterone levels, as well as a sonogram to determine your antral follicle count (AFC), which help dictate medication and treatment. You will receive routine sonograms to confirm follicular sizes and quantity. Subsequent blood tests and sonograms will aid in timing of the egg retrieval and establish a baseline for your endometrial lining thickness. This baseline will eventually become indicative of the likelihood an embryo will implant on the uterine wall. Sonogram and blood test results ultimately determine when you will begin your treatment cycle and which treatment you will benefit from the most.
Table 3.1 Procedural Overview
Mini-IVF™ stimulates your ovaries with minimal medications (an oral stimulant, such as Clomid, and an injectable combination of FSH and LH hormones) to produce only the best quality eggs your body can mature in one cycle (approximately one to three eggs). The mild nasal spray Synarel is used for ovulation induction, which has a short half-life in the body and does not have the side effect profile common to hCG. The major benefits of the Mini-IVF™ protocol are listed below.
Step 1: Ovarian Stimulation and Cycle Monitoring
On or near day three of your menstrual cycle, you will begin a daily course of an oral stimulant, such as Clomid, as needed, until your follicles have developed sufficiently for ovulation. Some injectable medication may also be necessary depending on your hormonal requirements. Routine sonograms and blood tests will monitor follicular growth progression and ovulation timing.
Figure 3.1 Follicular Growth Progression: Once follicles have
reached the desired size, ovulation will be triggered.
Step 2: Egg Retrieval
Prior to ovulation, once your follicles have reached the desired size and your hormone levels have risen, a trigger will be used to prompt final maturation, approximately 36 hours before egg retrieval. On the day of retrieval, a thin, flexible ultrasound-guided needle will be directed to the ovaries through the vaginal canal for egg collection. Since this protocol uses a small, flexible needle and produces only a few eggs, retrievals are relatively quick and simple. Note: You have the option of local anesthesia or IV sedation. However, most patients choose local anesthesia with an antianxielytic such as valium.
After retrieval you may experience spotting and abdominal tenderness. This is normal and should subside shortly after the procedure. Though the entire retrieval process will last approximately three to ten minutes, please allow a few hours for recovery. Note, on a case-by-case basis, if any of your eggs are not fully matured at the time of retrieval, they may be developed via in-vitro maturation (IVM).
Figure 3.2 Egg Retrieval: An ultrasound-guided needed
will be directed to the ovaries through the vaginal canal.
Step 3: Sperm Collection
Immediately following egg retrieval, sperm is collected from your male partner through ejaculation in preparation for fertilization. If your partner is unavailable the day of your retrieval, he may produce sperm at an earlier time and it will be frozen until needed. Sperm previously obtained from a TESE may be used at this time. Also, if you wish to use a sperm donor, your personal care team can guide you in the process of obtaining donor sperm prior to egg retrieval.
Step 4: Fertilization and Assisted Hatching
In most cases, the sperm is added to your mature egg(s) and fertilized via intracytoplasmic (ICSI) sperm injection. Once fertilized, cell division occurs in the zygote and may be transferred on the second day after fertilization. If the plan is to transfer an embryo into the uterus five days after fertilization, it must "hatch," or escape from the zona pellucida, before it can implant for pregnancy. Thus, all zygotes in our laboratory undergo laser-assisted hatching on the third day after fertilization to enhance implantation as an embryo.
Figure 3.3 Fertilization: Sperm and egg are fertilized.
Step 5: Culturing and Selection
Based on a patient's clinical history, embryos are cultured for up to five days prior to transfer. The culturing process aids in selecting the best quality embryos for transfer, ensuring the viability of the embryo to undergo implantation, gestation and live birth.
Step 6: Embryo Transfer
Embryo transfer only takes a few minutes and requires no incision or medication. In preparation, it is important that you maintain a regular schedule and avoid stress and strenuous exercise.
The embryos are placed in a small amount of fluid and injected gently into the uterus through the cervix with a long, thin catheter. The transfer feels similar to a pap smear and requires no anesthesia, though you may experience minor cramping following the transfer. Post-transfer, embryo implantation generally requires two to five days.
Since New Hope promotes a single-zygote/embryo transfer policy, you can choose to freeze surplus embryos using our vitrification freezing method to be placed in your personal embryo bank.
Figure 3.4 Embryo Transfer: Embryos are injected into the uterus.
Step 7: Confirmation
A pregnancy test performed seven to twelve days following transfer will confirm whether the embryo has successfully implanted. An ultrasound, typically performed three weeks after a positive pregnancy blood test, will confirm pregnancy.
While gentle protocols like Mini-IVF™ offer significantly lower risks and fewer side effects when compared to conventional IVF, any prescribed medications may have side effects and can pose a risk to your health. To best manage these risks, it helps to be informed. Please carefully review the potential risks and medication side effects below and discuss any questions or concerns with your personal care team.
Ovarian Hyper Stimulation Syndrome (OHSS)
Ovarian Hyper Stimulation Syndrome is the most common risk associated with conventional IVF, although very uncommon, it can also occur in minimal stimulation cycles. During ovarian stimulation, the maturation of a large number of follicles within the ovary can cause the ovary to swell. As the follicles grow, the eggs inside are surrounded by fluid. When many eggs are retrieved, fluid can accumulate in the abdomen or the chest, requiring hospitalization. Vomiting, diarrhea and shortness of breath are symptoms of severe OHSS, but discomfort and ovarian tenderness are also indicators. If you experience any of these symptoms, contact your doctor immediately.
Multiple embryo transfers can result in a high-order pregnancy and the health risks to the mother and child are significant. Additionally, the chances of premature delivery increase with higher-order multiples. We advocate single embryo transfer to eliminate the risk of multiple births.
If you experience any of the symptoms or side effects listed below, please contact your doctor immediately.
|Birth Control Pills
(drospirenone and ethinyl estradiol)
|Use:||Birth control pills are used for suppression of FSH and LH.|
|How it works:||Birth control pills suppress the production of FSH and LH, which preventing the formation of a follicle and release of an egg.|
|Side effects:||Headaches, nausea, bloating, spotting between periods and breast tenderness.|
|Use:||Clomid is used to stimulate the production of follicle stimulating hormone (FSH) and luteinizing hormone (LH), needed for ovulation induction and with continued use, premature ovulation suppression.|
|How it works:||Clomid causes the body to think estrogen levels are low, which results in the release of FSH and LH. These hormones ultimately stimulate production of follicles and the release of mature eggs. With extended use, Clomid acts to block the production of LH, which helps prevent premature ovulation.|
|Side effects:||Abdominal or pelvic discomfort, bloating, nausea, vomiting, breast tenderness, hot flashes, blurred vision, headache and irregular spotting. While Clomid is generally well tolerated, patients may experience mild side effects such as hot flashes, headaches, bloating and breast tenderness.|
|Use:||Estrace is a form of estrogen used to encourage growth of the uterine lining.|
|How it works:||Estrace mimics the effects of estrogen normally produced by the ovaries. It increases secretions from the cervix and promotes endometrial lining growth.|
|Side effects:||Nausea, vomiting, appetite loss, swollen breasts, acne or skin color changes, decreased sex drive or difficulty achieving orgasm, migraines, dizziness, chest pain, vaginal pain, dryness or discomfort, swelling of the ankles or feet, depression, changes in menstrual periods and irregular spotting.|
|Use:||Femara is used for the stimulation of follicles and ovulation induction.|
|How it works:||Femara blocks the production of estrogen, causing the release of FSH and LH.|
|Side effects:||Side effects: Hot flashes, headache, loss of appetite, weight gain, general body discomfort, weakness, fatigue, nausea and diarrhea.|
(ganirelix acetate/cetrorelix acetate)
|Use:||Ganirelix and Centrotide are forms of a protein used to reduce the amounts of certain hormones to suppress premature ovulation.|
|How it works:||Ganirelix and Cetrotide are injectable gonadotropin-releasing hormone (GnRH) antagonists that suppress the production and activity of LH and FSH. The amount of estrogen present is reduced.|
|Side effects:||Headache, nausea, pain, redness, irritation and itching at injection site, abdominal swelling, pain or cramping.|
(human chorionic gonadotropin)
|Use:||An hCG injection is used to induce ovulation.|
|How it works:||hCG mimics the action of the LH surge and triggers ovulation approximately 36-48 hours after its initial use. Egg retrievals can be timed as close to ovulation as possible to increase the chance of retrieving a mature egg.|
|Side effects:||Headache, hot flashes, mood swings, muscle pain, nasal irritation and runny nose.|
|Use:||This drug reduces inflammation to make follicles less sensible to rupture.|
|How it works:||As a nonsteroidal anti-inflammatory drug, ibuprofen reduces hormones that cause inflammation and pain in the body. As the follicle is less inflamed, it is less likely to rupture prematurely.|
|Side effects:||Heartburn, diarrhea, constipation, bloating, gas, dizziness, drowsiness, rash and headache.|
|Menopur and Repronex
|Use:||Menopur and Repronex are an equal mixture of the naturally occurring follicle-stimulating hormone (FSH) and luteinizing hormone (LH) in the form of a subcutaneous injectable. They are more commonly used in women with a low FSH baseline.|
|How it works:||Menopur and Repronex are a combination of FSH and LH hormones that stimulate ovaries to produce follicles.|
|Side effects:||Abdominal pain, back pain, breast enlargement, chills, nausea, dizziness, fever, flu-like symptoms, flushing, general body discomfort, headache, menstrual changes, muscle or joint pain and pain or rash at the injection site.|
|Use:||Synarel is a nasal spray used to induce ovulation and cause final follicular maturation.|
|How it works:||Synarel causes an LH surge, which triggers ovulation approximately 36-48 hours after its initial use. Egg retrievals can be timed as close to ovulation as possible to increase the chance of retrieving a mature egg.|
|Side effects:||Headache, hot flashes, mood swings, muscle pain, nasal irritation and runny nose.|
Below is a list of frequently asked questions. If the following answers do not fully address your questions or concerns, please do not hesitate to contact a member of your personal care team.
Why do some fertility treatments begin with birth control pills?
Birth control pills do not affect a woman's ability to become pregnant once she has discontinued their use. Rather, the medication regulates a woman's cycle to synchronize follicle development prior to ovarian stimulation.
Is there an age limit for Mini IVF™?
We do not have an age limit for pre-menopausal women.
If I decide to use a surrogate, are there special considerations?
There are complex legal issues associated with surrogacy that should be first discussed with an attorney who specializes in surrogacy prior to making decisions on treatment.
What percentage of patients choose Mini-IVF™?
Ninety-five percent of our patients choose this protocol.
Who is a candidate for Mini-IVF™?
Mini-IVF™ is suitable for all pre-menopausal women even if they have responded poorly to previous conventional IVF attempts.
Can stress or changes to my normal routine affect the treatment process?
Yes. It is necessary to reduce stress and changes to your daily routine during the entire treatment process.
Why does Mini-IVF™ require fewer hormones?
Exposure to high doses of hormones can mature a large quantity of eggs at the expense of egg quality. Lower hormone dosages help the body produce only the best quality eggs a woman can mature in one cycle to produce a healthy baby.
How long will I take medications before egg retrieval?
Most women take medication for nine to 13 days.
Will all my retrieved eggs be transferred?
The number of eggs retrieved is not necessarily the number of embryos viable for transfer.
What is Comparative Genomic Hybridization (CGH)?
CGH is used to detect genetic abnormalities in eggs and embryos. Specifically, CGH is used to analyze the copy number changes in DNA to identify abnormal regions in the genome.
Does New Hope perform multiple embryo transfers?
At New Hope, we promote single-embryo transfers to reduce the risks associated with multiple births. Surplus embryos can be frozen using our vitrification method and stored in your personal embryo bank for later use.
Clomid has been used since the 1980s. Are newer and more efficacious drugs available in place of Clomid?
Clomid remains the most prescribed fertility drug worldwide and is considered the first line in infertility treatment medication.
Are Clomid success rates better today compared to when it was first introduced?
Clomid success rates have improved markedly due to technical advances in the field of assisted reproduction.
How often can I take a course of Clomid?
We generally allow patients to use Clomid for five to ten cycles.
Can women over 35 use Clomid or is more aggressive hormone therapy required?
Women over 35 do very well with natural and low stimulation cycles using Clomid. These women generally produce higher FSH in response to Clomid because they have a smaller ovarian reserve than younger women and therefore do not usually require the FSH injections used in conventional therapy.
Why does Mini-IVF™ use Synarel instead of HCG?
HCG has a long half-life, causing the stimulation of immature follicles which can lead to cyst formation in subsequent treatment cycles. Synarel, alternatively, is strong enough to induce ovulation of larger follicles, but has a very short half-life. This preserves smaller follicles for future cycles, rather than stimulating them prematurely. As a result, the chances of healthy egg production are increased and women can cycle continuously. Synarel is especially advantageous for older patients with a limited ovarian reserve.
How do you know I will not ovulate prior to retrieval?
During your menstrual cycle, an estrogen sensor activates the hypothalamus to trigger an LH surge, which induces final maturation when the lead follicle reaches its optimal size. Clomid causes the body to think estrogen levels are low, which results in the release of FSH and LH. These hormones ultimately stimulate follicular production and the release of mature eggs. Over time, though, Clomid acts to block the production of LH, which helps reduce the chances of premature ovulation.
Why is injectable FSH recommended for some women undergoing Mini-IVF™?
Often, patients with a very low baseline FSH cannot produce enough of the hormone with Clomid and require additional FSH to aid follicular development.
Do fertility drugs cause cysts?
Sometimes an immature follicle can evolve into a cyst in the following cycle. In particular, HCG injections can facilitate cyst formation. The presence of a cyst does not necessarily mean you cannot begin another cycle. We minimize the risk of cyst formation by using Synarel as a trigger instead of HCG.
What happens if I do not become pregnant?
If your treatment is not successful, your personal care team will meet with you to discuss your options.
Preparing for your fertility treatment can be stressful, both emotionally and financially. This chapter serves as a place to find answers to all those last minute questions concerning your fertility treatment plan.
Your Personal Care Team at New Hope will work with you and your oncology team to coordinate care and design a tailored treatment plan. Many of the fertility treatments outlined in this handbook are available to patients who are survivors of various types of cancer or are looking to preserve their fertility prior to undergoing cancer treatment.
New Hope offers gentle stimulation techniques to aid in fertility preservation through oocyte or embryo cryopreservation. From the start of stimulation to banking, the process usually lasts three to four weeks and facilitates a speedy return to all other necessary treatments. A combination of Femara or Tamoxifen with gonadotropin injections has proven safe and effective in such protocols (drug information below).
We require the approval of your treating oncologist and ask that you provide all medical records pertaining to your cancer treatment including surgical and biopsy reports, as well as pathology reports and any tumor marker tests.
|Use:||An aromatase inhibitor used in the treatment of breast cancer. One of the effects of inhibiting aromatase is the stimulation of hormones which then induce oocyte development.|
|How it works:||Femara blocks the production of estrogen, therefore the body receives fewer growth signals and cancer growth can be slowed or stopped. Decreased estrogen levels also cause the release of FSH and LH which stimulates follicular development and ovulation.|
|Side effects:||Hot flashes, headache, loss of appetite, weight gain, general body discomfort, weakness, fatigue, nausea and diarrhea.|
|Use:||Tamoxifen is used in the treatment of breast cancer to delay recurrence. By blocking hormones which may stimulate cancer recurrence, hormones that stimulate the ovaries are produced.|
|How it works:||Tamoxifen blocks the actions of estrogen causing the release of FSH and LH. FSH and LH stimulate follicular development and ovulation.|
|Side effects:||Bone pain, constipation, decreased sex drive or difficulty achieving orgasm, headache, redness or skin changes, coughing, hot flashes, muscle pain, nausea, fatigue, vaginal discharge and weight loss.|
As an out-of-town patient, below are some important factors to consider prior to starting treatment.
The provided IVF Checklist for Pre-Screening Testing lists all infectious disease and genetic screening tests that must be completed prior to starting an IVF cycle. If any of the required medical testing is performed outside of our facility, please fax us all medical records and test results. All infectious disease tests must be completed within one year from the date you start your IVF cycle at New Hope. If pre-screening tests were completed more than one year ago, they are invalid and will need to be re-administered before your IVF cycle can begin. Genetic screening tests are accepted regardless of the date performed. IVF screening test results will determine the candidacy of you and your partner.
All consent forms must be read prior to your visit to New Hope and are available online for your review at www.newhopefertility.com, by clicking "New Patient." On the day of your appointment at New Hope, a nurse will assist you in completing all consent forms and witness you and your partner's signature(s).
You must contact our Financial Department prior to the start of your IVF cycle. Financial Coordinators are available Monday through Friday between 9 a.m. and 5 p.m. EST.
If you are on the first day of your period or are to schedule a monitoring visit, please call and inform our clinical staff that you are an out of town monitoring patient and need orders for your local clinic. Physician orders for the first monitoring visit will then be sent to your local clinic. This ensures all correct testing is performed and that results will be sent directly to our clinic. It is also necessary to find a local clinic or hospital that can perform "same day" results on hormone levels so you can receive detailed instructions immediately following the review of results for each monitoring visit. Finally, please be mindful of coordinating office hours and whether weekend monitoring is possible when choosing a local clinic.
Please be sure to call our office by 3 p.m. EST each monitoring day if you have not received a call from your Personal Care Team with instructions. This may mean that we have not received the day's results and will need to follow up with your clinic. Also, please inform our clinical staff of your preferred pharmacy, their contact information and business hours.
On the day of your egg retrieval, if your plan is to fertilize the oocytes retrieved, a semen specimen must be available. If the sperm is fresh, your spouse/partner will be asked to produce a semen specimen. If the sperm is frozen, whether from a spouse/partner or donor, it must be at New Hope prior to the egg retrieval.
If you have any questions regarding semen analysis, semen collection or sperm freezing/storage or transporting frozen sperm vials, please call and speak with someone in our Andrology Laboratory prior to starting your IVF cycle.
As you approach the date of your egg retrieval, we recommend that you and your spouse/partner begin preparations for the trip to our office in New York. Your Personal Care team will help you coordinate scheduling to ensure you arrive to New York on time.
As part of your Personal Care Team, a Financial Coordinator is available to discuss all concerns about financing your treatment. However, since each person receives an individualized treatment plan, you will receive your plan and pricing information during the initial consultation. If applicable, prior to your initial consultation, we will contact your insurance provider to get a comprehensive understanding of your fertility coverage and when necessary, obtain all required pre-authorizations and file all in-network claims paperwork on your behalf.
During the initial consultation, your Financial Coordinator will also schedule payment for all fees not covered by your insurance, co-pays, out of network charges and deductibles. All fees must be paid in full prior to starting your treatment course. We accept cash, money orders and most major credit cards.
Medical information published for New Hope Fertility Center is strictly for informational purposes and does not replace or preclude medical advice provided by licensed health care professionals. While special consideration has been made to ensure correctness, currency and completeness, errors are possible and the medical field is dynamic. The reader assumes full and sole responsibility for any action taken based on information provided in this handbook. All information should be carefully reviewed with your health care provider and as such, New Hope Fertility Center is not liable for any explicit, implicit, exceptional or otherwise harmful incidence.
This handbook and all components and elements thereof cannot be reproduced, duplicated, distributed, or modified in any form without New Hope Fertility Center's explicit written permission.
At New Hope, we are committed to providing our patients expert care in a professional and comforting environment. If you have any comments or concerns, please do not hesitate to contact us.
784 Park Avenue, New York, New York 10021
4 Columbus Circle, New York, New York 10019
Tel 212.517.7676 Fax 212.396.0600