INFERTILITY

Education, counseling and communication are the cornerstones of our Fertility Care Program philosophy at Bedford Commons OB-GYN, P.A. With these tools, we believe our patients are able to make well-informed decisions. This booklet has been prepared by our Practice to provide you with specific information regarding the various fertility tests and treatment options that may be recommended by our Fertility Care Team.

Your evaluation will begin with an interview by a fertility care provider. She will obtain a medical history from you and your partner to assist the physician in selecting the most comprehensive program that is appropriate for you. Once you have completed the initial evaluation, you will be scheduled to meet with a physician. The physician will review the information, perform a physical examination, if necessary, and discuss a plan for further testing and treatment to meet your specific needs.

Our Fertility Care Team is available to provide specific education and to assist in scheduling recommended tests and treatments. They can provide more in-depth education for you and answer any questions that may arise during this process. You will also receive training for prescribed injectable medications if they are recommended.

PRE-APPOINTMENT FORMS

Please print the two forms and complete them before your first Fertility Program appointment. Bring the forms to this first appointment.

Fertility-Female Medical History
Fertility-Male Medical History
Genetic History Questionnaire

FERTILITY EVALUATION

Laboratory Testing
Blood tests that detect hormones secreted from the pituitary gland, the ovary, and the adrenal gland are sometimes recommended in the course of an infertility evaluation. Some of these tests are performed on a specific day of your menstrual cycle. This will be reviewed with you when testing is advised.

Semen Analysis
A semen analysis is used to examine the quantity and quality of the sperm in a given sample from the male partner. The semen analysis should be preceded by at least two days of abstinence. For the best results, the semen specimen should be freshly collected by masturbation into a sterile container and delivered to the designated laboratory within one hour from the time of collection. During transportation, the specimen should be kept at body temperature (i.e., tucked inside a shirt during cold weather). The specimen should not be refrigerated or heated. You will be given specific laboratory instructions when this test is ordered. It should be noted that medications, viral illnesses, drugs and temperature extremes might alter the results of a semen analysis. If an abnormal result is encountered, it is common to request a second analysis to confirm the findings.

Hysterosalpingogram (HSG)
The hysterosalpingogram is a useful test to assess the structure and patency (degree of openness) of the cervical canal, uterine cavity and both fallopian tubes. The gynecologist with a radiology technician present performs the test in a hospital setting. The HSG involves the passage of an iodine-containing dye through the cervix, uterus and tubes. This is monitored by a continuous x-ray called fluoroscopy. Generally, the HSG is performed during the first half of the menstrual cycle, after the period has stopped but before the anticipated time of ovulation. Approximately one hour prior to the test, 600 mg. of ibuprofen (Motrin) or 220 mg. of naproxen (Aleve) should be taken to alleviate mild or moderate cramping that may be experienced during the test. If you have had a problem in the past with tubal infection (such as pelvic inflammatory disease), your doctor may also recommend the use of antibiotics for the HSG test. While the HSG is generally well tolerated by most patients, cramping may be experienced after the test. It is recommended that you report a temperature above 100.4, chills, heavy vaginal bleeding or prolonged, severe pelvic cramping following the HSG to your physician.

Ultrasound
Your physician may schedule an ultrasound in the course of your infertility investigation and management. The ultrasound exam is an office procedure that uses high frequency sound waves (not radiation) to view your reproductive organs during various times of your menstrual cycle. The ultrasound is routinely used to observe the ovarian follicle (egg) formation, growth, and ovulation in both spontaneous cycles and cycles induced by fertility medications. In most instances, a transvaginal ultrasound is performed by placing the probe into the vagina to obtain the best view of these structures. Occasionally, a specialized ultrasound procedure called a sonohysterogram is recommended. This test is performed by placing a small catheter into the uterine cavity to infuse a small amount of water while utilizing transvaginal ultrasonography to visualize the contour of the uterine cavity.

Laparoscopy
Laparoscopy is an outpatient (same day) surgical procedure that is performed in a hospital or surgical center. This procedure is recommended if the reason for the infertility is not identified by the standard evaluation, or if a woman has not conceived after a short course of fertility medication. Laparoscopy can be helpful in identifying the presence of endometriosis or adhesions (scarring) in the pelvis, and to assess the patency (openness) of the fallopian tubes. The procedure takes approximately one hour and is performed under general anesthesia. The abdomen is inflated through a small needle with carbon dioxide gas. A thin laparoscope is inserted through a small incision in the umbilicus (navel). Using a fiber optic light source, pelvic organs are easily visualized. Pictures are sometimes obtained for review after the procedure. You will be able to go home within a few hours and only require a few days to fully recover from the procedure. A post-operative appointment is scheduled approximately one week after the procedure to review the findings, answer questions, and to plan appropriate management with the new information.

Hysteroscopy
Hysteroscopy is an outpatient surgical procedure that is performed in a hospital setting. A thin hysteroscope utilizing a fiberoptic light source is inserted into the uterine cavity through the cervix. This procedure is recommended if other testing or history has suggested the presence of an endometrial polyp, submucous myoma (fibroid), uterine septum or blocked fallopian tubes. Many times during such a procedure, special instruments can be threaded through the hysteroscope to treat these problems. You will be able to return home the same day as the procedure and may experience some mild cramping and bleeding after the procedure. In most cases, you can return to normal activities the next day.

Ovulation Predictor Kit – (OPK)
The use of an ovulation predictor kit is sometimes recommended as it detects the monthly surge of Luteinizing Hormone (LH). This hormone is produced by the pituitary gland in the brain and signals the ovary to release an egg (ovulation). On average, the LH surge (positive test result) precedes ovulation by 24 to 36 hours. Your kit will come with instructions on what day to begin testing for the LH surge. The LH surge will indicate that you are about to ovulate and will optimize the timing for intercourse. It is sometimes used for the timing of post-coital tests and artificial insemination. Ovulation predictor kits can be purchased at your local pharmacy. It is very important to follow the kit’s instructions closely.

Postcoital Test
The Postcoital test is performed just prior to ovulation and approximately 3-12 hours after intercourse. Your provider obtains a sample of the cervical mucous during a pelvic exam. The cervical mucous is placed on a slide and analyzed for sperm activity. This test is infrequently performed in the routine evaluation for infertility, but there may be circumstances when the provider will recommend this test.

FERTILITY TREATMENT

Fertility Medications

Clomiphene Citrate (Clomid or Serophene)

Clomiphene Citrate is an oral medication that is commonly prescribed for women to induce ovulation in a timely fashion. Clomiphene therapy is generally initiated between Cycle Day 3 and 5 and is continued for a total of 5 days. Cycle Day 1 is defined as the first day that vaginal bleeding occurs. The initial dose of Clomiphene is usually 50mg. Depending on the patient’s response, the Clomiphene dose may be increased by 50 mg. increments up to a maximum dose of 250 mg. Ovulation typically occurs 5 to 10 days after the last dose. If a pregnancy has not occurred within 3-6 ovulatory cycles of Clomiphene therapy, an alternative form of therapy may be considered. Generally, Clomiphene is well tolerated with minimal discomfort and less than 10% of patients experience side effects. The most common side effects are hot flushes, abdominal bloating or pain, nausea or vomiting, breast discomfort, or visual disturbance. Multiple pregnancies occur in approximately 8% of women who conceive while taking Clomiphene, with triplets occurring 0.5% of the time.

Injectable Fertility Medications (Gonadotropins)

The development and release of an egg from the ovary is controlled by two hormones, Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). Gonadotropins act directly on the ovaries to stimulate follicular development. These medications cannot be taken orally because these proteins would be digested and inactivated in the stomach; therefore, they must be administered by injection.

If you have been advised to start a cycle with these injectable medications, you should contact our staff on the first day of your menses for further instructions. The cycle is carefully monitored with ultrasound exams and estrogen blood tests to check the status of follicle development in the ovaries so that medication doses can be adjusted daily by your physician. Usually, the medication is started on Cycle Day 3 to 5 and is generally given in the evening on a daily basis for a period of 7-12 days.

The most frequent side effects are ovarian over stimulation (hyperstimulation) and multiple pregnancies. Mild ovarian hyperstimulation is common and involves a brief period of lower abdominal discomfort. More severe hyperstimulation is infrequent (less than 2%) and may involve more severe abdominal pain, fluid retention, nausea and vomiting. The overall risk of multiple pregnancies is estimated to be 10-30% with the majority of these being twin pregnancies. With careful monitoring, the risk of these side effects is significantly reduced. Studies show that approximately 75% of women who take these medications will ovulate. It is estimated that 20-42% of patients receiving injectable fertility medications will conceive as long as their fallopian tubes are open and the sperm counts are adequate.

Human Chorionic Gonadotropin (HCG)

Human Chorionic Gonadotropin (HCG) is used to trigger ovulation of the dominant ovarian follicles in conjunction with Clomiphene or injectable fertility medications (gonadotropins). It is administered as a subcutaneous injection. Possible side effects from HCG include headache, irritability, restlessness, depression and fatigue.

Procedures

Intrauterine Insemination (IUI)

This procedure is frequently recommended in the setting of decreased sperm count or motility, or when fertility medications are being used. There are several chemical reactions that naturally occur in the vagina and cervix before semen can pass through the uterus on the way to the fallopian tubes. IUI is performed at the time of ovulation. In order to place sperm directly into the uterus, the semen sample is specially prepared in the office shortly before the procedure. With a specialized catheter, the specimen is placed through the cervix and deposited inside the uterus. The procedure is sometimes accompanied by mild cramping. We usually recommend that the patient remain lying down for about 15 minutes following the procedure.

In-Vitro Fertilization (IVF)

In-Vitro Fertilization is a procedure that is performed by specialists in the field of reproductive endocrinology and involves uniting the egg and sperm outside the body in a special laboratory. The fertilized egg is then placed inside the uterus to continue its development. Your physician may advise referral to a reproductive endocrinologist for IVF during the course of your evaluation and treatment. Bedford Commons OB-GYN has professional relationships with several reproductive endocrinologists at state-of-the-art facilities in Boston and Dartmouth Medical Center. Frequently, these consultants can co-manage your recommended therapy with Bedford Commons OB-GYN physicians, and for your convenience, several tests can be performed on site at our office.

LOOKING AHEAD

As you embark on this approach to your evaluation, we encourage you to maintain a close, open relationship with our Fertility Care Team. We want to assist you in understanding the science of fertility, as well as support you in coping with the emotions that frequently surface surrounding these issues. In this way, we can most effectively and accurately discover what is interfering with your fertility, and enhance your chances for a successful pregnancy while maintaining your general feeling of good health.

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