Males and Semen Analysis
Tests for Ovulation
Tests for Tubes
Induction of Ovulation
IUI Intrauterine Insemination or Sperm Wash
IVF or Test Tube Babies (and ICSI)
Ectopic Pregnancy (Tubal Pregnancy)
PCOS PolyCystic Ovarian Syndrome
How do people get pregnant? This is a long and amazing story. In short, boy meets girl. And this is what we need to investigate when pregnancy is delayed. So, for boy, we need to make sure that the semen has good quality sperm in terms of number and movement. For girl, we need to look for evidence of ovulation. Unlike sperm, we cannot really see the egg, but we can run some hormone tests that predict ovulation. We can also follow the growth of the egg by transvaginal ultrasound. For the 'meet' part, we do tests that show that the uterine tubes are open.
If we find a problem in any of these, we plan treatment to overcome it. If everything comes back normal, we still go ahead with our treatment according to a stepped plan.
Make sure you are taking your folic acid. The best effect is to take it for at least 3 months before you do get pregnant. We may also start you on other supplements like vitamin D, baby Aspirin, etc. There is some evidence that these improve your ovulation and decrease the chances of miscarriage.
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Males and Semen Analysis
This has nothing to do with potency or the ability to have intercourse. It is a microscopic analysis of sperm in the semen. If I have given you a lab requisition for a semen analysis (for your partner), visit the receptionist for more info. She will give you a kit with a small container, instructions and addresses of the labs that run the test. The sample is not processed at all lab locations. A physician has to be on site to read it within a fixed time frame. Sometimes semen analysis can be done in a fertility lab.
Instructions: He should abstain (have no sex, no ejaculation) for 2-5 days before the test. For best results, there should be no less than 2 and no more than 5 days of abstinence. . The specimen should be collected directly into the sterile container provided. No condoms or lubricants should be used as this may interfere with the proper testing procedures. All the seminal fluid should be collected into the sterile container. The first part of the ejaculate has the greatest concentration of sperms. The time of ejaculation should be recorded on the container, together with his name (and of course date).
The specimen should be transported to the lab within a maximum of about 1 hour, and should be kept at body temperature during transport. You may need to keep it in an internal pocket or under your armpit in really cold weather.
In the testing kit you have a detailed copy of the instructions and the lab locations that currently accept specimens.
Special Sperm testing
May include using strict criteria or DNA fragmentation testing. These may be offered as needed. Indications may include unexplained infertility (inability to get pregnant when all tests have come back normal), or previousl failure of fertility testing.
Other Male Tests:
We ask for blood hormone levels, and sometimes KAryotyping (a genetics test for chromosomes) if there are low number of sperm cell, repeated failure of fertility treatment, recurrent miscarriages, etc)
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Tests for Ovulation
Typically some hormones tests will be arranged. Some (FSH, LH, Estradiol) need to be done early on in the period (usually days 2 or 3 or 4). Others, like Progesterone, typically later in the period (20, 21 or 22). AMH, Prolactin and TSH, if needed, can be done at any time. AMH is still not a standardized test, is done in a lab in California, and labs typically charge you something around $100 to perform. Results may take 10-14 days to come back.
Tests for the Tubes
And this is for the 'meet' part. If the sperm and egg cannot meet, pregnancy in the 'old fashion way' may not be possible. The gold standard test for the tubes is a procedure called Laparoscopy with Tubal Dye. This is a procedure that is done in the hospital, in the OR. You need to be put to sleep for this procedure. Basically, we use a camera (the laparoscope) that goes into your tummy through your belly button. We then inject a blue dye through your cervix, and look and see if the dye spills over from the tubes. This is the same path that the sperm will walk.
Laparoscopy has some other advantages over other methods. We can actually see the uterus, the tubes and the ovaries, and can see if there are other problems in them. The classic finding usually is Endometriosis (endo). If we do find endo, we can treat it at the same time of the laparoscopy.
Laparoscopy is a day procedure, with minimal pain post operatively, and short recovery. You go home from the hospital the same day, and can go to work in 1-2 days after the procedure. You will need someone to come with you to drive you home.
SonoHysteroGraphy (SHG): This is basically an ultrasound examination. A small catheter goes up through your cervix and a dye is injected through. Using ultrasound, we can test to see if your tubes are open or not.
This is a relatively simple procedure, well, similar to your usual ultrasound scan. It may be a bit crampy, though. You can drive in and out of the ultrasound center yourself. It may not be conclusive in all cases, though, and you may need to for for the laparoscopy later on. It is typically done on 2 sessions, the first immediately after the period has finshed, the second 1-2 days later. You need to call the ultrasound center to book when your period starts.
HysterosSalpingoGraphy (HSG): This is an x-ray examination. It is similar to SHG, but uses x-ray not ultrasound.
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Induction of Ovulation (Clomiphene, Femara, FSH shots)
Ovulation occurs as a result of a complex process involving parts of the brain, the pituitary gland, hormones, and the ovaries. Put simply, the brain 'tells' the pituitary to produce a hormone that 'tells' the ovary to produce an egg. The female hormone Estrogen is produced in this process as well. When there is enough of the hormone Estrogen, the brain stops the command and waits to see if we get pregnant or not. If not, the hormone level drops, the brain feels the drop, and therefore calls on the ovary again to produce more eggs. It is with the hormone levles dropping that you get your period.
Clomiphene and letrezole (the chemical name of drugs used to induce ovulation) will act on the above pathway to make your ovary produce eggs. The reason to use them can be because you are not making eggs on your own, or not as often or as strong as they should be. They work in different ways, but the end result is the same. They help you ovulate and hopefully this will make you get pregnant.
We will talk more about who qualifies and who will benefit from their use.
Classically they are taken on days 5-6-7-8-9 of your cycle for Clomiphene and days 3-4-5-6-7 for Letrezole. Day 1 is your first day of the period, or when you first saw bright red blood.
We usually monitor you by ultrasound during your treatment. A baseline ultrasound is done before you start the medication, so this needs to be done within the first few days of your periods (yes, you are still mentruating). And then again on day 10, 11 or 12 to monitor how you reacted or responded to the medication. We may continue ultrasound every 1-2 days until the eggs reach a size indicating that you are about to ovulate. We sometimes ask for a hormonal test to make sure that your eggs are properly producing the hormone Estrogen, not just getting bigger on ultrasound.
Depending on your clinical course, we may then recommend having intercourse on one of the days when we think you are ovulating. We may alternatively give you a shot to trigger ovulation, so that we have more control in knowing when ovulation will happen. This is especially true when we have planned IUI (or sperm wash).
Side effects are usually mild, and include hot flashes, visual changes, breast tenderness, nausea, vomiting, etc. We know some 5-8% may end up with twin pregnancy. You may think this is nice, but when you have 2 babies at the same time it is a handful and pregnancy can be more complicated.
Ovarian enlargement and abdominal swelling are know complications of induction of ovulation, luckily with the medications take by mouth this is very rare, and is usually mild when it happens.
You will take these medications for something between 3-6 months, if we think you ovulated on them. If you have not been pregnant by that time, we will review our options and see what alternate methods can be used.
FSH: There are times when medications by mouth are not enough to make you ovulate, and you may need to take some shots. These contain the hormone FSH that stimulates your ovaries to produce eggs. They are 'stronger' than the pills in a sense. They are more likely to make you ovulate, have a higher chance of producing more than one egg, usually actually much more, and may be associated with more chances of twin pregnancy. You will need to be monitored more closely with ultrasound and blood work while using this kind of medication. Again, they are more expensive than the pills.
OHSS: There is chance that you may end up with something called OHSS (Ovarian Hyper Stimulation Syndrome) when you take shots. The ovaries swell and have many eggs in them. The ovaries may be painful, and can be quite large. You may feel bloated and your tummy may swell. Rarely you may have some fluid collection and other complications as well. With the doses we use for just induction of ovulation and sperm wash this complication is not very common, but when you are planned for test tube babies (IVF-ICSI), the chances of OHSS happening become higher. It may be mild or severe. It is usually managed be observing you and following up on how you change every day. There are methods to prevent it from happening, or making it less severe. You will be give more information before you are started on these shots.
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Intra Uterine Insemination- IUI (or sperm wash)
Is basically taking a semen sample from your partner (the same way as for the semen analysis), process it in the lab in a special way, and then inject this inside your uterus. There are many reasons why you may need this step, including reduced number or activity of sperm, or sometimes when no reason is found for delayed pregnancy.
Your tubes need to be open for this test to be done.
What we usually do is give you one or the others of a medicine to make you ovulate (induction of ovulation). Ultrasound monitoring of the eggs is then done as usual. When the egg reaches a certain size, and looks ready we plan the procedure. We usually will give you a shot that makes you ovulate at a predictable time. We want to 'time' the insemination so that sperm is present at the time that the egg is coming out of the ovary. The shot is a human hormone called Chorionic Gonadotropin (can have different trade names). When the egg is ready, we give you the shot on one day and the wash will be arranged for the following day.
We work in collaboration with IVF Canada in Scarborough. The lab requests that all specimens processed at their site to be tested for some communicable diseases. Since these tests take about 2 weeks for the results to come back from the public health labs, I usually like to have them done a bit early on, and have them ready in your chart. Actually, we only need your partner to get tested for this procedure, however, you will need to be tested for nearly the same things when you get pregnant. This is why I recommend that you go together.
On the day we will have the procedure done (the following day after the shot) we arranged for the lab to be ready for you. You can go with your partner and he can produce the sample there (they have private rooms). Or if you prefer, you can have the sample produced at home and you bring with you to the lab. They will process it and give you the sample in a special container that you need to bring to our office. In the office, we ill proceed with the insemination. Be sure to contact the lab to make arrangements with them regarding how you will arrange for the sample, and for other instructions. Before you leave our office, you should be given the time frame and any special instructions as well as the phone numbers that you may need. We usually arrange for this to occur around the lunch hour so as not to interfere with your partner's schedule. You will need to take 3-4 hours off work that day.
There is hardly any more discomfort with this procedure than what you may have with a routine Pap test. You will need to stay with us for about 30 minute in the office. You can drive back home or go back to work when we are done. You should not use Ibuprophen, Advil, Aleve or similar pain medications for a few days before and after the procedure. Tylenol is fine.
There may be an additional cost to this process.
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IVF or test tube babies
This is a procedure that has helped a huge number of couples to fulfill their dream of forming their own family. The procedure in short combines eggs and sperm in a test tube, and this is where the name comes from . The sperm we get the same way as in a semen analysis (sometimes if there was a problem with the male partner, other methods can be used, extraction is usually done by a Urologist). The eggs we get from the female partner. She gets medications for induction of ovulation, usually shots (FSH, and a hCG shot). The eggs and sperm are kept in special incubators for anything between 2 and 5 days. They are then transferred into the uterus.
This is a very shot description of a long and complicated procedure. We do this in collaboration with IVF Canada. You will be given more detailed information about this option if we think this is the best option for you.
ICSI is a special technique that is added to IVF. One sperm is injected inside one egg to make sure we get a fertilized egg.
More and more centers now are shifting to freezing all embryos. The idea is that with all the medications that we use for stimulating the eggs to growth, the uterus might not be at its best to receive the emrbyo. Waiting one or two months will let the uterus settle, and a frozen embryo trasnfer cycle is done. Ths will also prevent OHSS.
IVF is funded by the Ministry of Health since Janurary 2016. One cycle per female with a valid health card. There is usually an extra cost that you will incur, the most significant of which is the medication cost. Again, more detailed will be given to you as needed.
With IVF there may be a higher chance of OHSS, multiple pregnacies and possibel Ectopic pregnancies.
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This is any pregnancy that does not occur inside the cavity of the uterus. In most cases the pregnancy occurs in the tube. Only the uterus can carry a baby for 9 months. The tube has very thin walls, and will not be able to carry the baby for long before it bursts open. The pregnancy is lost and the pregnant woman will bleed from the tube, and may have some vaginal bleeding as well. There is usually a sharp pain with this as well.
About 1 in 200 pregnancies will be an ectopic pregnancy or about 0.5% of pregnacies. With fertility treatment the chances may be higher than this. Ectopic pregnancy may be a serious problem if missed, so we recommend that you follow up with is closely up until we clearly see your baby inside your uterus by ultrasound. If you have to move to another place, make sure you contact a gynecologist who specializes in fertility management, or at least go to a walk in or Emergency Department in a hospital if you have any abdominal pain or vaginal bleeding. Do mention that you have been under fertility treatment.We typically will fit you in within one or two days to follow up if you have any of these symptoms.
To make the diagnosis of ectopic pregnancy is tricky. It is based on a pregnancy blood level higher than 1500 and an ultrasound that shows no pregnancy inside the uterus. Sometimes you may bleed prior to the level reaching 1500, say 900. At this level we know that even with a normal pregnancy we will not be able to see a pregnancy inside the uterus, because the level is too low. At other times you may have some bleeding inside the uterus that the radiologist may interpret as an early pregnancy sac, when in reality you have an ectopic pregnancy.
The treatment depends on how early the diagnosis is made, how high the levels are and if you are in pain or bleeding. Options may include just follow up closely, an IM shot (medication called Methotrexate-more info will be given as needed), surgery through a laparoscopy or open surgery. With surgery the tube may be saved or may have to be removed.
More information about each option will be discussed with you if you were diagnosed with ectopic pregnancy.
It is important to receive your Rhogam shot if you are Rh negative. If you do not know your blood group, make sure you get tested.
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PCOS or PolyCystic Ovarian Syndrome
Normally women will have a menstrual period once a month. This is the result a complicated series of events that prepare the uterus for a pregnancy. If no pregnancy occurs, the uterus loses its inside lining in the form of the menstrual blood, and tries again the following month.
The events are under control of some hormones, mainly FSH and LH. These effect the ovary to produce an egg, and in the making also produce the hormones Estrogen and Progesterone (or E and P). Inside the ovary, that are a few eggs that start to grow once every month. One of the eggs will overgrow all the others, literally eat up all hormones to its own advantage, and this results in it becoming the only one to leave the ovary that month. This occurs in relation to some wavy pattern of hormones.
If we have PCOS, the eggs in the ovary are all the same size, not one of them is large enough to ovulate, or to stop the others from growing. We lose the wavy hormonal pattern, and the FHS and LH hormones end up being higher than normal, and in kind of a flat line. The end result is no ovulation, late periods or may be none at all for a few months on end. With this, you may have increased body hair, acne, usually increased body fat, and may be high blood pressure and some changes in the blood cholesterol.
The fat itself will act to make this condition continue, and it becomes more difficult to lose the extra pounds. These changes are caused in part by a hormone called IGF, some factor that may also have something to do with diabetes. The treatment, therefore, may be started by Metformin, a medication that may be used for some types of diabetes, but that may also help make periods regular and cause you to ovulate.It will also help you lose weight, given you are start a diet.
With PCO, you need to take care of what you eat. The idea is to reduce carbohydrate intake. You should also STOP eating sugar. This is tricky. You need to stop adding sugar to beverages, stop eating (and drinking) food that has sugar (juice, cake, ice cream, pop, etc). And this hold true for both natural and fake sugars. So, you need to stop drinking regular pop as well as diet pop. There is more to it than just calories. Even diet sugars (aspertame and similar products) may still cause your insulin and IGF to go up, and this keeps the PCO cycle going on.
If you have PCOS, and especially if you are not menstruating every month, you need to do something or the other. To start with, we may take a sample from the inside lining of the uterus to make sure you do not have any abnormal cells that developed because of the irregular menstruation. The treatment after that will depend on whether you want to get pregnant or not. If you do not plan to get pregnant in the near future, you may start birth control pills to make your periods regular, and to protect your uterus and bone density. If you plan on a pregnancy, we usually start you on metformin and the one of the methods of induction of ovulation. With PCOS you are at higher risk of developing OHSS than other women.
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There are many occasions that we may be using birth control pills. This is used to regularte your cycle, control your PCO before treatment, etc.
If we are going through an induction of ovulation cycle, we may need to see you every other day. This may affect your work schedule. We will try to accomodate early or late appointments. We also usually are working 12-1 pm, so you can come on your lunch hour.
Sometimes we may need to see you on weekend. Dr Hadi will make arrangements to meet you in the office. On weekends, our receptionist might not always be available. If you prefer the presence of a third party at the time of the ultrasound, please inform us so that we can try to accomodate that. On weekends, sometimes the better option would be if you have someone accompany you to the visit, as our receptionist might not always be available.
Sometimes, if Dr Abdel Hadi is not avilable in Whitby, and is working that day in IVF Canada in Scarborough, we might ask you to see him there.