IUI (Intrauterine insemination)

Once known as artificial insemination (AI), intrauterine insemination (IUI) is the process by which sperm is deposited in a woman's uterus through artificial means. For many couples, this is a less invasive and more affordable alternative to IVF.

The IUI process is when a very thin flexible catheter is inserted through the cervix and washed sperm is injected into the uterus. Most women consider IUI to be fairly painless, along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is ovulation-related rather than from the IUI. The catheter often isn't felt because the cervix is already slightly open for ovulation.

You will be given instructions on how long beforehand and afterwards to abstain from intercourse, and any resting periods after the IUI.

When timing is based on an hCG injection (trigger) that forces ovulation, the IUIs are usually done between 24 and 48 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the hCG.

Some doctors will base timing of IUI on a natural LH surge. In that case, a single IUI at 36 hours is the norm, but doing them at 24 hours is also pretty common since ovulation may be a bit earlier. When two inseminations are planned, they are usually timed between 12 and 48 hours after the surge is detected.

IUI can help Clomid cycles where the shortage of cervical mucus may interfere with timed intercourse by bypasing the cervix entirely. IUI increases the chance of success on both oral and injectable cycles no matter what the sperm count, and is occasionally done on unmedicated cycles as well. It does make sense to try IUI if you can and haven’t had success with intercourse.

The success rates are reported to be just under 6% and as high as 26% per cycle. The low statistics are with one follicle, while multiple follicles resulted in as high 26% success. See the end of the post for links to IUI success rates.


FREQUENTLY ASKED QUESTIONS

When and where are sperm collected?
Sperm can be collected either at home, if you live close to your fertility clinic, or at the doctor’s office. The man will be provided with a sterile collection cup, where he can deposit his ejaculate. If you plan on using a fresh sample, then this sample needs to be delivered to your RE within a half hour of ejaculation. In some cases, a special type of condom may also be used for sperm collection. Frozen sperm from sperm donors can also be used for IUI.

Does sperm need to be prepared before IUI?
Yes, sperm washing must occur before IUI can happen. This process can take anywhere from 30 minutes with simple sperm wash to two hours with the swim up technique. Insemination should occur shortly after the sperm has been prepared.

Is a certain sperm count necessary for IUI?
Although the minimum sperm count necessary to have an IUI performed is one million, it is normally recommended that a sperm count of at least 5 million be used. However, the less sperm that is used, the lower the chances of success. Therefore, a sperm count between 20 and 30 million is usually thought of as ideal.

Is IUI painful?
Although it can cause some discomfort, mainly when the catheter is passed through the cervix, overall IUI is a relatively painless procedure. Some women have likened it to a pap smear in terms of discomfort.

Will I be successful with IUI the first time?
Like IVF, a few cycles of IUI may be necessary before you are successful. Many fertility doctors recommend doing two inseminations a short time apart (back to back IUI) in order to increase your chances of pregnancy. Using different fertility drugs also may help. However, if you fail to have any results after trying a few cycles with both Clomid and injectable fertility drugs, you may want to consider trying IVF.

Are there any risks associated with IUI?
IUI is one of the least stressful fertility treatments on a woman’s body, especially if she is not taking any fertility drugs. It also has very few associated risks, although cramping, bleeding or spotting may occur during or after the procedure. There is also a risk of infection, including STDs, particularly if the sperm you are using has not been properly screened and/or you are not very familiar with the health background of the sperm provider.

Women using fertility drugs do have a few more risks to worry about, which are particular to the medications they are receiving. However, with proper and regular monitoring, these risks should be minimized.

How much can I expect to pay for IUI?
It is difficult to say exactly how much one will pay for IUI as the associated costs can vary considerably from fertility clinic to fertility clinic, and with the variables of your insurance coverage. Additionally, if you are using fertility drugs, then you will also need to pay for these medications as well as ultrasounds and bloodwork. Moreover, using donor sperm can also increase the price.

The cost for just IUI can range from $300 to $700. However, with any "extras" you may incur, the price can go up to $5,000 or more.

At what size are follicles considered mature?
Many doctors monitor follicle development during IUI cycles. Most trigger when the dominant follicle is within a certain size range. While there is always some difference in doctor preference, the norms are unmedicated 20-24mm, clomiphene citrate 20-24mm, FSH-only meds 17 or 18mm minimum, and FSH+LH would be 16 or 17mm minimum. It is possible for slightly smaller follicles, 14-15mm, to contain a viable egg. Also, follicles continue to grow until they release, usually at a rate of about 1-2 mm per day. A woman may ovulate more than one follicle in a cycle, but the releases will occur within 24 hours. When hCG is not used, only follicles close in size are likely to release. The use of hCG induces ovulation in about 95 percent of women, and will get most mature follicles to rupture.
 
What should estradiol (E2) level be at time of hCG trigger?
The E2 level should be 200-600pg/ml per 18mm follicle. Some doctors are content with a minimum level of 150, but higher tends to be better.   

Is there anything I should do or avoid after IUI?

• Feel free to get up and move about after IUI as your cervix will close, keeping the newly deposited sperm right where it should be. However, many women prefer to continue lying down immediately after the procedure, which your doctor will likely encourage as well.
• While it won’t hurt you to take it easy for a few days, there really is no reason why you can’t resume your regular activities right away.
• Have sex. This will only help to increase your chances of conceiving, after all. However, if you experienced any bleeding during your IUI procedure, you may want to wait 48 hours before having sex.
• You can take acetaminophen, like Tylenol, if you are experiencing any pain or cramps after the procedure but avoid NSAIDs, such as ibuprofen.
• Wondering whether or not you can swim? While it hasn’t been shown to interfere with IUI, there’s nothing wrong with being prudent in your actions and waiting a couple of days to swim. If you are using suppository medications, though, you may want to ask your fertility doctor whether swimming will interfere with these medications.

Source site


More helpful information:

http://www.advancedfertility.com/insem.htm

http://www.babycenter.com/0_fertility-treatment-artificial-insemination-iui_4092.bc

http://www.fertilityplus.org/faq/iui.html

http://www.infertilitybooks.com/onlinebooks/malpani/chapter24.html

http://www.shadygrovefertility.com/iui_success_rates 

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EMD 3.19.11

Medications

For a more comprehensive medication list and video instruction, see the end of the post.

There are numerous, perfectly valid medications and therapies that are not mentioned here. Do not be discouraged if you do not see something mentioned.
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Fertility Lifelines payment options and discounts
Vivelle Dot  coupon for one month free (1 month = up to 12 patches)
Synthroid money saving tips and coupon
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CLOMID (clomiphene citrate)  
ORAL
Clomid is used for the induction of ovulation, and frequently for women with disorders like PCOS and anovulation (anovulation: absence of ovulation or failure to ovulate). Please note that while Clomid is among the most common prescribed fertility meds, this does not mean it is for everyone. For example, it is not generally effective for women over age 40. Only women with specific symptoms and/or disorders should take Clomid, as indicated by a doctor. Please be sure your doctor does proper testing (bloodwork, sperm analysis, and HSG at a minimum) before jumping to treatment. Clomid cycles should be monitored with blood work and ultrasound to prevent complications with your health, and to avoid risk of High Order Multiples (HOM).

Clomid works through a complex interaction of brain chemistry and glandular hormone production. In short, clomid induces ovulation by affecting the brain/pituitary gland and by impacting key reproductive hormones that facilitate ovulation. Clomid works through the following contiguous steps (though this is a bit oversimplified):

• Clomid is taken early in the cycle as prescribed by your doctor.
• Clomid sends a message to the brain that estrogen levels are low.
• This causes the brain to release more GnRH, a hormone.
• This tells the pituitary gland to make the hormone follicle stimulating hormone (FSH) and luteinizing hormone (LH).
• FSH stimulates the development/maturation of the follicle or egg. LH is the hormone that facilitates ovulation.
• Ovulation is the release of the egg: Hence, clomid "induces" ovulation.

As clomid affects the level of luteinizing hormone in your system, if you start testing too early in your cycle with a urine ovulation test (which detects LH levels), you run the risk of receiving a false positive. Ask your doctor about monitoring ultrasounds to see if clomid is producing follicles, not effecting your lining and not creating cysts.

Side effects:  hot flashes, abdominal or pelvic pain and/or bloating, upset stomach and vomiting, breast tenderness, headache, spotting between periods, change in vision, vaginal dryness, insomnia, nervous tension, and lightheadedness.


FEMARA / LETROZOLE 
ORAL
In many fertility centers, clomiphene citrate (Clomid) has been the drug of first choice for either ovulation induction or superovulation for many years. In general, it has been a relatively effective medication. However, Clomid lasts for a long time in the body and may therefore have an adverse effect on the cervical mucus and uterine lining. Some groups of patients, such as women with PCOS, do not respond well to Clomid.

One of the earliest studies using letrozole as a fertility drug looked at 12 women with inadequate response to Clomid. Ovulation on letrozole occurred in 9 of 12 cycles and 3 patients conceived. A later study by the same investigators compared the effects of letrozole to those of Clomid. This time 19 women were studied. Ten women received Clomid and nine women received letrozole. This study was unable to demonstrate any difference in the number of women who ovulated, the number of eggs that developed in each woman, or the thickness of the uterine lining during treatment. However, a more recent study by a different group of investigators found that compared with Clomid, letrozole is associated with a thicker uterine lining and a lower miscarriage rate.

Side effects:  headache, hot flashes, and breast tenderness.


GONADOTROPINS 
INJECTABLE, SUBCUTANEOUS (SOMETIMES INTRAMUSCULAR)
Luteinizing hormone (LH) and follicle-stimulating hormone (FSH) are necessary for egg production. Early in the menstrual cycle, a woman with low hormone levels who is not ovulating can have daily human menopausal gonadotropin (hMG) or recombinant human FSH (rFSH) injections for an average of 12 days. If this helps develop mature follicles, the ovary is ready to ovulate. One dose of human chorionic gonadotropin (hCG) is then used to stimulate ovulation.

Gonadotropins differ for oral medications in that FSH is directly administered into your system. Oral medications (Clomid/Femara) trick your body into producing more FSH of it's own. They work in completely different ways, and you cannot compare oral medication cycles to injectable cycles without considering the method of action.

In women  Gonadotropins may be used:

• To stimulate ovulation related to low natural gonadotropin or estrogen levels. (This is most commonly seen in women with excessive exercise or eating disorders.)
• When clomiphene alone or clomiphene combined with another medicine has been ineffective for correcting irregular or no ovulation caused by PCOS.
• For developing multiple egg follicles on the ovaries. Multiple eggs are harvested and used in assisted reproductive techniques such as in vitro fertilization or gamete intrafallopian transfer.
• In combination with IUI for couples with unexplained infertility when clomiphene has not worked.

In men  Gonadotropin therapy can treat low sperm counts caused by low levels of natural gonadotropins.

Side effects:  OHSS, headache, abdominal pain, ovarian enlargement and tenderness. In men it may increase breast size.

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There are several brand names for this injectable medication including Gonal-F, Repronex, Menopur, Follistm, Bravelle, Luveris.

Video links on administering the shots:
Gonal-f Pen
Gonal-f Vial
Follistm Pen
Menopur (also, You Tube VIDEO)

Ferring Fertility video training guides
     (BRAVELLE/MENOPUR/REPRONEX/NOVAREL)


hCG (TRIGGER) 
INJECTIONS, INTRAMUSCULAR
Human chorionic gonadotropin (hCG) is a hormone closely similar in its biologic effect to LH, which induces ovulation, and is taken once testing indicates the oocytes on the ovaries are ready to be released. It performs two functions: structural changes inside the eggs to make them able to be fertilized and expansion of the fluid inside the follicles (egg sacs) that would eventually lead to rupture and ovulation. Ovulation normally occurs between 36-42 hours after HCG administration. Follow your doctors instructions closely as to how much, and when to administer.

In the event that you may be at risk for OHSS, your trigger may be at a lower dose, or Lupron may be substituted.

Brand names for hCG include Ovidrel, Novarel and Pregnyl, as well as generic versions.

Side effects:  redness, bruising and tenderness in the injection site, nausea, vomiting.

Video instructions:
Ovidrel
Novarel


GANIRELIX AND CETROTIDE (ANTAGONISTS) 
INJECTABLE, SUBCUTANEOUS
These both block the effects of the naturally occurring gonadotropin-releasing hormone (GnRH). GnRH controls the release of another hormone, luteinizing hormone (LH), which induces ovulation (release of an egg from the ovary) during the menstral cycle. During hormone treatment for ovarian stimulation, premature ovulation may lead to eggs that are not suitable for fertilization. Both Ganirelix (premixed syringes) and Cetrotide (vials) are used to prevent premature ovulation during controlled ovarian stimulation.


LUPRON (leuprolide acetate) (ANTAGON) 
INJECTABLE, SUBCUTANEOUS
Is an analog of gonadotropin releasing hormone (GnRH). When given as a subcutaneous (just below the skin) injection, it will stimulate the "turning-off" of your pituitary gland. We are able to take advantage of the suppressive actions to improve the recruitment of multiple follicles and prevent premature ovulation. Room temperature storage is advised. Be sure not to keep each vial past the expiration date. One vial will provide approximately four weeks of injections.

Side effects: Hot flashes may be felt when your estrogen level lowers and will disappear when you begin gonadotropin injections. Occasionally, patients experience headaches as well.


BIRTH CONTROL PILLS (BCP)
For IVF  It has become popular in some centers, to place all women on birth control pills as the start of an IVF cycle. This may be fine for women with a lot of eggs but it does not work very well for the women with fewer eggs. Birth control pills are used to help coordinate the start of an IVF cycle so that the egg retrieval procedures of a group of women will occur at roughly the same time, making it easier for the doctors and laboratory. For the women with fewer eggs however, the suppressive effects of the birth control pills can limit the number of eggs that are retrieved and leads to the use of much more medication in the process.

For Cysts  If you have a functional cyst that is larger in size and causing some symptoms, birth control pills may be prescribed. The purpose of birth control pills is to alter your hormone levels so the cyst will shrink. Birth control pills will reduce the probability of other cysts growing.


ANTIBIOTIC (Doxycycline, Tetracycline, Keflex)
Generally only the woman will take antibiotics. When performing the procedure to retrieve the eggs, a needle is placed through the vaginal wall and into the abdominal space. Antibiotics minimize the risk of an infection due to this puncture, as fevers are not good for developing embryos. If men have an infection documented on semen analysis, they may be treated with antibiotics.

Side effects: stomach upset, allergic reactions (hives, itching, swelling) vaginal yeast infections in women.


PROGESTERONE
INJECTIONS, INTRAMUSCULAR; SUPPOSITORIES
This hormone will act upon the lining of the uterus (the endometrium) to make it receptive for embryo implantation. As part of the egg retrieval process, progesterone-producing cells are removed along with the follicular fluid and oocytes, making the ovaries unable to produce progesterone sufficiently. Progesterone is vital for endometrial development and continued embryo support. Typical administration is intramuscular injections or suppositories, or a combination of both.

Progesterone and IVF
Other uses for progesterone

Side effects:  Breast tenderness, soreness at the injection sites, delayed onset of your period (even in the absence of pregnancy)


PRE-NATAL VITAMINS
Studies have shown that increasing the intake of folic acid prior to conception helps to decrease the chances of certain spinal-cord-defects in babies. It is also a good idea from a general health point of view to be on these multi-vitamins, prior to and throughout pregnancy.

Side effects:  Stomach upset, nausea, constipation


METHYLPREDNISOLONE (Medrol)
This steroid hormone is sometimes taken in conjunction with the Embryo Transfer, often with procedures like Assisted Hatching. It is taken to suppress any inflammatory reaction that might occur between the embryo(s) and the endometrial lining.

Side effects:  Fluid retention


LOW-DOSE ASPIRIN
A very high blood level of estrogen, which will result from the gonadotropin drugs, can have the potential effect of increasing the coagulation factors in the bloodstream (especially in the small vessels that supply the uterus and ovaries). Aspirin, in low doses, will decrease the effects of those clotting factors, and in turn, increase blood flow to the tissue.

Administration:  1 (80mg) tablet, by mouth, per day.
Side effects:  Stomach upset, prolonged bleeding time


DEXAMETHASONE (Decadron)
Patients who are found to have an immunologic problem (presence of certain antibodies) that could be potentially affecting their fertility will be given a course of this steroid medication. Steroids work by suppressing the body’s response to detected antibodies.

Side effects:  Reported side-effects normally occur only at higher doses, and when taken for extended periods of time


ESTROGEN
ORAL, SUPPOSITORY, OR PATCH
Estrogen helps maintain the endometrial lining of the uterus. While some early studies have shown that patients taking both progesterone and estrogen supplements during an IVF cycle after the egg retrieval have higher clinical pregnancy rates, newer studies seem to dispute this. However, as more research is still needed to study this, some Reproductive Endocrinologists (REs) prescribe estrogen supplements to help support the growth of the endometrium.

Can also be used as part of Estrogen Priming Protocol for IVF.



Information and Video Instruction

http://www.villagefertilitypharmacy.com/medications-and-video-injection-lessons
http://www.nyufertilitycenter.org/ivf/injections
http://ivfshootemup.blogspot.com/

Tips
http://twincranes.wordpress.com/tag/injections-for-ivf/
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EMD 3.19.2011

Uterine Abnoramalites

Perhaps the single largest factor in pregnancy a is the uterus. Many women find that having an abnormality of the uterus is a factor in their inability to carry a pregnancy or in their inability to conceive a pregnancy.

The Septate Uterus

The septate uterus is the most common congenital uterine anomaly and is a condition where a wall or septum partially or fully separates the uterus into two complete cavities. This congenital factor is suspected of affecting one in four woman who have reproductive failure.

A uterine x-ray, called a hysterosalpingogram or HSG, along with gathering clinical facts, is used to make the initial diagnosis. The HSG procedure is often used to detect scar tissue, polyps, fibroids or a uterus which is abnormally shaped. Treatment for septate uterus is surgical since hormones are not of much benefit in this instance.

A metroplasty, the surgical procedure used to remove the septum which divide the uterus, can be done either through a hysterscope (a telescope-like device that is placed in the vagina and then into the uterus) or via a small incision in the abdomen, called a laparomaty. There is less time involved in recovery using the hysteroscope than the laparotomy.

The success rate of this surgery indicates that about 80 percent of women who have undergone the surgery to remove the septum and reshape their uterus have gone on to become pregnant and to carry the baby to term.

For more information about Septums please follow these links:

http://yourtotalhealth.ivillage.com/uterine-septum.html

http://www.advancedfertility.com/uterus.htm

http://fertstert.wordpress.com/2008/11/04/hysteroscopic-resection-of-the-uterine-septum-is-it-always-a-necessity/

Hystroscopicresectioningof septum

SHG - SIS Study to detect uterine abnormalities

Fibroids

Uterine fibroids are growths that develop from the muscle tissue of the uterus. They also are called leiomyomas or myomas.

The size, shape, and location of fibroids can vary greatly. They may be present inside the uterus, on its outer surface or within its wall, or attached to it by a stem-like structure.

Fibroids can range in size from small, pea-sized growths to large, round ones that may be more than 5–6 inches wide. As they grow, they can distort the inside as well as the outside of the uterus. Sometimes fibroids grow large enough to completely fill the pelvis or abdomen.

A woman may have only one fibroid or many of varying sizes. Whether fibroids will occur singly or in groups is hard to predict. They may remain very small for a long time, suddenly grow rapidly, or grow slowly over a number of years.

For more information:

http://www.acog.org/publications/patient_education/bp074.cfm

http://www.nichd.nih.gov/publications/pubs/fibroids/sub1.cfm#treatments

http://www.fibroidsecondopinion.com/fibroids-and-pregnancy/

http://www.myomectomy.net/

Polyps

Uterine polyps sometimes cause problems with fertility - or can increase the risk of miscarriage. A "normal" uterine cavity and endometrial lining is necessary in order to conceive and maintain a pregnancy.


For more information:

http://www.advancedfertility.com/uterinepolyp.htm

http://www.fertilityfactor.com/uterine-polyps.html

Recurrent Miscarriages

Miscarriage is one of the most devastating experiences that can happen to a woman. Having one miscarriage is sadly, not that uncommon. Approximately two out of every ten pregnancies will result in miscarriage. After having one miscarriage most women go on to have a healthy pregnancy. Still there are a few women that will continue to have two, three or more miscarriages. Women are considered to have recurrent miscarriages when they have two or three miscarriages in a row. According to the American Society for Reproductive Medicine, only about one percent of women will have three consecutive miscarriages or more. Many doctors will not perform any tests until after a woman has had three consecutive miscarriages. Even with testing, doctors may not be able to determine the cause of recurrent miscarriage.

Possible recurrent miscarriage causes generally fall into the following categories:

• Anatomical
• Blood clotting/immunological
• Hormonal
• Genetic
• Unknown

Anatomical Causes of Miscarriages:

Sometimes, something is physically different about a woman’s uterus in a way that reduces her chances of a successful pregnancy. This might mean her uterine shape is abnormal or her cervix is weakened in a way that reduces her odds of a successful pregnancy. Anatomical factors that may cause recurrent miscarriages include:

• Uterine septum (or other congenital problems)
• Cervical insufficiency
• Fibroids (controversial)
• Uterine scarring

Blood Clotting/Immunological:

The exact mechanisms by which blood clotting disorders cause miscarriages are not yet well understood, but the primary condition in this category that doctors test for is called antiphospholipid syndrome. Hereditary thrombophilias, such as Factor V Leiden, have been implicated in late pregnancy losses.

You may find mention of other immune system-based miscarriage causes around the Internet, such as elevated Natural Killer cells or HLA incompatibility, but these factors are not widely accepted as miscarriage causes by the mainstream medical community.

Hormonal:

The idea that hormonal problems cause recurrent miscarriages is controversial. Progesterone deficiency, particularly, is hotly debated, and asking different doctors about the issue may result in different answers. Low progesterone should be considered inconclusive as a recurrent miscarriage cause. These conditions have been tied to recurrent miscarriages also, but they require more research.

• Elevated prolactin
• Insulin resistance
• Thyroid disorders

Genetic:

Sometimes, recurrent miscarriages do have a chromosomal cause. Women (and men) older than 35 have a greater tendency to produce eggs or sperm with chromosomal abnormalities.

In other cases, one or both partners may have a balanced translocation or other silent chromosomal abnormality that gives the couple a statistically increased odds of miscarriage in each pregnancy.

Unknown:

Medical practitioners can find a cause for a couple’s recurrent miscarriages only about half the time. The other half of the time, the cause is unknown. If you end up falling into this category, take heart. Studies have found that couples with recurrent miscarriage due to unknown causes have a 70% chance of eventually having a normal pregnancy.

Testing:

What follows is a list of the most common tests that doctors use for women with recurrent miscarriages. Note that the field of recurrent miscarriage treatment is fraught with controversy -- the jury is still out on some possible miscarriage causes, and many common treatments for recurrent miscarriages are not proven to work.

Note: The exact tests that your practitioner runs may be different from this list.

Testing for problems with the uterus:

• Hysterosalpingogram (HSG)
  During this imaging test, dye is injected into the uterus and an X-ray is taken; it looks for an abnormal shape of the uterus that might cause problems in pregnancy.

• Hysteroscopy
  A hysteroscopy involves inserting a thin telescope into the uterus to get the most accurate picture. A doctor may be able to repair minor problems during the test.

Blood Tests:

• Lupus Anticoagulant Antibodies
  Lupus anticoagulant antibodies are one of the markers for antiphospholipid syndrome.

• Anticardiolipin Antibodies
  Anticardiolipin antibodies are another marker for antiphospholipid syndrome.

• PT and aPTT
  PT stands for Prothrombin Time, and it is a test to see how fast the blood clots. aPTT stands for Activated Partial Thromboplastin Time, and it is another blood clotting test. Abnormal results on either might be associated with hereditary thrombophilias.

• MTHFR Gene Mutation
  Mutations in the MTHFR gene can impair the body's ability to absorb folic acid. A few studies have associated MTHFR gene mutations with increased risk of miscarriages, but most have found the gene not to be a major factor in causing miscarriages.

• Protein C, Factor V Leiden, Protein S deficiency, Prothrombin gene mutation and Antithrombin III deficiency
  These are the hereditary thrombophilias that seem to be linked to miscarriages after 10 weeks. Some doctors test for these and others do not.

• Thyroid Panel
  Some evidence suggests that hypothyroidism may increase risk of second-trimester miscarriage, but the evidence is not conclusive. Some practitioners routinely test women for thyroid issues and others do not.

• Progesterone
  The link between progesterone and miscarriages is a matter of hot debate. When doctors do test progesterone, the test usually involves a blood draw a week after ovulation, or on day 21 of a 28-day cycle.

• Karyotyping of the Parents
  This test would be performed on both parents and looks for problems in the genetic structure that might boost pregnancy loss risks, such as balanced translocation.

Other Tests:

• Fetal Tissue Karyotyping
  If a woman had a D&C for her most recent miscarriage, the doctor may want to order a chromosomal test of the tissue in order to rule out chromosomal abnormalities as a cause of the misarriages.

You may have mixed feelings about seeking testing. Recurrent miscarriages can put you in the strange position of actually wanting to find something wrong with you, because putting a name to the problem and having a potential treatment might make the idea of the next pregnancy seem a little less scary. Some women even feel scared to proceed with testing because they’re afraid they won’t find answers.

If you feel that way, it’s understandable, but try to remember that even if you don’t get answers, you should feel some reassurance that at least you can try again knowing that you do not have a known medical problem to get in the way of your having a successful pregnancy. Even though statistics may not be reassuring, studies indicate that 70% of couples who have recurrent miscarriages without a known cause do eventually go on to have a successful pregnancy. So the odds are still high that someday this ordeal that you are going through right now will just be a bad memory.

Information on Specific Diagnoses:

Balanced Translocation
Balanced Translocation Support group

Factor V Leiden
Factor V Leiden

MTHFR
MTHFR
MTHFR

Tubal Factor Infertility (TFI)

When an obstruction prevents the egg from traveling down the tube, the woman has a blocked fallopian tube. It can occur on one or both sides. This is also known as tubal factor infertility, and is the cause of infertility in 40% of infertile women.

How Do Blocked Fallopian Tubes Cause Infertility?

Each month, when ovulation occurs, an egg is released from one of the ovaries. The egg travels from the ovary, through the tubes, and into the uterus. The sperm also need to swim their way from the cervix, through the uterus, and through the fallopian tubes to get the egg. Fertilization usually takes place while the egg is traveling through the tube.

If one or both fallopian tubes are blocked, the egg cannot reach the uterus, and the sperm cannot reach the egg, preventing fertilization and pregnancy.

It's also possible for the tube not to be blocked totally, but only partially. This can increase the risk of a tubal pregnancy, or ectopic pregnancy.

What is Hydrosalpinx?

A specific kind of blocked fallopian tube, hydrosalpinx is when a blockage causes the tube to dilate (increase in diameter) and fill with fluid. The fluid blocks the egg and sperm, preventing fertilization and pregnancy.

Can You Get Pregnant With a Blocked Fallopian Tube?

If only one fallopian tube is blocked, but the other is clear, it may still be possible to achieve pregnancy. It depends on how well the ovary on the side of the clear tube is functioning, and also what caused the blocked tube in the first place.

Plus, since ovulation takes place on different sides from month to month, when the ovary on the blocked side ovulates, pregnancy cannot be achieved. So it may take longer to get pregnant.

What are the Symptoms of Blocked Fallopian Tubes?

Unlike anovulation, where irregular menstrual cycles may hint to a problem, blocked fallopian tubes rarely cause symptoms. A specific kind of blocked fallopian tube, called hydrosalpinx, may cause lower abdominal pain and unusual vaginal discharge, but not every woman will have these symptoms.

However, some of the causes of blocked fallopian tubes might lead to hints of a problem. For example, endometriosis and pelvic inflammatory disease may cause painful menstruation and painful sexual intercourse. But these symptoms don't necessarily point to blocked tubes.

What Causes Blocked Fallopian Tubes?

The most common cause of blocked fallopian tubes is pelvic inflammatory disease (PID). PID is most often the result of a sexually transmitting disease, but it isn't always related to an STD. Also, even if PID is no longer present, a history of PID increases the risk of blocked tubes.

Other potential causes of blocked fallopian tubes:

• Current or history of an STD infection, specifically Chlamydia or Gonorrhea
• History of uterine infection caused by an abortion or miscarriage
• History of a ruptured appendix
• History of abdominal surgery
• Previous ectopic pregnancy
• Prior surgery involving the fallopian tubes
• Endometriosis

How are Blocked Tubes Diagnosed?

Blocked tubes are usually diagnosed with a specialized x-ray, called a hysterosalpingogram, or HSG. This test involves placing a dye through the cervix, using a tiny tube. Once the dye has been given, the doctor will take x-rays of your pelvic area.

• All About Hysterosalpingogram (HSG)

If all is normal, the dye will go through the uterus, through the tubes, and spill out around the ovaries and into the pelvic cavity. If the dye doesn't get through the tubes, then you may have a blocked fallopian tube.

It's important to know that 15% of women have a "false positive," where the dye doesn't get past the uterus and into the tube. The blockage appears to be right where the fallopian tube and uterus meet. If this happens, the doctor may repeat the test another time, or order a different test to confirm.

Other tests that may be ordered include ultrasound, exploratory laparoscopic surgery, or hysteroscopy (where they take a thin camera and place it through your cervix, to look at your uterus). Blood work to check for the presence of Chlamydia antibodies (which would imply previous or current infection) may also be ordered.

What are the Potential Treatments for Blocked Tubes?

If you have one open tube, and are otherwise healthy, you might be able to get pregnant without too much help. Your doctor may give you fertility drugs to increase the chances of ovulating on the side with the open tube. This is not an option, however, if both tubes are blocked.

In some cases, laparoscopic surgery can open blocked tubes or remove scar tissue that is causing problems. Unfortunately, this treatment doesn't always work. The chance of success depends on how old you are (the younger, the better), how bad and where the blockage is, and the cause of blockage.

If just a few adhesions are between the tubes and ovaries, then your chances of getting pregnant after surgery are good. If you have a blocked tube that is otherwise healthy, you have a 20% to 40% chance of getting pregnant after surgery.

But if thick, multiple adhesions and scarring are between your tubes and ovaries, or if you have been diagnosed with hydrosalpinx, surgery may not be a good option for you. Also, if there are any male infertility issues, you might want to skip surgery. In these cases, IVF treatment is your best bet.

Also important to note is that your risk of ectopic pregnancy is higher after surgery to treat tubal blockage. Your doctor should closely monitor you, if you do get pregnant.

For more information:

http://www.advancedfertility.com/tubal.htm
http://www.beachcenter.com/surgical/tubal.shtml

Sources:

Conceiving After Tubal Surgery: Fact Sheet. American Association of Reproductive Medicine. Accessed November 6, 2008. http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/ConceivingAfterTubalSurgery.pdf

Hydrosalpinx: Fact Sheet. American Association of Reproductive Medicine. Accessed November 6, 2008. http://www.asrm.org/uploadedFiles/ASRM_Content/Resources/Patient_Resources/Fact_Sheets_and_Info_Booklets/hydrosa(1).pdf

Endometriosis (Endo)

Endometriosis (from endo, "inside", and metra, "womb") is a gynecological medical condition in which endometrial-like cells appear and flourish in areas outside the uterine cavity, most commonly on the ovaries. The uterine cavity is lined by endometrial cells, which are under the influence of female hormones. These endometrial-like cells in areas outside the uterus (endometriosis) are influenced by hormonal changes and respond in a way that is similar to the cells found inside the uterus. Symptoms often worsen with the menstrual cycle.

Endometriosis is estrogen dependent and typically seen during the reproductive years; it has been estimated that endometriosis occurs in roughly 5-10% of women. Symptoms may depend on the site of active endometriosis. Its main but not universal symptom is pelvic pain in various manifestations.

The natural behavior of the endometrium is to respond to hormones produced in the body, particularly estrogen, during each menstrual cycle. The endometrium builds up to a thick, blood vessel-rich, glandular layer in preparation for pregnancy. When pregnancy does not occur then the endometrium sheds this blood and results in a period.

A similar reaction takes place in the stray cells that have found their way into the pelvic cavity. Each month they respond to hormones, and break down and bleed, but the blood and tissue shed from these endometrial growths have no way of leaving the body. This results in internal bleeding, breakdown of the blood and tissue from these sites, and leads to inflammation. It also can result in the gradual growth or worsening of the endometriosis.

Many women start to suspect something is wrong when the amount of pain they feel with their periods worsens. For other women the disease may not throw up any noticeable symptoms, but they may be having problems with their fertility and are not successful in conceiving. It is then that they seek medical advice which could lead to further investigation.

As endometriosis can lead to anatomical distorsions and adhesions (the fibrous bands that form between tissues and organs following recovery from an injury), the causality may be easy to understand; however, the link between infertility and endometriosis remains enigmatic when the extent of endometriosis is limited. It has been suggested that endometriotic lesions release factors which are detrimental to embryos, or, alternatively, endometriosis may more likely develop in women who fail to conceive for other reasons and thus be a secondary phenomenon.

DIAGNOSING ENDOMETRIOSIS

Physical examination
A pelvic examination involves the physician feeling and looking for abnormalities that are associated with endometriosis. Physical findings depend on the severity and location of the disease. There may be palpable nodules or tenderness in the pelvic region, enlarged ovaries, a tipped-back (retro-displaced) uterus, or lesions on the vagina or on surgical scars.

Laparoscopy
A laparoscopy is an exploratory procedure that allows the physician to see inside the pelvic region to observe and check for endometrial growths. The procedure involves making a small incision near the navel and inserting a laparoscope (a long, thin, lighted instrument) into the abdomen. The abdomen is distended with carbon dioxide gas to make it easier to see the abdominal organs. Usually, the endometrial growths can easily be seen. Because Endometriosis implants or growths vary in appearance and can be mistaken for other conditions, the lesions should be surgically removed and examined under a microscope to confirm the presence of the disease.

Imaging tests
Imaging tests (e.g. pelvic ultrasound, magnetic resonance imaging) may be used to identify individual endometrial lesions, but they are not used to determine the extent of the disease. The implants are not easily identified using this method.

Biochemical markers
There has been extensive investigation of a membrane antigen called CA-125 in women with Endometriosis. Several reports suggest that levels of CA-125 are elevated in women with Endometriosis, particularly those in the advanced stages of the disease. A recent study of this antigen level, showed it to be high in 90 percent of women with Endometriosis. Possible diagnosis with a blood test to check levels of CA-125 could be used to check for Endometriosis.


LINKS
Wikipedia
About
Endometriosis.org

Endo Resolved

Theendometriosisassociation
ERC


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Diminished Ovarian Reserve (DOR)

Ovarian reserve may be defined as the youthfulness or health of the ovaries and the eggs (oocytes) they contain. Measurement of ovarian reserve, an important factor in female fertility potential, can only be approximated because precise tests are not currently available. Testing for diminished ovarian reserve gives couples the advantage of a more realistic estimate of the likelihood of fertility with treatment.

Average pregnancy rates decline gradually with age and do so more sharply after age 37. This is striking when one considers that menopause, the time when the ovary is effectively devoid of eggs, occurs on average at age 51. Therefore, for many women fertility begins to decline 15-20 years or more before the ovary is depleted of eggs. The actual degree and rate of decline varies from woman to woman. The aging of the eggs occurs because women make no new eggs after birth, in contrast to men who continue to make new sperm throughout adult life.

As fertility declines, the incidence of miscarriage also rises. Estimates for miscarriage rates are 10-20% under 35 years, 15-30% for 35-39 years, and about 35-60% for over 40 years.

This information implies that the functional capacity of the egg to create a live-born baby declines long before depletion of all eggs from the ovary.

Links for more information:
- Determining ovarian reserve
- General information
- Anti-mullerian Hormone

Male Factor Infertility (MFI)

Getting the news that your facing MFI can be devestating for both partners.

The great news is with advances in MFI many couples will conceive a child with some help from their RE's and MFI Urologists.

If you receive a diagnosis like 0 sperm in the sample or your husband is missing the Vas Deferens, it is very important that you find a reputable Urologist that specializes in MFI. Link and more info below.


Normal numbers of a semen analysis (SA) are:

Volume	2.0 to 5.0 mL or more
Sperm number	20 million/mL or more
Motility	50 percent or more
Forward Progression	at least 2+ forward progression
Morphology	WHO> 30 percent; or Kruger, at least 4%

And

No significant sperm clumping or agglutination No significant white blood cells or red blood cells No hyperviscosity (increased thickening of the seminal fluid)

Infertility effects one in every six couples who are trying to conceive. In at least half of all cases of infertility a male factor is a major or contributing cause. This means that about 10% of all men in the United States who are attempting to conceive suffer from infertility.

The most common identifiable cause of infertility in men is varicocele. This is a condition of enlarged veins in the scrotum that causes abnormalities in the temperature regulation of the testis. Enzymes that are responsible for both sperm and hormone (testosterone) production have an optimal temperature at which they operate most effectively. If this temperature is elevated by even one degree, sperm and testosterone production are adversely effected.

The second major cause of infertility in men is blockages or obstructions of the male reproductive tract. This is particularly true for men with zero sperm count, a condition called "azoospermia." Men with zero sperm count can be divided into two broad groups:

1. men who have an obstruction problem or blockage, meaning they are making sperm, but the sperm can't get out, or
2. men who have a production problem, meaning they are not making sperm, a condition called "non-obstructive " azoospermia."

We can easily determine which group an infertile male is in by doing a testicular biopsy, also using a microscope to minimize discomfort and complications.

Blockage can also be caused by a urinary tract infection or by the sexually transmitted diseases chlamydia and gonorrhea. Bacteria can infect the tiny duct called the "epididymis," which is essentially a swimming school for sperm before they are able to swim to fertilize an egg. Infection of the epididymis can cause scarring and blockage, inhibiting the sperm from leaving the duct to fertilize an egg. With the use of microscopes employing 30-power magnification, blockage repair success rates are extremely high.

One of the most common causes of blockage is vasectomy. Approximately 500,000 to a million men undergo vasectomy each year in this country for permanent birth control.

Approximately 1% of all infertile men are born with the congenital absence of the vas deferens, the "equivalent" of a vasectomy. Unfortunately, there are no artificial tubes strong enough to replace the vas deferens. However, we are now able to help such men conceive using an operating microscope to retrieve sperm from the tiny ducts of the epididymis, freeze them and use them later for in- vitro fertilization (IVF) with the injection of the single sperm directly into an egg.

Another cause of MFI is Andropause, or what is sometimes referred to as, male menopause. For most men, testosterone levels drop as the age but for some it happens much earlier and this causes lower and lower sperm counts. Sometimes testosterone replacement therapy can help increase counts.

Helpful links and information about MFI, general and specific diagnosis:

General Information

Male Reproductive System

Male Work-up

Additional Info on MFI Testing

Causes

The emotions
additional info

Varicocele

Microsurgical Varicocelectomy (graphic photos)

ICSI

Azoospermia

Non-Obstuctive Azoospermia

Andropause

Vas Deferens (CBAVD)

TESE

Lifestyle, Dietary and Vitamins to improve MFI

Alternative Treatment

Source website - more information
more info

TW

Polycystic Ovarian Syndrom (PCOS)

PCOS stands for Polycystic Ovarian Syndrome. PCOS is a serious condition which can affect a woman in a number of areas, including her hormones, fertility, heart, blood pressure, insulin production, blood vessels and appearance. Women who have PCOS have high levels of androgens. They have an irregular menstrual cycle or no menstrual cycle. They typically have fluid-filled sacs, called cysts, on their ovaries. PCOS is the most common hormonal reproductive problem in women of childbearing age. Somewhere between 5 and 10% of women of childbearing age have PCOS.

There is no single test to diagnose PCOS. Your doctor will take a medical history and perform a physical exam. This exam may include an ultrasound, checking your hormone levels, and measure glucose levels in the blood. At the physical exam the doctor will want to evaluate the areas of increased hair growth, so try to allow the natural hair growth for a few days before the visit. During a pelvic exam, the ovaries may be enlarged or swollen by the increased number of small cysts. This can be seen more easily by vaginal ultrasound, or screening, to examine the ovaries for cysts and the endometrium. The endometrium is the lining of the uterus. The uterine lining may become thicker if there has not been a regular period.

Symptoms of PCOS may include:

- infertility due to not ovulating
- acne, oily skin or dandruff
- type 2 diabetes
- pelvic pain
- excessive snoring and breathing stops while sleeping
- sleep apnea
- high blood pressure
- infrequent or no periods
- irregular bleeding
- increased growth of hair, including hair on the face, chest, stomach, back, thumbs, or toes
- weight gain or obesity, usually carrying extra weight around the waist
- high cholesterol
- male-pattern baldness or thinning hair
- patches of thickened and dark brown or black skin on the neck, arms, breasts, or thighs
- skin tags, or tiny excess flaps of skin in the armpits or neck area

Helpful sites:

Soul Cysters

PCOSupport

Infertility Physicion Explanation of PCOS - This is one of the best explanations of PCOS that I have ever found. Polycystic Ovary Syndrome (PCOS) FAQ - A thourough FAQ for PCOS. Polycystic Ovarian Syndrome (PCOS) - Frequently Asked Questions Polycystic Ovarian Syndrome - PCOS Research and its Findings SoulCysters Online Community - The largest online community of women with Polycystic Ovarian Syndrome (PCOS). Polycystic Ovarian Syndrome Association - Women with PCOS helping others. WebMD's explanation of PCOS - A thorough explanation of PCOS and what steps need to be taken. Polycystic Ovary Syndrome - Harvard's Medical School's Explanation of PCOS. Disease Profile of PCOS - Distinguishing the different types of PCOS PCOS Diagnostic Lab Tests - Lab tests that should be done for pcos diagnosis. Hormone Levels & Fertility Bloodwork Chart - Information Written by Patients, for Patients. Information about PCOS and its effects on your health - A site with lots of information on healing and reversing the effects of Insulin Resistance. Insulin Resistance Syndrome - Insulin Resistance Information. Thin-PCOS Information - Article about Metformin and Clomid for thin "cysters". Treating PCOS - Current Trends Project PCOS - Awareness, Information, and Support for PCOS TTC with PCOS - Personal web page to help understand and treat PCOS Metformin: A Beginner's Guide - Understanding the Benefits of Metformin Metformin (Glucophage) - Benefits & Side Effects - Great Explanation of the Benefits and Side Effects of Metformin & Glucophage for PCOS. The Power of Cinnamon - A research article stating the correlation in cinnamon consumption and reducing insulin resistance. Clomid vs. Femera - Comparing the two medications for the use of infertility WebMD's Progesterone Test - Great Explanation of the Benefits and Side Effects of Progesterone for PCOS. About Progesterone - Progesterone Effects on the Female Body. Androgen Deficiency in Women - Review of the Subject PCOS: Increased Risk of Cancer - The relationship of endometrial cancer and PCOS Letter to Doctors and Patients - Phytotherapy (Herbal Therapy) for polycystic ovarian syndrome PCOS Coach - Understanding and Treating PCOS PCOS - Dealing Day-to-Day Breastfeeding and Polycystic Ovarian Syndrome (PCOS) - Articles concerning the effects of PCOS on breastfeeding. PCOS and Breastfeeding - A Chat with a researcher concerning her findings on the effects of PCOS on breastfeeding. Breastfeeding and PCOS - Living and Feeding With Low Milk Supply. Breastfeeding and PCOS - Learning How to Breastfeed with PCOS. The Way We Live Now - A PCOS Diagnosis

Book Recommendations:

• A Patient's Guide to PCOS - Walter Futterweit
• PCOS and Your Fertility - Colette Harris
• The Savvy Woman's Guide to PCOS - Elizabeth Lee Vliet
• PCOS: Polycystic Ovarian Syndrome - The Hidden Epidemic - Samuel Thatcher
• What to Do When the Doctor Says It's PCOS - Milton Hammerly
• Polycystic Ovary Syndrome: Fighting Back! - Angela Kay Dotson
• PCOS: A Woman's Guide to Dealing with Polycystic Ovary Syndrome - Colette Harris
• Living with PCOS - Richard S. Legro
• New Glucose Revolution Guide to Living Well with PCOS - Dr. Jennie Brand-Miller
• The Insulin-Resistance Diet - Cheryle R. Hart M.D.
• The Low GI Diet Revolution - Dr. Jennie Brand-Miller
• The PCOS Diet Book - Colette Harris

Hypothyroidism and hyperthyroidism

Thyroidism is caused by either underproduction or over production of the thyroid gland. The production levels can be detected by a CD3 blood test. Please keep in mind that many fertility experts believe that the recommended amount of TSH should be lower in TTC/Pregnant woman then in the general public. That recommended amount is 0.24 - 2.99. When getting your blood drawn it is recommended you ask for your levels, if it is higher then the above recommended amount, please be proactive and ask questions! Some doctors still are not on the same page about what is the correct level, it is important to seek advice from a Endrocrynologist (thyroid specialist).


Hypothyroidism is when your TSH levels are above the recommended amount. Thyroid disease is interrelated with women's hormones, and can have an impact on menstrual cycles, fertility, estrogen/progesterone levels, successful pregnancy and/or miscarriage, the ability to breastfeed and menopause.

For more information please read the following links:

WebMD

About.com

Hypothyroidism Diet

Thyroidism and pregnancy


Hyperthyroidism is when your TSH level fall below what the recommended amount is.

For more information about hyperthyroidism please read the following links:

The Mayo Clinic

Web MD medications

About.com - general information

Testing

• In about 20 percent of cases, infertility is due to a cause involving only the male partner.
• In about 30 to 40 percent of cases, infertility is due to causes involving both the male and female.
• In the remaining 40 to 50 percent of cases, infertility is due entirely to a cause involving the female.

There are several basic tests that everyone should have before beginning treatment:

Cycle Day 3 (CD3) blood work. This is blood drawn on the 3rd day after you get your period. This blood draw will check different hormone levels. You can check a complete list of hormone levels here

Hysterosalpingogram (HSG) - This is a test where dye is inserted using a catheter into your cervix to watch the flow from your tubes to your uterus. This will tell you if you have anything blocking your tubes. Here is more information about the HSG

Semen Analysis (SA) - This is your husbands/partners part in the testing. What it will check for is amount, motility and morphology of his sperm. Keep in mind that even if you have a diagnosed issue, you should not rule out issues with your husband, in fact, 30% of cases the cause is attributed to both male and female factors, meaning there is an issue with both of you. For a chart of normal and abnormal results click here

Additional testing:

Besides the above tests that everyone should have, there a a couple of other tests that you should consider, especially if your doctor feels it is needed or after all other tests are done you feel you need more answers.

Laproscopy - Check here for more information

Sonohysterogram (SIS or SHG) - Check here for more information

7 day past ovulation (7dpo) bloodwork - This will check if you have ovulated and if your progesterone levels are considered high enough. If you have a short luteal phase you should ask about this.

Diagnostic Hysterscopy - Check here for more information

What now: Where to begin and insurance

If you have a known issue or suspect that you have an issue, do not hesitate to talk to a health provider as soon as you are considering trying to conceive. This can include any previous condition or concern with the reproductive organs of either partner, or irregular or infrequent periods for the female. At the least, they can guide you through a basic preconception workup and give you guidelines when to ask for help in the future.

If you are approaching the year mark if you're under 35, or the 6 month mark if you're over 35 and are not sure where to begin, first, check your insurance. Not every insurance is the same, even if it is through the same insurance company so call them to find out exactly what is and is not covered. This really is the best and only way to know for sure. Call more than one time, as one representative may not be as thorough as the next.

There are 15 states in the United States that mandate insurers and companies offer infertility coverage. Each mandate within each different state is different so be sure to check what your state requires. There are also loopholes to these mandates, so never assume you are covered.

For information on mandated states:
RESOLVE: state mandates and coverage

For questions to ask your employer and insurer:
important questions to consider (Attain Fertility)
benefit checklist (San Diego Fertility Center)

For more information:
INCIID: PAGE 1, PAGE 2, PAGE 3
RESOLVE on insurance
ASRM on insurance

Unfortunately there are many people who do not have any insurance coverage. Resolve offers some information and strategies to look into. Not one plan is right for everyone.

Who should you see for treatment? 
A board certified Reproductive Endocrinologist (RE) is an Obstetrician-Gynecologist with advanced education (a mandatory three year fellowship) and research in Reproductive Endocrinology. These highly trained and qualified physicians treat Reproductive Disorders that affect children, women, men, and the mature woman. They are certified with the American Board of Obstetrics and Gynecology in the Sub-Specialty of Reproductive Endocrinology and Infertility. It is important to find a doctor who responsive and well matched to your needs and diagnosis. Most importantly, a reproductive endocrinologist specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem than an OB/GYN who treats only a few infertility cases each year. It is ideal to have a clinic that is open 7 days a week, for optimal procedure timing.

Again, check with your insurance to see if you need a referral to see a Reproductive Endocrinologist (RE), some insurance do require referrals either through your primary care physician (PCP) or a gynecologist (GYN), if that is the case make an appointment with them to get a referral. Some plans also require a pre-authorization prior to a consultation, or prior to any diagnostics and treatment. The only way to know for sure is to call and check what your plan covers.

Call the RE you are interested in seeing and confirm that they take your insurance. If they are part of a larger group of REs, see if the entire group is covered. Sometimes REs not listed under your plan are actually within your network, and vice versa.

Dr Geoffrey Scher article: How do I choose the right RE and IVF program?
Which includes how to interpret those CDC and SART outcome statistics.

If you have no coverage at all you need to make a difficult decision because RE's can be more costly then GYNs and GYN appointments can squeak through the cracks and be covered before diagnosis of infertility. If that is the case, please be proactive and choose your GYN very carefully for the reasons mentioned above. You don't want to regret your choice, and think, "I wish I hadn't spent all that time and money with my OB/GYN." It can be a tremendous waste of time, and money that you could put toward treatment with a specialist who can get to the root of your problem.

Some indications that your GYN is not giving you the same care that an RE would be:  If you are starting treatments and neither you or your partner have had a comprehensive workup (please see TESTING), you should closely scrutinize your choice to proceed. Same with undergoing a treatment cycle and having minimal or no monitoring. Frequent monitoring (blood work and ultrasound at the start of your cycle, repeating every other or every day from cd7 or so until ovulation) on any fertility medication is important to your health as well as to the success of your cycle. Fertility drugs are not miracle drugs that will fix all issues of infertility. Being thoroughly tested and going through properly controlled treatment cycles will save you both time and money in the long run.

It is helpful to have all your previous medical records forwarded to your RE; some REs only need you to bring them the day of the appointment, others want them in advance, so call and confirm when this needs to be done. It is wise to have all records sent to you, and to make copies to give to your RE's office. This way you avoid costly handling fees, plus you have your records on hand should you ever need to reference them, or give them to another doctor, since doctors cannot forward records previously given to them by another doctor or by the patient.

Your first appointment will involve a lot of discussion about your background, your family history, your partner's background and his history. It is not required that your partner attend this meeting, but it is highly beneficial for everyone involved to be present. You may have an internal ultrasound at this visit, and diagnostic testing may be scheduled or performed. Please see the THIS post for more information.

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General information: Am I infertile?

The definition of infertility recognized by both doctors and insurance companies:
Couples who are under the age of 35 who have tried unsuccessfully for over 1 year, if over 35 tried unsuccessfully for 6 months, unless otherwise diagnosed with an issue.

For those of you who are not at the year mark (I will use the 1 year, if you are over 35 self edit to say 6 months) there are some things that can help you be sure that you are ovulating and that you are timing sex correctly.

Not all bodies are created equal, many websites suggest that ovulation occurs 14 days before your period. This is inaccurate for a lot of woman, not everyone does have a 14 day luteal phase (the time after ovulation until your period). Because of that fact you should use other methods to determine when you are ovulating. A couple of methods are ovulation predictor kits (OPK) where you pee on a stick and if the line is as dark or darker then the control line you will ovulate within 12-48 hours after your first positive. Another method is charting, where you take your basil body temperature each morning and your temperature will show an increase after ovulation.

Charting is somewhat involved and there are websites as well as books that can help. www.fertilityfriend.com is a great site that will walk you through the ins and outs of charting. Taking Charge of Your Fertility is a must read for anyone trying to conceive, and they have their own charting website and software as well.

If it shows that after a few months of charting you are not ovulating, now would be the time to talk to your doctor. If you are ovulating, it can take the average couple 6 months to a year to conceive. Keep trying! Yes, no one wants it to take 7 months, especially when you see a lot of people that it works right away for, but it does not mean at this time that there is a problem, your BFP could be right around the corner.

Further reading:
INCIID glossary of medical terms
INCIID general infertility FAQ
RESOLVE general infertility information
FERTILITY PLUS Hormone Levels and Fertility Bloodwork

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