The Center for Reproductive Health provides leading technologies to facilitate the success in fertility treatments for all patients. We provide many treatment programs that are tailored toward the individual patient.
We understand how important it is to have the right treatment for each specific patient's situation and that the patient feels comfortable with their treatment decision.
This journey is chosen by our patients, and we know how essential it is to provide the best possible care to prove that they made the right decision.
Infertility has most commonly been clinically defined as the failure to achieve a pregnancy during 1 year of regular, unprotected intercourse. Although this is a reasonable guideline, a woman approaching age 35 would be well served to initiate an infertility evaluation before waiting for a full 12 months. By the time infertile couples decide to seek assistance, most are anxious that they may never be able to have children. Therefore, they desire timely answers and swift action.
The initial goal of the Center for Reproductive Health is to provide an evaluation that is appropriate to the patient’s circumstances while being prompt, convenient, minimally invasive, fiscally responsible, and as comprehensive as possible.
To start, Dr. Vasquez and his staff perform a thorough initial history and physical examination, which are essential in finding the cause of infertility. The laboratory evaluation can also reveal abnormalities that can escape detection even by a careful history. Preliminary questioning about the patients’ concerns and suspicions regarding the etiology of their infertility is helpful because they sometimes have an intuitive sense about issues that may be contributing to their infertility, which may not otherwise be exposed during the course of a routine evaluation.
When trying to estimate a couples’ fertility potential, the normal functioning of all of the basic components of the reproductive system (patent tubes, normal ovulation etc.) is evaluated and assured. Some of the most important factors that help predict spontaneous fertility potential for a couple include the age of the female partner, the duration of infertility, the use of previous fertility interventions, and the proportion of sperm with normal motility, viability and morphology. A number of other variables also contribute significantly to a couples’ overall fecundity. Some notable examples include the body mass index of both partners and whether or not the female partner is a smoker.
The different categories of infertility causes traditionally have included: male factor, ovulatory dysfunction, tubal/pelvic-peritoneal factor, uterine factor, and unexplained infertility. A more recently recognized category that has become increasingly relevant as patients continue to wait longer to have children, has been termed “diminished ovarian reserve” (DOR).
Challenges of executing an optimum laboratory investigation for infertility include the need to rapidly, safely, and inexpensively comprehensively screen the critical reproductive components. These include estimating the quality and quantity of both sets of gametes, determining the condition and function of the reproductive anatomy, and assessing the state of the endocrine control system.
The basic initial infertility evaluation has become streamlined and simplified over the years. The routine testing that currently warrants consideration includes:
1. Evaluation of ovarian reserve.
2. Evaluation of ovulation
3. Evaluation of male factor (semen analysis)
4. Evaluation of the fallopian tubes and uterine cavity (HSG)
5. Transvaginal pelvic ultrasound
The term ovarian reserve is used to describe ovarian oocyte quantity and quality, both of which decline over time. The peak number of oocytes is found in females at 20 weeks of fetal life, and this number declines until menopause. The number of primordial follicles is approximately 500,000 at menarche; menopause occurs once that pool is nearly depleted. Fewer small antral ovarian follicles (less than 10 mm) are visualized by transvaginal ultrasound with advancing age. This is assumed to be due to a reduced pool of follicles available for ovulation. Several factors may accelerate follicle depletion including ovarian endometriomas, ovarian surgery such as cystectomy or extensive biopsy, genetic predisposition to early menopause, chemotherapy, radiation, and smoking.
With aging, there is an increase in chromosomal aneuploidy in oocytes, and a decrease in the total number of oocytes available for ovulation. Oocytes obtained from women of advanced age show an increased prevalence of meiotic spindle abnormalities which results in an increased risk of chromosomal misalignment and genetic aneuploidy due to nondisjunctional events during meiosis. The increased rate of chromosomal aneuploidy causes decreased reproductive efficiency as manifest by decreased pregnancy and increased miscarriage rates, both of which contribute to a decreased chance for live birth.
Ovarian Reserve Testing
Several factors have been evaluated as potential markers of ovarian reserve including follicle-stimulating hormone (FSH), inhibin B, estradiol (E2), and antimüllerian hormone (AMH). Additionally, ultrasound measurement of resting (antral) follicles has also been advocated as a reflection of ovarian reserve. Provocative tests also have been used including the gonadotropin-releasing hormone (GnRH) agonist test, clomiphene citrate challenge test (CCCT), and the exogenous FSH ovarian reserve test (EFORT). These tests assess the ability of a woman to respond to ovulation induction agents, but their utility in assessing the prognosis for conceiving is limited.
AMH is a member of the transforming growth factor ß family and is produced by the pre-granulosa cells of the primordial follicles. AMH levels decrease during the reproductive years and become undetectable at menopause. In theory, the AMH level may be a better marker of ovarian reserve as it represents the number of primordial follicles and has no intra-cycle variability. One significant advantage of AMH is that it does not require assessment in the early follicular phase as there is no variability throughout the menstrual cycle. Additionally, AMH levels may be assessed during treatment with hormonal contraception or during GnRH agonist therapy.
Antral Follicle Counts
Ultrasound has been used to predict ovarian reserve. Neither ovarian volume measurements nor vascular resistance have been correlated with ovarian responsiveness to gonadotropin stimulation. However, the antral follicle count (AFC)—unilocular intraovarian cystic areas measuring 2 to 9 mm— in the early follicular phase with transvaginal ultrasound is correlated with ovarian reserve and seems to be a better predictor of ovarian responsiveness to gonadotropin stimulation than basal FSH.
Designed to detect blockages in the fallopian tubes, a hysterosalpingogram (HSG) is a fertility testing technique that involves the injection of a special dye into the uterus through the cervical opening. The progression of the dye is then monitored via x-ray. If there are no blockages present, the dye will fill the uterus, move through the fallopian tubes and out into the abdominal cavity. If a blockage exists, the dye will stop, indicating both its presence and its location. A hysterosalpingogram can also be used to evaluate the size and shape of the uterus and detect such conditions as a bicornuate or septated uterus, both of which can cause recurrent miscarriage.
Semen Analysis/ Andrology
Semen Analysis is generally the first infertility testing procedure performed during a couple's fertility assessment because it is non-invasive and can tell us a great deal. The semen is collected by masturbation into a sterile specimen cup and sent immediately to our lab. There, the sample will be examined and several measurements will be taken. Among these are quantity of semen, concentration of sperm, sperm motility, and sperm morphology.
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