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.
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
Early warning signs of an ectopic pregnancy include abnormal bleeding and pelvic pain. An ultrasound will help confirm the diagnosis of an ectopic pregnancy.
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 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.
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.
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.
While an IUI can be very effective, some women may experience mild side effects. These include:
- Discomfort during the actual procedure
- Reaction to the medication(s) used to induce ovulation
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.
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.
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.
- 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.
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.
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.
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.
Women with PCOS may require assistance in stimulating ovulation. See Treatment options for additional information on fertility medications.
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 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.
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.
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.
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.
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
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Dr. Copperman explains in his interview that it is not necessarily the incidence of infertility in women that is increasing, but that it is more socially acceptable now to seek help for any medical condition, including infertility. He also explains how there are many successful paths available to couples today to help them build their families.See Video