Infertility Programs at Infertility Solutions in Allentown, Scranton, Pennsylvania

Selected Infertility Programs

IUI
Superovulation
Cryo-Preservation Program
Assisted Hatching
Donor sperm insemination. (TDI)
Shared Egg Donor Program
PGD

IUI

Intrauterine insemination, or IUI, is the process in which sperm are directly placed in the uterus in an attempt to achieve pregnancy. In the normal situation a women's cervix is a barrier to entry by sperm. It estimated that with an excellent specimen in which a half billion sperm are deposited in the vagina, only about 1 million will get into the cervix, only 100,000 will enter the uterus at any one time, only 1000 will enter the tubes and perhaps 200 sperm will actually find the egg. [ additional information ]

The problem of achieving pregnancy from the viewpoint of sperm is both a qualitative and a quantitative problem. When sperm quality is diminished an even smaller number of sperm are likely to enter the uterus.

Our objective in utilizing intrauterine insemination is usually to place at least 10 million motile sperm into the uterine cavity. Prior to placing the sperm into the uterine cavity it must first be separated from the semen. Directly placing semen instead of just the sperm inside the uterus would likely cause pain and could make the patient ill. There are a number of methods used by laboratories to separate sperm from semen. Depending upon a particular individuals specimen some methods are likely to work better in terms of achieving pregnancy than others. The Male Fertility Assessment Laboratory utilizes a number of different methods that it can individualize to a man's sperm. In Infertility Solutions, we feel that intrauterine insemination is most effective when ovulation is being actively managed. Our approach is to perform the intrauterine insemination on the morning in which we cause ovulation to occur.

Intrauterine insemination is indicated for mild to moderate male factor infertility. If the sperm are sufficiently poor that a reasonable number of likely functional sperm cannot be obtained from the ejaculate, we believe that intrauterine insemination is a waste of time. Although pregnancies have been reported with this technology with very poor sperm it is possible that the occurrence of these pregnancies is as likely due to chance as to the application of this technology.

Another well established indication for intrauterine insemination is when the couple has an abnormal well timed post coital test. To compensate for an abnormal post coital test we feel that intrauterine insemination is the most cost and time efficient technology.

Intrauterine insemination can also (at least theoretically) enhance the pregnancy rate per cycle in patients with normal sperm and endometriosis. One of the best accepted theroies as to why endometriosis causes infertility is due to endometriosis causing increased macrophage activity in the abdomen. The macrophages destroy the sperm which enter the abdomen before the sperm can fertilize an egg. With more sperm in the abdomen, there is a higher probability that some sperm will reach the egg.

Over the years our pregnancy rate with this therapy for male factor with patients selected as described above has varied between 12% and 25% percent per cycle depending on whether or not gonadotropins were used. (Note that the pregnancy rate is the delivery rate together with the miscarriage rate. The miscarriage rate is about 15% of clinical pregnancies.)

Superovulation

A very important tool in infertility is the use of gonadotropins. These drugs include Pergonal, Metrodin, Fertinex, Follistim, Gonal F, Humagon and Repronex. This class of medications can be used in a number of ways with and without other medications. Our objective in using these drugs is either to improve egg quality and/or increase the availability of the number of eggs to be produced. Although we use these drugs in several ways, our therapies are always individualized to a patient's response.

One of our primary approaches is a low dose medication approach. We believe that this works primarily because it improves egg quality and corrects minor degrees of ovarian dysfunction. My initial experience utilizing this method was published several years ago.
[ bibliographical reference ]

The other common method we utilize is a more aggressive ovulation where we generally try to maximize egg number and utilize a combination of gonadotropins and a medication like Lupron. The ovulation induction that we use in this sense is very similar to the one that we use prior to an in vitro fertilization cycle.

Based on the literature we usually combine superovulation with IUI because we feel that it makes the pregnancy rate about 25% higher than it would otherwise be. This is likely due to several factors. Since IUI delivers more sperm to the egg, it likely compensates for partially recognized or unrecognized sperm factors. It also partially compensates for endometriosis (treated and untreated).

Infertility Solutions' Cryolaboratory

Infertility Solutions cryobank provides freezing and storage of sperm for men who require chemotherapy or radiotherapy with the potential for causing their sterility. Frozen sperm can be used to achieve pregnancy after the man has recovered from his underlying disease. Most commonly we freeze sperm from men with Hodgkin's disease and with testicular cancer. Some men also choose to cryopreserve their sperm prior to having a vasectomy.

Embryos can also be frozen and stored for patients who produce excess embryos with in vitro fertilization at Infertility Solutions. Cryopreservation of embryos can decrease the cost of achieving pregnancy by providing several tries at pregnancy from a single IVF cycle. It can also help decrease the risk of high order multiple pregnancies. The best results can be obtained using embryos frozen on day 1 after IVF. Good results can also be obtained using embryos frozen on day 5 or 6. The technology for effectively freezing unfertilized eggs is still being developed.

We also store donor sperm that has been purchased from commercial sperm banks. Primarily this serves to simplify our donor insemination program for our patients. However, some of our patients will also buy additional specimens from a donor used to achieve pregnancy so that they can utilize the same donor to achieve additional pregnancies.

Testicular biopsy specimens can also be stored and used to fertilize eggs of a partner in the situation where a man does not produce sperm in his ejaculate. This is a component of our TESE program.

Cryopreserved sperm, embryos and tissue can be stored virtually forever. Specimens are stored in liquid nitrogen at a temperature (-196C) below that required for chemical reactions to take place.

Assisted Hatching

The egg is surrounded by a shell called the zona pellucida [ additional information ]. After fertilization the embryo divides inside of this shell. In unassisted pregnancies, the growing embryo rests on the endometrial surface for three to four days before breaking out of the shell. If the embryo is unable to break out of the shell, it cannot make contact with the maternal endometrium and pregnancy cannot be established.(Link to article). As women age it is more difficult for the embryo to get out of this shell. Assisting this process along has been shown to increase fertility in women above 38-years-old. The procedure can only be done as a component of in vitro fertilization. This is a micro-operative procedure performed on embryos. Each embryo is grasped by a holding pipette and a portion of the zona pellucida is disolved. This is usually done after three days of culture and prior to transfer.

Donor sperm insemination. (TDI)

The use of donor sperm to achieve pregnancy in the setting of no sperm or poor sperm in the male partner is a very old technology. Prior to the l980's almost all donor insemination programs utilized fresh sperm. However, because of concern about transmitting AID's and hepatitis almost all sperm used for donor insemination today has been cryopreserved. There are now well established standards for evaluating and testing donors who are willing to provide sperm for this use. Today most sperm available for donor insemination has been collected by a small number of commercial sperm banks. As a result, we believe that donor sperm from these sources is safer than it has ever been before. Sperm is obtained from well evaluated donors and it is cryopreserved. Prior to release of that sperm for use in patients the donors are again retested for AIDS and Hepatitis.

One unintended effect of the need to cryopreserve sperm prior to use in donor insemination is that it is more difficult to achieve pregnancy with sperm that has been cryopreserved as opposed high quality fresh sperm. We feel that this problem can be overcome by utilizing intrauterine insemination as a component of the donor insemination program and by actively managing ovulation. Our approach is based on our experience, some of which has been published. [ bibliographical reference ] When donor insemination utilizes intrauterine insemination as opposed to cervical insemination our pregnancy rate was two and one-half to three times higher. Intrauterine insemination with actively managed ovulation also makes a cycle less expensive in that it suffices to use a single insemination. Older methods utilizing cervical or vaginal insemination usually required multiple sperm inseminations to work.

The primary issues related to donor insemination are psychological. Is the couple comfortable with this form of therapy? In our experience many couples are initially not comfortable with the idea or donor insemination. The process of coming to terms with the need for donor insemination can sometimes take a long time. I have taken care of couples who were not ready for donor insemination when the issue was raised, but who returned several years later finally ready for this therapy.

Generally, our approach to couples desiring donor insemination is to obtain a complete history and perform a physical examination. Most of the time that evaluation suggests that the couple is normal with the exception of not having sperm. We then undertake four trials, attempting pregnancy using donor sperm. If the couple is not pregnant after four tries we then move to a more complete infertility work-up. If that work-up is negative, we usually next move to superovulation.

Over the years our pregnancy rate per cycle of donor insemination has been approximately 20%/cycle overall. Gonadotropins were used in those patients who did not achieve pregnancy. The pregnancy rate without gonadotropins was 18%/cycle. With gonadotropins it was 26%/cycle.

Shared Egg Donor Program

The shared egg donor program is a new program for Infertility Solutions, P.C.. The program has two objectives. The first is to provide in vitro fertilization services for some patients who cannot afford them and do not have adequate insurance coverage to pay for them. The second is to provide donor eggs for use in women who either do not produce eggs on their own, or produce poor quality eggs.

Recent data suggests that approximately 10% of patients who undergo IVF over age 40 are using donor eggs. There are several sources for eggs. If one wishes to utilize a "paid" donor there are commercial entities that do a fairly good job of screening patients and can often provide a diversity of donors. However, utilizing these services can be quite expensive. Probably the best way to utilize a donor is for the patient to find someone who is related to her and who is willing to undergo an IVF stimulation and retrival for her. For many patients this is either not possible or family members who would be willing to do this are too old to provide useful eggs. Shared egg donors have been used in the United States for a number of years. In some countries, such as Britain, where payment for egg donation is not considered acceptable, shared egg donors are a major source of donor eggs for older women.

Generally, recipients are over age 40 or are younger and have had an early menopause. Optimally, donors are either sufficiently young that they are likely to produce a large number of eggs with superovulation, or they have a condition such as polycystic ovarian syndrome which commonly enables them to produce large number of eggs. The age cut off for donors in this program is 32-years-old.

The use of shared egg donors is uncommon in the United States although it is the preferred approach in some countries for ethical reasons. In a small practice such as ours where we can really know our shared donors, we think it is the better way to go when donor eggs are needed. Recipient patients benefit from both the decreased costs and likely increased efficacy. The following is reprinted from a recent newsletter.

(Reprint) The availability of donor eggs is essential for current recommended treatment of "older" infertility patients. Although it is our practice to undertake IVF in the well-informed patient who wishes to do so, many IVF programs utilize age (or day FSH level) cutoffs. In such programs donor eggs is the only option for "older" patients. This has led to both a shortage of donor eggs and significant inflation in the fees paid to the donor for the time and trouble involved in going thru a cycle. This adds a minimum of $5000 to the cost of each donor cycle.

In prior newsletters we have written about the ethical desirability of using shared egg donors as opposed to paid donors. In a standard donor program, donors are recruited through advertising and are at least partly induced to participate because of the fee they will receive. This is partly a commercial venture. We are concerned about the issue of paying for someone's eggs and feel that the higher the fee, the greater inducement for the donor to misrepresent herself. In a shared egg donor program, the donor is in a non-commercial doctor patient relationship. Information she has supplied to the doctor needs to be accurate or it will not benefit her. The patient is willing to undertake a vigorous ovulation induction for IVF and the eggs are split between the donor and recipient with the objective of achieving pregnancy in both women. The potential of achieving pregnancy causes donors to accept a much more aggressive ovulation induction than reimbursing them with money would have . In addition to ethical benefits and lower costs of a shared egg program, we strongly believe that a shared egg donor program is also clinically superior to a traditional donor egg program. We would like to take this opportunity to address some of the concerns our patients have raised in the past about the differences between these approaches.

With a shared egg donor program, I will get fewer eggs to work with than a traditional donor program. Because of the shortage of donors, many traditional programs require recipients to share eggs from a single donor. Most paid donors underestimate what they will have to go through to produce eggs for an IVF cycle. Programs try hard not to push these donors very aggressively, which limits the number of eggs that they end up producing. At any age there is significant variability in the number of eggs that different women produce. Most of the patients that we use in our shared egg program have used gonadotropins in the past and have a higher than average likelihood of a good response during the donor cycle.

With a shared egg donor program, I would expect a lower pregnancy rate than with a traditional donor program because the paid donors are likely to be younger. Although no direct comparisons exist, based on published data, this is unlikely to be true. Although the natural pregnancy rate is higher for younger compared to older patients, within the age range of our shared egg donors, this difference can be compensated for by IVF (especially the ability to select the best appearing of several embryos for transfer). Recently IVF data shows no decline in pregnancy rates from age 25 to 33. Our donor cut-off age is 32 and donors can be selected because of prior good response to gonadotropins or because they had a prior IVF cycle with a very good response, which did not result in a delivery.

PGD

PGD involves biopsy or removal of a single cell from a day 3 / eight cell embryo so that genetic testing can be done on the single cell. This can be used to avoid transferring embryos that are genetically abnormal either due to a known single gene defect or age effects. It can also be done for sex selection (with near 100% efficacy). It plays an important role in treating recurrent pregnancy loss when the standard work-up is otherwise negative.

We utilize one of the most experienced outside groups to both biopsy the embryo and to undertake genetic testing on it. This is a powerful technique that is relatively new to the clinical IVF community. It adds several thousand dollars to the cost of an IVF cycle.