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Clomiphene Citrate, or "Clomid" is often referred to as the "fertility pill". It is used to treat infertile women who have an ovulation problem. It works by helping the pituitary gland (located at the base of the brain) improve the stimulation of developing follicles (eggs) in the ovaries. Clomiphene is most often prescribed to those patients who have been found to have an abnormality with their cycle, though combined with intrauterine insemination, it may be useful in the treatment of unexplained infertility.

Clomiphene is usually prescribed for five days each cycle, usually beginning on day three or five. Of all women treated with clomiphene 60% to 80% will ovulate normally. Nearly 10% of women treated with Clomiphene may experience side mild side effects, including hot flashes, blurred vision, nausea, bloating sensation, and headaches. Serious side effects are rarely seen with clomiphene therapy. The frequency of twins occurring in women who conceive while taking clomiphene has been reported to be as high as 10%. In addition, new studies suggest that long-term use of clomiphene for more than 12 cycles may place patients at an increased risk of developing ovarian cancer.

A number of studies have confirmed a significantly improved pregnancy rate with injectable medications that stimulate "superovulation". This improvement in pregnancy rate is due primarily to the increased number of eggs produced. "Fertility drugs," including Pergonal, Humegon, Metrodin, Gonal-F, and Follistim are administered beginning on the second or third cycle day and given for six to nine consecutive days. Response to these drugs is monitored by frequent vaginal ultrasounds and blood estrogen determinations. At a time in the cycle when the ovarian follicles reach a designated size, and estrogen levels are appropriate, an injection of the hormone HCG is given to trigger ovulation. Ovulation usually occurs 36-48 hours after the HCG injection. Thus, intercourse or insemination should be timed accordingly.

Performing intrauterine insemination may result in an increase in the number of sperm at the site of fertilization in the fallopian tube. Generally only 1 of 2000 sperm ejaculated into the vagina make can later be found in the fallopian tube. Therefore, adding insemination to stimulated cycles may further improve the pregnancy rate. A possible side effect of the injectable fertility drugs is ovarian hyperstimulation, a condition in which the ovaries are tender and enlarged. In severe cases, a woman may have swelling from retaining excessive amounts of body fluid in the tissues. Fortunately, severe hyperstimulation is rare, occurring in less than one percent of treatment cycles.

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Intrauterine Insemination is often an important part of treatment for couples that are infertile due to sperm disorders. IUI involves injecting sperm through a narrow catheter into the wife's reproductive tract. For most couples, artificial insemination is performed with the husband's sperm. Depending on the husband's sperm count and motility, the wife's cervical mucus quality at the fertile time of her cycle and the estimated time to egg release from the ovarian follicle, a well timed IUI can be very effective. In a laboratory, the sperm can be separated from the seminal fluid and resuspended 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 into the uterine cavity. Usually the insemination itself causes little if any discomfort.

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In vitro fertilization, or IVF, is a procedure that involves retrieving eggs and sperm from the bodies of the male and female partners and placing them together in a laboratory dish to enhance fertilization. Fertilized eggs are then transferred several days later into the female partner's uterus where implantation and embryo development will hopefully occur as in a normal pregnancy. IVF is performed by physicians who specialize in reproductive medicine and have received additional education and training in the evaluation and treatment of male and female infertility.

IVF was originally developed in the early 1970s to treat infertility caused by blocked or damaged fallopian tubes. By 1978, the first IVF baby, Louise Brown, was born in the United Kingdom. Since then, the number of IVF procedures performed each year has increased and the success rate has improved significantly. IVF involves several different treatment stages:

 

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At times, there are not enough normal sperm to fertilize the eggs retrieved during an IVF cycle. Over the past several years, embryologists have developed a technique to catch a single sperm and inject it directly into an egg. Indications for ICSI include men with extremely low concentrations of sperm (less than 6 million motile sperm), men whose sperm have failed to fertilize eggs in previous cycles of IVF, and men with complete absence of sperm (azoospermia) who need the sperm to be retrieved directly from the testicle and then injected into the egg. In a good program with a high quality laboratory, the success rate should not be reduced when ICSI is required.

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Embryo cryopreservation is a method used to preserve embryos by cooling and storing them at low temperatures. The benefit of embryo cryopreservation is that it permits the use of thawed embryos in an otherwise natural cycle, sparing the patient from undergoing ovulation induction, egg retrieval and the associated costs. Unfortunately, nearly 50% of all cryopreserved embryos do not survive the freezing and thawing process intact. There does not appear to be any increased risk of birth defects from cryopreserved embryos, and there does not appear to be a maximum length of time that the embryos can be stored.

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More than 150,000 women in the United States can't bear 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 uses the male partner's sperm to fertilize eggs donated by an anonymous female donor, and is followed by transfer of the fertilized egg into the female partner's uterus.

Egg donors are typically healthy women between ages 21 and 31 who have no known genetic or sexually transmitted diseases. They should be screened for genetic, hormonal, psychological, infectious, and physical diseases. Egg donors usually take injectable hormones for eight to ten days to increase their egg production. Donor 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. These hormones include estrogen which can be taken orally or administered in patches that attach to the skin and progesterone administered by injections. As in IVF, three embryos are normally transferred to increase the couple's chances of pregnancy. In a good program, more than 50% of ovum recipients should receive positive pregnancy tests on their first attempt.

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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. 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 (due to the extremely small incision) and decreased cost (since the patient nearly always goes home the same day). Aside from the treatment of extremely large fibroids, most pelvic surgery can be performed laparoscopically.

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If a uterine abnormality is suspected following the hysterosalpingogram, your doctor may recommend hysteroscopy. Hysteroscopy is performed with a thin telescope, called a hysteroscope, equipped with a fiber optic light. The hysteroscope is inserted through the cervix into the uterus and enables the doctor to see any uterine abnormalities or growths. Photographs or videotape may be taken for future reference. This procedure is usually performed in the early half of a woman's cycle so that the build-up of the endometrium does not obscure the doctor's view. This procedure is usually performed on an out-patient basis with moderate sedation being used. Full recovery of the patient occurs within days.

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Uterine fibroids are abnormal growths in the uterus and almost always are non-cancerous. Uterine fibroids are also one of the most common causes of infertility in women. 40% of hysterectomies are performed for the treatment of uterine fibroids. New microsurgical techniques have been developed to make myomectomy a choice for some women. Myomectomy is a surgery that removes the fibroid tumor and leaves the female organs intact. Reconstruction of the uterus is often part of the procedure. Specialists who perform myomectomies can discuss whether or not this is a procedure to resolve your problem and whether or not the procedure can be done on an outpatient basis. Medications are another option for treating fibroid tumors in some women. Prescription medications are available that can shrink the size of the fibroid and lessen heavy bleeding and pain. These medications can be used for a limited period of time and require careful monitoring by a physician.

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Preimplantation Genetic Diagnosis (PGD) is an advanced genetic technique which allows an individual embryo to be analyzed. PGD is a recommended procedure for patients who are carriers of a genetic anomaly or are affected by a genetic condition that drastically reduces the probability of passing the anomaly to their offspring. Additionally, some patients with advanced maternal age or a history of recurrent miscarriages use PGD to select embryos that do not possess chromosomal abnormalities.

The technique of PGD involves the removal and analysis of a limited number of cells from a developing embryo. The analysis of these cells may be performed by fluorescent in situ hybridization (FISH) or polymerase chain reaction (PCR), which allows a geneticist to provide information on the individual embryo's chromosomal make-up. PGD cases require extended embryo culture (see Blastocyst transfer and culture) to allow for enough time for genetic analysis to be performed. In consultation with the patient's physician and embryology laboratory, the decision of which embryo(s) and how many embryos to transfer will be made.

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