Your Initial Consultation

For individuals struggling with infertility or recurrent pregnancy loss, seeking care in a timely manner may impact treatment options. For infertile individuals, the American Society of Reproductive Medicine (ASRM) and the American College of Obstetricians and Gynecologists recommend evaluation and treatment after one year of unprotected, well timed intercourse, or six months if the female is older than 35 years. ASRM recommends evaluation after three or more pregnancy losses.

Infertility can be complex and impacted by a number of factors, and the focus of the initial evaluation with the physician will be to establish a course of care tailored to your infertility challenge. An equal proportion of male-factor and female-factor causes are attributed to infertility, so if you have a partner we encourage you both to attend the initial consultation. During the visit, your reproductive endocrinologist will conduct a thorough examination [see Diagnostic Procedures below], which includes a review of your medical history and records, a physical exam and an ultrasound of the female partner to visualize the ovaries and uterus. Hormone levels may also be tested through simple blood work.

Next, your reproductive endocrinologist will introduce you to your primary nurse and the rest of the medical team, whom you will be working closely with throughout your treatment. Your nurse will review your treatment plan and discuss any further diagnostic testing recommended by your physician. She will also help you schedule the necessary procedures. Your nurse will be your primary contact during your treatment, providing any day-to-day instructions and facilitating the entire process.

Finally, you will sit down with a finance coordinator to discuss your insurance, infertility benefits, and finance options. Reproductive Medicine Associates of New York offers a variety of financial options and we want to make sure you are aware of the programs and benefits you may be eligible for, which will be explained to you at this meeting.

Many patients find it helpful to create a list of questions to bring to the initial consultation, given so much is reviewed during this time in the office. Please feel free to contact us if you find you have questions at any time during your consultation or care with RMA of New York.

In order to determine the proper course of treatment, the following diagnostic tests may be performed:

• History and Physical Examination of the female:
• A thorough medical history should include information about:
• Past surgeries
• Exposure to tobacco, alcohol, drugs, or environmental toxins
• Past or current sexually transmitted diseases
• Menstrual cycle patterns
• Any past pregnancies, terminations, or miscarriages
• A physical examination that may include a transvaginal ultrasound

In addition, if there is a male partner, his medical history should also be obtained. Only after evaluation of medical history and a thorough physical examination can an appropriate treatment plan be determined. This plan may include further diagnostic testing than what is performed at the initial consultation.

• Pre-conception health: To increase the probability of a healthy baby, basic steps should be taken prior to attempting conception. The first "pre-conceptual counseling" appointment with an OB/GYN should occur approximately 4 months before attempting to conceive. This consultation is also a chance to discuss problems with previous pregnancies, social issues, environmental exposures, and general health. If not previously done, a hematocrit to check for anemia, a rubella titer to check for immunity to rubella, and other blood tests can be performed. A thorough family history and blood tests for genetic diseases (Cystic Fibrosis, Tay Sachs, etc.) may be indicated.
• Basic recommendations: About 3 months prior to pregnancy and through the first couple of months of pregnancy, the Center for Disease Control recommends taking a folic acid vitamin or consuming foods on a daily basis that contain a minimum of 0.4mg. Repeated studies have shown that the intake of 0.4mg of folic acid daily prior to conception and during early pregnancy helps to significantly reduce the risk of the baby being born with a serious neural tube defect such as spina bifida, anencephaly, or encephalocele. Other pre-conception health habits include:
• Limiting intake of alcohol, coffee, tea, soda, and other foods and beverages containing caffeine
• Avoiding use of recreational drugs (such as marijuana) and overuse of prescription and over-the-counter drugs
• Avoiding exposure to toxic substances, such as industrial chemicals, herbicides, and pesticides
• Maintaining good personal hygiene and health practices
• Attempting to maintain a body weight within 15% of ideal body weight for one's height and body frame. Obesity has been found to affect regular ovulation; therefore, maintaining a healthy diet and staying within an acceptable BMI can aid conception
• Transvaginal Ultrasound: An internal ultrasound is used to evaluate a woman's uterus and ovaries. The transducer on a transvaginal ultrasound is a long probe that is inserted into the vagina covered with lubricant and a condom. The reproductive endocrinologist will be able to see the uterus, ovaries, and sometimes the fallopian tubes. The procedure is not painful, and many women prefer it to an abdominal ultrasound, for which the bladder must be full.
• Semen analysis: Sperm count and quality of the male partner is easily assessed by a semen analysis. The most accurate test results are achieved when abstaining from ejaculation for 2-4 days prior to the semen analysis appointment. The semen analysis will include basic parameters such as sperm number, motility, and morphology (shape). In a normal ejaculation, the total volume of semen is between a half and a whole teaspoon. As part of the semen analysis, the technician will determine the number of sperm present in the ejaculate. A normal sperm concentration falls between 20 million/mL and 200 million/mL. The technician looks at how well the sperm are moving and counts the total percentage of motile sperm by figuring how many sperm per 100 are moving. At least 50% of any given sperm population should be moving to be considered motile within an acceptable range. A well-developed sperm can propel itself up a woman's reproductive tract at a rate of more than 2 inches an hour. Finally, the technician determines the shape or morphology of the sperm. Sperm heads should be oval-shaped without irregularities.
  In the event that the semen analysis is abnormal, it should be repeated. If repeated semen analyses are abnormal or if the male partner is known to have any medical conditions or history that may be contributing to fertility complications, he should seek the help of a urologist specializing in male-factor infertility. The evaluation of the male partner will typically include a physical examination and further diagnostic testing. In many cases, male and female treatment can be concurrent to expedite the fertility treatment process.
• Female Hormone Testing: Tests of specific hormones may provide important clues about a woman's hormonal function and reproductive system. Perhaps the most important hormonal test that a woman should undergo is an FSH (Follicle Stimulating Hormone) test. Typically performed on day 3 of the menstrual cycle, this test can provide information about the quality of a woman's eggs. An abnormal, or high, FSH level can mean that it will be more difficult for the woman to conceive.
• Endometrial Biopsy: This procedure involves scraping a small amount of tissue from the endometrium shortly before menstruation is due, typically between 11 and 13 days following ovulation. It should ONLY be performed after a pregnancy test reveals that the woman is not pregnant. This test is often used to determine if a woman has a luteal phase defect- a hormonal imbalance that may prevent a woman from sustaining a pregnancy because not enough progesterone is produced.
• Post-coital Test: The post-coital test is a quick, painless procedure that may give information on how the cervical mucous and sperm interact. The test must be done within one to two days before or after ovulation. Basal body temperature charts or ovulation predicting kits are very helpful in determining the time of ovulation. A couple should abstain from intercourse for 2 days before ovulation and then have intercourse 2-8 hours prior to the office visit for the post-coital test. A speculum is placed in the vagina, as it would be for a pap smear. A syringe, without a needle, is then used to remove some mucous from the cervical opening. The speculum is then removed and the cervical mucous is evaluated. The specimen is placed under a microscope to look for the presence or absence of swimming sperm.
• Hysterosalpingogram: This test is used to examine a woman's uterus and fallopian tubes. It is essentially an x-ray procedure in which a dye is injected through the cervix into the uterus and fallopian tubes. This dye appears white on the x-ray, allowing the radiologist and physician to see if there are any abnormalities, such as an unusually shaped uterus, tumors, scar tissue or blockages in the fallopian tubes. If a woman is trying to conceive in the same cycle as an HSG, it is important schedule the test PRIOR to ovulation so that there is no danger of "flushing out" a released egg or developing embryo. Although most women report only minor cramping and short-term discomfort during this procedure, some women, especially those who have blocked tubes, report intense pain. Patients have the option of having a pain medication prescribed, which can be administered 30 minutes prior to the actual procedure.
• Basal Body Temperature Charting: A woman who is unsure of when she ovulates may be able to identify the time of ovulation by keeping a basal body temperature (BBT) chart for several months. Charting involves taking one's temperature every morning upon waking up and recording the results. For optimal accuracy, this must be performed before the woman drinks a cup of hot coffee or brushes her teeth, as these events can interfere with the temperature reading. When the temperature goes up 0.5 degrees, the woman is in the process of ovulating. Basal body temperature charting is not recommended as a method to plan intercourse, as the rise in temperature is caused by an increase in progesterone after the follicle's release of the egg, so the window of opportunity for conception may have passed by the time the temperature rises. Unfortunately, some patients find that BBT charting is time consuming, frustrating, and is a daily reminder that they are having difficulty conceiving. Though it is a reasonable first step to attempting conception, if the results are inconclusive after three months it is recommended that the couple move on to other methods, such as urinary LH detection kits, to detect ovulation.

Many causes of male-factor and female-factor infertility can be successfully overcome using a range of treatment options. Once your infertility testing has been completed, your physicians will review the results and recommend a treatment plan. This plan may include one or more treatment alternatives, such as ovulation induction to enhance the production of healthy eggs, minimally invasive surgery to correct or improve anatomical abnormalities, intrauterine insemination (IUI) or more advanced care using the Assisted Reproductive Technologies such as in vitro fertilization (IVF).

Clomiphene Citrate
Clomiphene Citrate (clomiphene), also known by brand names Clomid ® and Serophene ®, is used to treat infertile women who have an ovulation problem and 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 and may be used with timed intercourse or intrauterine insemination. It can also be effective in treating unexplained infertility when combined with intrauterine insemination.

Clomiphene is typically prescribed for five days each cycle, usually beginning on day 3 or 5. Of all women treated with clomiphene, 60% to 80% will ovulate normally, although pregnancy rates from clomiphene treatment is typically 10-15% per cycle. Approximately 10% of women treated with clomiphene may experience 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%. The American Society for Reproductive Medicine (ASRM) recommends no more than 6 clomiphene cycles be used before pursuing other treatment options, as the effectiveness of treatment decreases significantly after that point.

Follicle Stimulating Injectable Hormones
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. These drugs work by stimulating the ovaries to develop multiple mature eggs. These injectable medications, known by brand names Follistim® and Gonal-F®, are self 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, insemination or egg retrieval for an IVF cycle should be timed accordingly.

Many women experience side effects such as headaches, bloating, and moodiness, while some may also experience hot flashes, nausea, and blurred vision. Another possible side effect of injectable fertility medications is ovarian hyperstimulation syndrome (OHSS), 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. Any woman who suspects OHSS should contact her doctor. The physician may choose to drain fluid from the abdomen, which can easily be done in an outpatient setting. In extremely rare cases, OHSS may require a hospitalization.

Pregnancy rates with injectable medication vary depending on the treatment protocol and range from 15-20% with insemination or timed intercourse. Higher pregnancy rates can be achieved during in vitro fertilization, greater than 50% in young patients. See also IVF.

Usage of injectable medications has not been shown to increase the risk of ovarian cancer.

Medical and Hormonal Remedies for Men
Medical therapy can be an effective treatment for certain male factor infertility conditions. They are used as a first line treatment option for infections, hormonal abnormalities and erectile dysfunction.

Intrauterine Insemination (IUI)
Intrauterine insemination (IUI), also known as artificial insemination, can often be used as part of the treatment protocol for couples experiencing male-factor infertility. A well-timed IUI performed during ovulation utilizing a sample with good count and motility can be an effective treatment. In a laboratory, the sperm can be separated from the seminal fluid and re-suspended 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 directly into the uterine cavity. Usually the insemination itself causes little if any discomfort and the procedure is performed in just a couple minutes.

While an IUI can be very effective, some women may experience mild side effects. These include:

• Cramping
• Discomfort during the actual procedure
• Reaction to the medication(s) used to induce ovulation

In Vitro Fertilization

In vitro fertilization (IVF) is the process of retrieving eggs and sperm and manually fertilizing them in a laboratory dish outside the womb. Healthy embryos are then transferred back into the uterus with the goal of implantation and further embryo development. IVF is performed by physicians who specialize in reproductive medicine and have received additional education and training in the evaluation and treatment of male-factor and female-factor infertility.

IVF was originally developed in the early 1970’s to treat infertility caused by blocked or damaged fallopian tubes. Louise Brown, born in the United Kingdom in 1978, was the first baby conceived with the help of IVF. She made headlines again in 2006 when she went on to naturally conceive a healthy baby of her own. The technology of IVF and advanced reproductive technologies has improved markedly since then; and over 3 million babies have been born since Louise Brown with the help of IVF.

IVF involves four steps:

Intracytoplasmic Sperm Injection (ICSI)
Intracytoplasmic sperm injection (ICSI) is a type of in vitro fertilization procedure in which a single sperm is injected directly into the egg. It is a revolutionary technique that is provides effective treatment options for situations where few sperm are available for treatment or there are concerns about fertilization. Because some male factor infertility issues may be caused by chromosomal abnormalities in the male partner, it is important for those diagnosed with male factor infertility to have a thorough examination with a reproductive endocrinologist or urologist specializing in infertility.

Electroejaculation
Electroejaculation is a procedure that is performed when a medical or psychological condition prevents a male from ejaculating. During an electroejaculation procedure, the doctor inserts an electrical stimulation probe into the rectum. The doctor controls the amount of electrical stimulation delivered so that an ejaculation occurs. This can be done either in the office or in the operating room with anesthesia, depending on the sensory status of the patient. Alternative methods of sperm retrieval, including testicular sperm extraction, are recommended when penile vibratory stimulation and rectal probe ejaculation are unsuccessful or unavailable. See also Testicular Sperm Retrieval.

Blastocyst Transfer and Culture
A blastocyst is an embryo that has developed two different cell types and also contains a central fluid-filled cavity. The outer cells, called the trophectoderm, will become the placenta, and the inner cells will become the fetus. Blastocyst formation in the human usually occurs on the 5th day after fertilization. By the end of the sixth day, the blastocyst should hatch from its outer shell (the zona pellucida), and within another 24 hours the hatched blastocyst begins to implant in the lining of the mother's uterus.

Over the first two decades of experience with in vitro fertilization (IVF), embryos were routinely cultured for two to three days in the laboratory, and then transferred to the uterus. This is quite different than when embryos normally enter the uterus from the fallopian tube (day 5 or 6). During a natural cycle, 2-3 days after conception, embryos are typically found in the fallopian tubes and may not be ready to enter the uterus. Recently, laboratory culture conditions have been improved so that embryos resulting from an in vitro fertilization cycle can develop to the blastocyst stage in the laboratory, and therefore be replaced into the uterus at the more "natural" time, Day 5 or 6 after fertilization.

The additional benefit of waiting longer to transfer embryos is reducing the number of embryos needing to be transferred to result in a viable pregnancy. While extended culture of embryos will not improve the quality of an abnormal or poor quality embryo, by culturing embryos to the blastocyst stage there is more opportunity to choose the healthiest ones for transfer, thereby reducing the number transferred with the result of limiting the risk of a multiple gestation pregnancy.

Preimplantation Genetic Diagnosis - (PGD)
Traditional methods used to identify genetic disease require prenatal diagnosis through chorionic villus sampling (CVS) or amniocentesis, followed by potential termination of the pregnancy if the fetus is found to be affected. Recent scientific advances now allow the diagnosis of some genetic disorders before pregnancy is established using a technique known as pre-implantation genetic diagnosis (PGD). PGD combines the technology of in-vitro fertilization (IVF) with new molecular biology techniques.

A single cell is removed from an eight cell embryo in a procedure called an "embryo biopsy." This single cell is sent to a lab that specializes in detecting genetic abnormalities. If the embryo is found not to contain the genetic disorder being tested for, the embryo may be considered for transfer.

It is important to speak to both a genetic counselor and the treating physician to fully understand the accuracy rate of PGD.

Embryo Cryopreservation Also known as "embryo freezing," embryo cryopreservation is a method used to preserve embryos where they are stored at very low temperatures. Embryo cryopreservation allows the use of a woman’s own embryos for subsequent treatment cycles. A frozen embryo transfer cycle does not require use of follicle stimulating hormones and egg retrieval is not needed, thereby significant reducing the cost and invasive care as compared to an in vitro fertilization cycle using newly created embryos. Embryos may be stored indefinitely and there appears to be no increase risk of birth defects from cryopreserved embryos. However, embryo cryopreservation is not without risks, as almost 40 percent of cryopreserved embryos do not survive the freezing and thawing process. The pregnancy rates associated with frozen embryo transfer cycles are slightly lower than with fresh transfer. This may be caused by additional stress placed on the embryo during the cryopreservation and thawing process or simply by the selection of the most promising embryos for fresh transfer.

Oocyte Cryopreservation
Oocyte cryopreservation is a new and exciting experimental procedure that may help a woman preserve her reproductive potential. Women who may benefit from this procedure include:

1. Those women who are at risk of becoming sterile due to chemotherapy, radiotherapy or removal of their ovaries
2. Women who are choosing to delay reproduction, for personal or career reasons, while attempting to maintain their reproductive potential
3. Women who have a family history of endometriosis, early menopause or premature ovarian failure

Oocyte cryopreservation involves the extraction of a woman’s unfertilized eggs from her uterus. The process is the same as stage I and II of an in vitro fertilization cycle whereby the patient takes injectable hormones to increase oocyte production in order to obtain a number of eggs during the retrieval phase [see also In Vitro Fertilization]. The retrieved oocytes are then slowly cooled to a freeze and stored at extremely low temperatures. When the woman becomes ready to attempt pregnancy, a fertility specialist team will thaw the stored oocytes, attempt to fertilize the eggs and transfer subsequent embryos. See also Stages III and IV of an IVF cycle.

Ovum Donation
More than 150,000 women in the United States are unable to conceive 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 involves receiving from an appropriate donor. The donated eggs are then fertilized using male partner sperm or donor sperm, and results in the embryos being then transferred into the female recipient’s uterus.

Egg donors are typically healthy women between ages 21 and 32 who have been thoroughly screened to ensure they are physically healthy and fully aware of the donation process. Egg donors take injectable hormones for eight to ten days to increase their egg production. The 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. In some programs, more than half of women undergoing ovum donation conceive and deliver.

Hysteroscopy
Doctors will often perform an operative hysteroscopy if a uterine abnormality is suspected.

Use of a thin telescope called a "hysteroscope" enables the physician to insert operating tools, such as a scalpel or scissors, cautery devices or a laser fiber, into the uterus with precision and accuracy. The hysteroscope is also valuable in treating some forms of tubal occlusion, which is a blockage at the junction of the uterus and fallopian tube. Operative hysteroscopy is usually performed in the first part of the menstrual cycle so that the build-up of the endometrium does not block or obscure the physician’s view of the uterus.

Patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again two weeks after the procedure (with her next period).

Side effects of a hysteroscopy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling vaginal discharge, she should consult her physician immediately.

Laparoscopy
In a laparoscopy, 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 and is used in place of a more invasive abdominal procedure. At times, the procedure is performed to look for the cause of pelvic pain or infertility, and is called a "diagnostic" laparoscopy. Once a 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 and decreased cost attributed to the extremely small incision and the fact that the patient nearly always goes home the same day. Aside from the treatment of extremely large fibroids, most pelvic surgery can be performed laparoscopically.

Side effects of a laparoscopy may include vaginal discharge and slight discomfort. If a patient experiences heavy bleeding, blood clots, or foul-smelling discharge from the vagina or surgical site, she should consult her physician immediately.

Microsurgical Reconstruction, including Vasectomy reversal
Microsurgical reconstruction of the male reproductive tract is often a successful treatment used when an obstruction exists in the vas deferens or to reverse a vasectomy. A vasovasotomy is the operation most frequently performed for a vasectomy reversal and involves connecting the severed ends of the vas deferens. However, if following a vasectomy an obstruction has occurred in the epididymis, a vasoepididymostomy must be performed which involves connecting the vas deferens to the section of the epididymis that contains mature and motile sperm. After vasectomy reversal, sperm return to the semen in about 70 to 95% of men and pregnancy without assisted reproductive technology occurs in 30-75% of couples.

The chance for pregnancy following reconstructive surgery depends on many factors, most importantly the age and fertility status of the female partner and the number of years between the vasectomy and its reversal. The longer the period of time between vasectomy and reversal, the lower the chances for successful reversal.

Microsurgical reconstruction is a two to four hour operation and can be performed as an out patient procedure. Successful microsurgical reconstruction may allow couples to have subsequent children without resorting to invasive and expensive IVF treatments. However, a physician will consider the age and medical history of both partners to determine the optimal treatments to achieve a pregnancy. See also IVF and ICSI.

It is important to understand that after a successful microsurgical vasectomy reversal, the average interval until pregnancy is about one year.

A patient may return to normal activities 7 days after a microsurgical reconstruction, including resumption of intercourse after 4 weeks of abstinence. Attempts to achieve a pregnancy can occur upon resumption of intercourse.

Side effects of a surgery for microsurgical reconstruction may include swelling, hematoma, or infection at the surgical site.

Myomectomy
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.

If fibroids are small or are located within the cavity of the uterus (submucous), they can often be removed using a small fiber optic scope called a hysteroscope. In these cases, the procedure is a relatively quick outpatient procedure, and patients can usually return to their normal activities the following day with some minor limitations, and can typically try to start conceiving again 2 weeks after the procedure (with her next period).

If fibroids are larger or are located within the wall of the uterus (intramural), then removal is usually performed abdominal through a bikini incision in a procedure called an abdominal myomectomy. In these cases, the procedure may require 2 nights of hospitalization and recovery and two to three months prior to attempted conception.

Testicular Sperm Retrieval (TESA)
The testicular sperm aspiration/extraction (TESA) involves the direct removal of sperm from the testicles. Because comparatively few sperm are discovered during a TESA procedure compared to normal male ejaculate, it is required that IVF with ICSI be utilized in conjunction with the TESA procedure. TESA procedures are preformed either percutaneously or microscopically. Percutaneous testicular sperm retrieval.

When dealing with obstructive azoospermia (a blockage and normal sperm production is present), a simple percutaneous extraction of sperm is recommended. This procedure is performed under anesthesia (local or general) whereby a biopsy needle is utilized to extract a very small amount of testicular tissue. A laboratory expert will isolate sperm from the testicular tissue, which will be used in conjunction with ICSI during the IVF procedure. The wound is closed with a few small absorbable stitches.

Microscopic testicular sperm retrieval
In clinical scenarios in which the testes are not producing adequate amounts of sperm, also called non-obstructive azoospermia, microsurgical testicular sperm extraction is performed. Non-obstructive azoospermia may be the result of testicular atrophy, Y deletions, Kleinfelter’s cases, or post-chemotherapy/radiation. In this scenario, under general anesthesia, the TESA is performed using an operating microscope to search for testicular tubules that appear more developed and contain mature sperm. A microscopic TESA may take several hours. The tissue is removed and a laboratory expert will search the tissue for sperm which, if found, will be used in conjunction with ICSI during the IVF procedure.

A patient may return to normal activities 1-2 days after a percutaneous TESA procedure, and may resume intercourse within 1 week. A patient may return to normal activities 7 days after a microscopic TESA procedure, and may resume intercourse within 2 weeks.

Side effects of a TESA procedure may include hematoma, infection, and hydrocele.

Varicocele Repair
Varicoceles describe a condition where the veins located in the scrotum surrounding the testes are dilated and enlarged. Approximately 15% of all men have varicoceles and, for most men, they do not seem to impair testicular function. However, about 40% of all men with infertility have varicoceles and it is generally believed that the presence of a varicocele impairs sperm production. Although the exact effect a varicocele has on sperm production is not known, it is suspected that an increase in testicular temperature may occur, which does not allow for sperm to mature properly. Most infertile men with varicoceles have improvement of semen quality after varicocele repair, and some infertile men with varicoceles are able to achieve a conception after varicocele repair. Varicoceles are found during a physical examination. Upon detection, the physician will also order a semen analyses to determine if the varicocele may be impacting sperm production and maturation. For varicoceles that are suspected to be interfering with fertility, surgical repair may be recommended. Surgical repair of a varicocele is done in an outpatient surgical center with general or local anesthesia. The surgeon will ligate, or tie off, the dilated veins during the procedure that lasts approximately one hour. Many urologists will perform this procedure using microscopic techniques, as the higher magnification allows for increased precision. Surgical intervention is successful in 90% of cases in that the dilation of veins is corrected and does not recur; approximately 60-80% of men have improved sperm count and motility after repair of the varicocele. About 40% of couples will subsequently initiate a pregnancy following a varicocele repair.

A patient may return to normal activities 2-3 days after a varicocele repair, including resumption of intercourse after 1 week of abstinence. Attempts to achieve a pregnancy can occur upon resumption of intercourse.

Side effects of a surgery for varicocele repair may include an infection, hydrocele, hematoma, or recurrence, though these side effects are diminished by the use of microsurgical techniques.