Fertility Program: Advanced Reproductive Services
Each and every couple will have a personal and individualized treatment plan developed to meet their goals. Please follow these links to learn more about the advanced reproductive services we offer.
Ovulation Induction (OI), also referred to as Controlled Ovarian Hyperstimulation (COH), is often one of the first treatments recommended to patients and couples with fertility issues. Ovulation Induction is the use of fertility medications to help stimulate the recruitment of egg(s) development and/or trigger ovulation. These medications are given by injection. Pelvic ultrasounds and blood tests to measure hormone levels assist with monitoring egg(s) development to determine when one is most fertile and likely to ovulate. Assisted reproduction technology (ART) procedures, including IUI and IVF, utilize ovulation induction.
One of the risks of injectable fertility medications is the increase in multiple births to approximately 1 in 5. The majority of these pregnancies are twins, but 5 to 10 percent can be triplets or more, referred to as Higher Order Multiples. We are very careful in using these medications to minimize the incidence of multiple births.
Each patient and couple is unique, therefore, Dr. Lindheim will customize and tailor treatment and prescribe medications to fit the needs specifically for that individual patient or couple. In addition, Dr. Lindheim and our staff will provide a comprehensive discussion to educate and train an individual patient or couple on the possible side effects including Ovarian Hyperstimulation Syndrome (OHSS) which can be associated with nausea, vomiting, abdominal pain and bloating. On rare occasions, severe OHSS may cause fluid to suddenly build up in the abdomen and lungs and could result in hospitalization.
Intrauterine insemination (IUI), is the process of placing sperm into a woman’s uterus at the time that an egg is released from the ovary (ovulation). Sperm used during the IUI procedure are typically “washed” and can either be obtained from the woman’s male partner or from a sperm donor. “Washed” sperm — or sperm that is separated from the fluid that it swims in (seminal fluid) — makes the sperm more mobile and increases the number of moving sperm within the reproductive tract. The greater the number of moving sperm means the greater the likelihood that sperm will locate an egg.
To place the sperm inside the uterus, a speculum is gently inserted into the vagina and a very thin catheter is passed through the cervix into the uterus. This procedure causes no more discomfort than is usually experienced during a pap smear. The washed sperm is then released from the catheter. The IUI process, however, does not guarantee that the egg and sperm will come together to form an embryo (fertilization).The sperm must reach and fertilize the egg on its own.
IUI is used for a variety of conditions, including male infertility, cervical or mucous problems and to more exactly time the interaction of the sperm with the ovulating egg. For many patients and couples undergoing IUI, the use of hormone medications is needed and/or recommended to concurrently enhance the female partner’s fertility.
Over the past 5 years great advances have been made in the area of cryopreservation. As discussed in regards to embryo cryopreservation, the vitrification method is the method of choice for cryopreservation of oocytes (eggs). There are two significant reasons that a woman may choose to cryopreserve her oocytes.
The process to obtain the oocytes to cryopreserve is straightforward. It is the IVF process except the eggs once collected are not fertilized but rather cryopreserved. The patient then can have the embryology laboratory thaw the eggs in the future and fertilize them with the patient’s sperm choice. Once fertilized the embryos develop as if they were never frozen. Pregnancy outcome data suggest that success rates are running only about 15% lower in most categories. As this new advancement progresses please be sure to have current discussions with Dr. Lindheim as to your individual prognosis for success.
Pre-implantation genetic diagnosis (PGD) and Pre-implantation genetic screening (PGS) is a way for intended parents to prevent a pregnancy affected by a genetic condition or chromosomal disorder. This advanced testing identifies specific embryos that are free of abnormalities before they can be transferred into a woman’s uterus (womb) by way of in-vitro fertilization (IVF).
PGD-PGS can test for and potentially prevent many different diseases and genetic disorders, including:
In addition to safeguarding against genetic diseases or disorders, PGD-PGS can also assist intended parents interested in having a child who is a healthy bone marrow or blood match to another family member by selecting embryos that are an HLA (human leukocyte antigen) match. HLA are the proteins on white blood cells that are matched in order to do a blood or bone marrow transplant.
Single gene defects
Single gene defects are genetic disorders due to inheritance patterns (recessive or dominant) and can be passed on if they are prevalent in your family. Some of the more common single-gene disorders include Tay-Sachs disease, cystic fibrosis, muscular dystrophy, fragile X syndrome or spinal muscular atrophy.
Chromosome translocations are abnormalities of a chromosome’s structure. Translocations occur when fragments or pieces of a chromosome break off and rearrange onto a different chromosome or rearrange within itself. Translocations can either be balanced or unbalanced. Balanced translocations contain all genetic information, but pieces of chromosomes have switched places resulting in no gain or loss of chromosome material. Unbalanced translocations result in an individual having more or less chromosomal material, thus causing genetic defects.
Aneuploidy is a condition in which a cell has an incorrect number of chromosomes—too many or too few. Chromosomes contain all of your genes and DNA, the building blocks of the body. Humans have 46 chromosomes, or 23 pairs. These include chromosomes 1 to 22 (the autosomes) and chromosomes X and Y (the sex chromosomes.) During fertilization, an embryo receives 23 chromosomes from the sperm and 23 chromosomes from the egg to form either 46,XY (normal male) or 46,XX (normal female). Aneuploidy disorders do not typically run in families and can include Down syndrome, Trisomy 18, Trisomy 13 and Turner syndrome.
Limitations to PGD-PGS
The risk of a misdiagnosis resulting in a fetus or baby with chromosome abnormalities after PGD-PGS is less than 2 percent. However, PGD-PGS is unable to study every chromosome and does not guarantee the birth of a healthy baby.
Because of these limitations, prenatal testing later in pregnancy is strongly advised in order to confirm the diagnosis and review the number and structure of all the chromosomes.
Additional Prenatal Testing
Chorionic Villous Sampling (CVS) is a procedure done late in the first trimester (between 9 and 11 weeks) that takes cells from the placenta and analyzes them for chromosomal abnormalities.
Amniocentesis is a procedure usually done between 15 and 20 weeks of pregnancy that takes fluid from around the baby and analyzes the baby’s cells in the fluid for chromosomal abnormalities. Your obstetrician can provide you with more information on these important tests.
Also based on cell development, some PGD-PGS testing may yield no diagnosis, partial diagnosis or even sometimes result in no normal embryos for embryo transfer. The likelihood that this will happen is often dependent on your age.
Male factor infertility can result in a variety of issues such as complete absence of sperm in the ejaculate (azospermia) due to either an obstruction/blockage (obstructive azospermia) often caused by a previous vasectomy or congenital-birth defects. For these conditions, there is a surgical option of retrieving sperm from either the vas deferens, epididymis or testis to be used in an IVF cycle(s) to conceive. Because the surgically retrieved sperm are immature, fertilization is achieved by injecting selected sperm directly into the egg by a process called.
Males considering this option are required to see a urologist prior to surgery to assist with determining the best approach for retrieving sperm including:
Microsurgical Epididymal Sperm Aspiration (MESA)
MESA collects sperm by aspirating fluid from the epididymis of the male reproductive tract. A fine needle is inserted through the scrotum into the epididymis and sperm are obtained by gentle suction. This procedure is used for cases of obstructive azospermia
Testicular Sperm Aspiration (TESA)
TESA is where a fine needle is inserted into the testis and a sample of tissue is obtained by gentle suction and examined under the microscope. If sperm are not found, a small tissue sample (testicular biopsy) is taken through a small incision in the scrotum and testis, where sperm can then be extracted. This procedure is used for cases of non-obstructive azospermia.
If possible, MESA and TESA procedures are timed to coincide with the egg retrieval step during the IVF cycle. For some, scheduling may be an issue; Surgical Sperm Retrieval can be completed before the IVF cycle beings and frozen (cryopreserved) for future use. The extraction of sperm completed by MESA and TESA typically results in enough sperm to allow several IVF cycles. These procedures can be performed on an outpatient basis using sedation to eliminate any pain or discomfort.
While the most successful treatments for infertility are the assisted reproductive technologies (ART), certain patients have anatomical causes of infertility and require surgical techniques to correct anatomical disorders of the uterus, fallopian tubes and ovaries to help restore reproductive function.
Most reproductive surgery is minimally invasive — resulting in no or small incisions — and can be performed through an endoscope on an outpatient basis. An endoscope involves the use of either a laparoscope (a small telescope inserted into the abdominal wall) or a hysteroscope (a small telescope inserted within the uterine cavity) to see inside the patient's body. Minimally invasive surgery is often associated with decreased pain compared with that of traditional surgery and allows patients to return home the same day.
Dr. Lindheim is one of the most experienced surgeons in the country and is highly trained to perform the following pelvic or reproductive surgeries:
A tuboplasty corrects the blockage or scarring of the fallopian tube(s). Fallopian tube blockage can hinder the sperm and egg from reaching one another in order for fertilization to occur. This is often referred to as tubal infertility. Blockage or scarring may occur as a result of a previous pelvic infection, inflammation including endometriosis and previous pelvic surgery.
A tubal reversal is the re-opening or re-connecting of "tied" fallopian tubes from a previous tubal ligation or "having your tubes tied." A number of factors including the patient's age and how the tubes were "tied" determines if one is a candidate for this procedure. Unfortunately, not every tubal reversal is successful but the vast majority, as many as 75 percent of couples, achieve pregnancy.
Uterine malformation is the result of abnormal development of the uterus, fallopian tubes, cervix and/or vagina during fetal development. These abnormalities can result in symptoms including no menstrual cycles (amenorrhea), infertility, recurrent pregnancy loss and chronic pelvic pain. Whether surgery is needed depends on the extent of the individual's problem.
It is estimated that endometriosis occurs in roughly 5 to 10 percent of women. Endometriosis is a condition where tissue that normally lines the uterus develops outside the uterine cavity in abnormal locations such as the ovaries, fallopian tubes and abdominal cavity. Symptoms may depend on the location of the excess tissue development and can cause pelvic pain (often worsening during the menstrual cycle), painful intercourse and infertility. Treatment, such a hormone therapy, surgery or both, may help relieve the pain associated with endometriosis and restore one's fertility.
Some women who have had previous pelvic surgery, pelvic infections or suffer from endometriosis may have a buildup or excess of scar tissue. Surgical procedures can be performed to remove scar tissue because scar tissue can restrict the egg from reaching the fallopian tube. With endometriosis, the growth and bleeding cycle of endometrial implants causes irritation, inflammation and a release of toxins that produce scar tissue around the ovary. In this case, the entire ovary or fallopian tube can become encased in scar tissue and in more severe cases can stick to nearby structures such as the bowel.
Approximately 30 to 50 percent of women have fibroid tumors, which are typically benign, non-cancerous growths of muscle in the wall of the uterus. While most fibroid tumors go unnoticed, some can grow during the reproductive years, and depending on their size and location can cause infertility, recurrent miscarriages, excessive uterine bleeding, pain and pressure or severe anemia. Depending on their size and location, fibroid tumors can be removed either hysteroscopically or laparoscopically to restore normal fertility and menstrual function.
Ovarian cysts are fluid filled sacs within the ovary. While most are benign, non-cancerous and resolve on their own, some ovarian cysts cause infertility and pain and may require surgical removal.
Abnormal Uterine Bleeding
Abnormal uterine bleeding is heavy or irregular bleeding between periods that happens for different reasons including polyps, fibroids or cancer. This bleeding can also occur without any apparent cause and is also referred to as Dysfunctional Uterine Bleeding (DUB). Treatments include hormone therapy or hysteroscopy surgery.
The diagnosis of cancer can be given at any age. Cancer in a reproductive aged male or female can be particularly traumatic. Each year, more than 140,000 people are diagnosed with cancer during their childbearing years. While modern medicine gives young adults a better chance at surviving cancer and other serious diseases than ever before, treatments such as chemotherapy, radiation and surgery bring up many reproductive questions:
In addition, fertility preservation is not limited to oncology patients who will face chemotherapy, radiation, or surgical treatment. Patients requiring bone marrow, stem cell transplants, and even some with rheumatic diseases may face the decision of fertility sparing options.
Fortunately, there are steps patients can take in order to help safeguard their fertility. These include sperm banking for men and adolescent boys and eggs and embryo banking for women before undergoing cancer treatment.
At Wright State Physicians Obstetrics & Gynecology, we offer counseling, treatment, and support to discuss:
Before starting cancer treatment(s), it is important to discuss any concerns regarding your future fertility with your physician. An open discussion will help you plan your cancer treatment and assure a prompt referral to the reproductive fertility specialist soon after your diagnosis to explore your fertility sparing options.
The focus of each of these fertility sparing treatments is to store sperm, eggs or embryos before you undergo treatment for cancer. Once the cancer treatment is completed and you are healthy enough then the stored sperm, eggs or embryos are available for use.
Sperm banking (sperm freezing) is done before medical treatment begins. Semen samples are typically produced through masturbation in a private collection room. For males who have no sperm in their ejaculate—due either to an obstruction or testicular dysfunction—there is the option of undergoing Surgical Sperm Retrieval. Once collected, the sperm is assessed, processed, cryopreserved (frozen) and stored at our laboratory for future use by IUI or IVF.
Embryo banking (embryo freezing) involves harvesting a woman’s egg(s) and inseminating the eggs with sperm in the laboratory to produce an embryo for future use through IVF. This process takes about two weeks to complete. The resulting embryos are cryopreserved (frozen) and stored until you are in complete remission and healthy enough to become pregnant. Collaboration with your oncology physician is critical.
Oocyte (Egg) banking
Oocyte (Egg) banking is one of the newest innovations in field of assisted reproduction and has resulted in the birth of more than 1000 babies worldwide to date. Similar to embryo banking, egg banking also takes about two weeks to complete. The resulting eggs are cryopreserved through a process called vitrification and stored until you are healthy enough to become pregnant. This new technology potentially allows women to bank eggs without a significant other and alleviates issues of immediately identifying a sperm source. Again, collaboration with the treating physician is critical.