Infertility and In Vitro Fertilization

Infertility and In Vitro Fertilization

Today, in vitro fertilization (IVF) is practically a household word. But not so long ago it was a mysterious procedure for infertility that produced what were then known as "test-tube babies." Louise Brown, born in England in 1978, was the first such baby to be conceived outside her mother's womb.

Unlike the simpler process of artificial insemination -- in which sperm is placed in the uterus but conception precedes otherwise normally -- IVF involves combining eggs and sperm outside the body in a laboratory. Once an embryo or embryos form, they are then placed in the uterus. IVF is a complex and expensive procedure; only about 5% of couples with infertility seek it out. However, since its introduction in the U.S. in 1981, IVF and other similar techniques have resulted in more than 200,000 babies.

A Visual Guide to Understanding the Fundamentals of Conception

What Causes of Infertility Can IVF Treat?

When it comes to infertility, IVF may be an option if you or your partner have been diagnosed with:

• Endometriosis
• Low sperm counts
• Problems with the uterus or fallopian tubes
• Problems with ovulation
• Antibody problems that harm sperm or eggs
• The inability of sperm to penetrate or survive in the cervical mucus
• An unexplained fertility problem

IVF is never the first step in the treatment of infertility. Instead, it's reserved for cases in which other methods such as fertility drugs, surgery, and artificial insemination haven't worked.

If you think that IVF might make sense for you, carefully assess any treatment center before undergoing the procedure. Here are some questions to ask the staff at the fertility clinic:

• What is your pregnancy ratio per embryo transfer?
• What is your pregnancy rate for couples in our age group and with our fertility problem?
• What is the live birth rate for all couples who undergo this procedure each year at your facility?
• How many of those deliveries are twins or other multiple births?
• How much will the procedure cost, including the cost of the hormone treatments?
• How much does it cost to store embryos and how long can we store them?
• Do you participate in an egg donation program?

What You Can Expect From IVF

The first step in IVF involves injecting hormones so you produce multiple eggs each month instead of only one.You will then be tested to determine whether you're ready for egg retrieval.

Prior to the retrieval procedure, you will be given injections of a medication that ripens the developing eggs and starts the process of ovulation. Timing is important; the eggs must be retrieved just before they emerge from the follicles in the ovaries. If the eggs are taken out too early or too late, they won't develop normally. Your doctor may do blood tests or an ultrasound to be sure the eggs are at the right stage of development before retrieving them. The IVF facility will provide you with special instructions to follow the night before and the day of the procedure. Most women are given pain medication and the choice of being mildly sedated or going under full anesthesia.

What You Can Expect From IVF continued...

During the procedure, your doctor will locate follicles in the ovary with ultrasound and remove the eggs with a hollow needle. The procedure usually takes less than 30 minutes, but may take up to an hour.

Immediately following the retrieval, your eggs will be mixed in the laboratory with your partner's sperm, which he will have donated on the same day.

While you and your partner go home, the fertilized eggs are kept in the clinic under observation to ensure optimal growth. Depending on the clinic, you may even wait up to five days until the embryo reaches a more advanced blastocyst stage.

Once the embryos are ready, you will return to the IVF facility so doctors can transfer one or more into your uterus. This procedure is quicker and easier than the retrieval of the egg. The doctor will insert a flexible tube called a catheter through your vagina and cervix and into your uterus, where the embryos will be deposited. To increase the chances of pregnancy, most IVF experts recommend transferring three or four embryos at a time. However, this means you could have a multiple pregnancy, which can increase the health risks for both you and the babies.

Following the procedure, you would typically stay in bed for several hours and be discharged four to six hours later. Your doctor will probably perform a pregnancy test on you about two weeks after the embryo transfer.

In cases where the man's sperm count is extremely low, doctors may combine IVF with a procedure called intracytoplasmic sperm injection. In this procedure, a sperm is taken from semen -- or in some cases right from the testicles -- and inserted directly into the egg. Once a viable embryo is produced, it is transferred to the uterus using the usual IVF procedure.

Success Rates for IVF

Success rates for IVF vary depending on a number of factors, including the reason for infertility, where you're having the procedure done, and your age. The CDC compiles national statistics for all assisted reproductive technology procedures performed in the U.S. The statistics group together all procedures that constitute assisted reproduction technology (ART), including IVF, GIFT, and ZIFT, although IVF is by far the most common accounting for 99% of the procedures. The most recent report from 2007 found:

• Pregnancy was achieved in more than 32% of all cycles on average.
• The percentage of cycles that resulted in live births was 25.6% on average.

Other Issues With IVF

Any embryos that you do not use in your first IVF attempt can be frozen for later use. This will save you money if you undergo IVF a second or third time. If you do not want your leftover embryos, you may donate them to another infertile couple, or you and your partner can ask the clinic to destroy the embryos. Both you and your partner must agree before the clinic will destroy or donate your embryos.

A woman's age is a major factor in the success of IVF for any couple. For instance, a woman who is under age 35 and undergoes IVF has a 39.6% chance of having a baby, while a woman over age 40 has an 11.5% chance. However, the CDC recently found that the success rate is increasing in every age group as the techniques are refined and doctors become more experienced.

The Costs of IVF

The average cost of an IVF cycle in the U.S. is $12,400, according to the American Society of Reproductive Medicine. This price will vary depending on where you live, the amount of medications you're required to take, the number of IVF cycles you undergo, and the amount your insurance company will pay toward the procedure. You should thoroughly investigate your insurance company's coverage of IVF and ask for a written statement of your benefits. Although some states have enacted laws requiring insurance companies to cover at least some of the costs of infertility treatment, many states haven't.

Also be aware that some carriers will pay for infertility drugs and monitoring, but not for the cost of IVF or other artificial reproductive technology. RESOLVE: The National Infertility Association publishes a booklet called the "Infertility Insurance Advisor," which provides tips on reviewing your insurance benefits contract.

Annual sonograms are needed to verify correct IUD position

 A retrospective study of women who became pregnant while using intrauterine devices shows that more than half of the IUDs were malpositioned.


Though the displacement may have occurred over time, a UT Southwestern Medical Center researcher suggests that routine sonograms after IUD placement would in the least confirm proper initial positioning.


"Gynecologists typically do a pelvic and speculum exam after placing an IUD, but there's no sonogram involved," said Dr. Elysia Moschos, associate professor of obstetrics and gynecology and lead author of the study, available online and planned for the May issue of the American Journal of Obstetrics & Gynecology. "Based on the results of our study, we believe that sonographic evaluation of IUDs after insertion and for surveillance should be a topic of ongoing consideration."


In the retrospective study of 42 women with IUD placement and a positive pregnancy test, 36 had IUDs that were visualized through ultrasound and 2D imaging. Fifteen of these IUDs were normally positioned, and 21 were malpositioned.


Dr. Moschos said obstetricians and gynecologists should consider sonograms as part of the protocol after IUD insertion and possibly schedule them annually for those with IUDs, which can remain in the body for up to 10 years.


IUDs are a highly effective form of birth control, and pregnancy rates are extremely low. In the rare cases where women do become pregnant while using an IUD, transvaginal sonography during the first trimester can reduce complications by determining the pregnancy and IUD location, as well as whether the device can be retrieved.


Pregnancies complicated by an IUD's presence are at increased risk for first- and second-trimester miscarriage or preterm delivery if the device is left in place. While removing the IUD reduces these risks, the removal process itself carries a small risk of miscarriage.


In the study, 31 women had intrauterine pregnancies, three had ectopic pregnancies and eight had pregnancies of unknown location (biochemical proof of pregnancy but no sac in the uterus). Such cases, Dr. Moschos said, might indicate an early pregnancy that hasn't shown itself yet, an ectopic pregnancy or a miscarriage. Each of the eight pregnancies of unknown location in the study resulted in spontaneous abortion. The three ectopic pregnancies were treated successfully.


All of the patients had given birth before, with an average of two previous deliveries each. Their mean age was 26. The average length of time their IUD had been in place prior to pregnancy was just over two years. At the time the pregnancy was confirmed and IUD location verified, the mean gestational age was eight weeks.


Sonograms of the 31 women with intrauterine pregnancies showed that eight had IUDs within the endometrium; 17 had malpositioned devices; and six had IUDs which were not visible. Patient symptoms were not necessarily predictive of IUD malposition. Some women reported bleeding, pain and missing IUD strings, but 11 women had no indications.


Twenty women went on to have full-term deliveries, while six had failed pregnancies of 20 weeks or less. The outcomes for five of the 31 women were unavailable. Ten of the term pregnancies had successful IUD removals, and five others had no identifiable IUDs, later diagnosed as device expulsions.

14 Questions Women Are Too Embarrassed to Ask their Gynecologists or Girlfriends

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Reducing Birth Injuries & Deaths

Reducing Birth Injuries & Deaths

By LAURA LANDRO

As she was preparing to give birth at Columbia St. Mary's Hospital in Milwaukee last Christmas Eve, Jill Weinshel's blood pressure plunged and her baby's heart rate began to slow. The delivery team acted fast to stabilize both infant and mother. But as the situation became more risky, the decision was made to perform an emergency C-section.

The team had been through the scenario and others like it many times—in a series of training drills using a lifelike pregnant robot, named Noelle, that is programmed to simulate different types of birth emergencies. Though Ms. Weinshel was aware her baby's life was in danger, "it never seemed unmanageable because they were always one step ahead of it," she says. "Everyone knew what their role was and why they were there, and there was no hesitation." Baby Eli was born Dec. 24 at a healthy 7 pounds, 1 ounce.

The teamwork wasn't an accident: It was part of a broader effort at a handful of hospitals and health systems to bring more rigorous safety practices to the field of obstetrics, where communication and teamwork problems are the most commonly cited root cause when things go wrong. The changes, which have led to dramatic declines in birth injuries and deaths, include developing packages of procedures that have shown to produce the best results; making sure every nurse and technician is willing to speak up if they think something is wrong; and delivery-room training that uses robots as well as video cameras to capture and review each step taken, all to prepare for every imaginable scenario.

When Tragedy Strikes

Though relatively infrequent, injuries in the perinatal period—the time prior to and just after birth—can be devastating for families and lead to costly malpractice suits for hospitals. According to the latest data from the American College of Obstetricians and Gynecologists, nearly 91% of ob/gyns have had at least one liability claim filed against them, and 62% of the total claims were for obstetrics care, involving such cases as neurologically impaired or stillborn infants.

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Ascension Health

An obstetrics team at Columbia St. Mary's Hospital in Milwaukee practices safety measures using a high-tech baby simulator called Hal

To help address the problem, the federal Agency for Healthcare Research and Quality has awarded grants of about $3 million each to two groups working on better obstetrics safety: Ascension Health, which includes Columbia St. Mary's, and a team comprising Minneapolis-based Fairview Health Services and the University of Minnesota School of Public Health. The two Minnesota institutions are continuing work on an obstetrics-safety program begun in 2008 by a Charlotte, N.C.-based alliance of some 2,400 hospitals known as Premier Inc.

Studies by Premier have shown that five recurring issues are responsible for the majority of delivery-related problems: failure to initiate a timely Cesarean section; failure to recognize an infant in distress; failure to properly resuscitate a baby; inappropriate use of labor-inducing drugs; and misuse of vacuums and forceps. Injuries happen when delivery teams don't act quickly enough to deal with sudden unexpected events like shoulder dystocia, which occurs when the baby's shoulder gets stuck behind the mother's pubic bone. This can lead to muscle palsy and neurological injuries to the infant and physical trauma for the mother.

To deal with such situations, Premier developed a series of protocols doctors and nurses call "care bundles"—a collection of best practices that, when used together, get better results than any individual intervention.

Starting in July 2008, a group of 16 hospitals used the protocols in the delivery room; through 2009, the group reduced injuries to infants by 11.6% from a baseline period in 2006 and 2007, and reduced cases of insufficient oxygen that often cause infant brain damage by 31.4% against the baseline period.

At Ascension Health, whose Columbia St. Mary's is one of five hospitals participating in the federally funded effort, they're getting good results, too. In fiscal 2010, the St. Louis-based nonprofit, whose hospitals deliver about 75,000 babies a year, had an infant mortality rate of 0.48 per 1,000 births, and 0.65 cases of birth trauma per 1,000 births, according to chief medical officer David Pryor.

That's a drop of more than 50% since Ascension Health started its obstetrics-safety program in 2003, Dr. Pryor says, and compares with a national rate of 4.5 deaths and 1.84 birth injuries per 1,000 births.

"We are asking bold questions about why these things happen, what may have contributed to error and what could be done differently," says Ann Hendrich, Ascension Health's vice president of clinical excellence.

Care Bundles

Care bundles are an increasingly popular way of reviewing whole processes. Take, for example, vacuum-assisted births. Babies may suffer injuries such as scalp lacerations and hemorrhages from the vacuums used in tough deliveries. As a safety feature, a vacuum suction cup will pop off if there is too much traction or if the angle is inappropriate. But the definition of how many pop-offs are safe and how long the vacuum strategy should be used before doctors abandon it for another technique such as an emergency C-section has been loose.

In the vacuum care bundle, physicians or nurse midwives are required to do several things: discuss the risks, benefits and alternatives with the patient; document the conversation; and perform an examination to ensure that the baby is properly positioned, and that there is a high likelihood of success with the vacuum. The bundle also specifies that the vacuum be stopped after a set time period—20 to 30 minutes—or a maximum number of times that the vacuum pops off the infant's head, and that a back-up plan include emergency staffers on call for a C-section.

Summa Health System's Summa Akron City Hospital, a participant in the Premier program, conducted monthly high-risk simulations using various care bundles. The Akron, Ohio-based hospital audited as many as 80 charts a month to see if doctors were following recommended practices. It issued scorecards recognizing those physicians who were in compliance—and made sure to follow up with doctors who weren't. Other than in those areas where it had no adverse incidents for the previous five years, it showed a reduction in all other incidents including respiratory problems after birth, according to Vivian E. von Gruenigen, medical director of women's health services at Summa.

The majority of reports on infant deaths or harm cite poor communication between caregivers. Fairview physician Stanley Davis in Minneapolis, lead researcher for the new phase of the Premier safety program, says teamwork will be a strong focus.

In addition to mannequins or robots, training drills use employees in the roles of patients and families to simulate high-stress scenarios such as frightened parents, a mother who has an allergic reaction to a drug, or the absence of vital equipment or emergency personnel. Doctors and nurses then watch videos of themselves responding in the simulations to learn how they might have acted differently, much like athletes reviewing game tapes.

Not Infallible

The aim to is to get doctors to recognize they aren't infallible, and to encourage all team members to speak up if they see a problem brewing.

"We still have errors when a junior person sees something and is afraid to speak up," says Phillip Rauk, a specialist in maternal and fetal medicine at University of Minnesota Medical Center.

As for physicians themselves, Dr. Rauk says, most generally believe these kinds of things don't happen in their practices. Some may not realize their routines aren't as safe as they think, he adds, or that potential risks and near misses are occurring.

Paul Burstein, who delivered Ms. Weinshel's baby at Columbia St. Mary's, says this kind of training through simulations has helped change the culture in the delivery room, and has added a dimension to his skills that he didn't learn in medical school. He still relies on his medical instincts and experience, he says, but care bundles have better prepared him for emergencies.

"I do have a mental checklist now of what to do," Dr. Burstein says. "It has given me more confidence that I'm thinking about what could happen. And I know other members of the team are on the same page."

Fetal Monitoring

Fetal monitoring is by and large done electronically in birthing facilities. Electronic Fetal Monitors are used to detect and trace the fetal heart rate and uterine contractions. These are usually monitored at the same time however, each one can be obtained separately. In terms of electronic fetal monitoring, it is either external or internal.

Fetal monitoring is a valuable tool for measuring fetal well being and assessing labor progress. Due to the sensitivity of the monitor, it may indicate a contraction is diminishing even before you notice the pain subsiding. This information can be a very useful energy saving tool and source of encouragement for you and your partner. Continuous electronic fetal monitoring does limit your mobility regarding walking around, however, if you are able, sitting up in a chair or on the side of the bed with your legs supported are options to staying confined to the bed.

• External Fetal Monitoring
• Internal Fetal Monitoring

External Fetal Monitoring

External fetal monitoring means that the baby's heartbeat is detected by placing a small round ultrasound (high-speed sound waves) disc with ultrasound gel on your abdomen and held in place by a lightweight stretchable band or belt. Uterine contractions are recorded from a pressure-sensitive device that is placed on your abdomen and also held by a lightweight stretchable band or belt. External monitoring of contractions in this manner only tells how often your contractions are occurring and how long each is lasting, but not their actual strength.

When you first arrive at the hospital or birthing center, part of the initial assessment of you and the baby is 20-30 minutes of externally monitoring your uterine contraction pattern and the baby's heart rate in response to them. Usually, if the initial fetal heart rate and contraction pattern show that both mom and baby are doing well, the monitor is removed and used intermittently. If there are no indications for continuous fetal monitoring, it is OK to ask the nurse to remove the monitor to allow you to walk. 

Internal Fetal Monitoring

If your physician, midwife or labor nurse(s) feel a need to observe the baby's heartbeat more closely, internal monitoring may be used. A smallelectrode is attached to the baby's scalp to directly monitor the baby's heartbeat. This is possible only after the bag of water has/or is broken. Internal fetal heart rate monitoring may be more comfortable since one of the pieces places around the mother's abdomen will be removed, which allows more freedom of movement.

Depending on your labor progress, it may also become necessary for your provider and labor nurse(s) to know the actual strength of your contractions. This is done internally by performing a vaginal exam and placing a thin, catheter-shaped monitoring device inside the uterus.

Internal fetal monitoring is a valuable tool for measuring fetal well-being and strength of contractions. Due to the sensitivity of the monitor, it may indicate a contraction is diminishing even before you notice the pain subsiding. This information can be seen on the fetal monitor graph paper and can be a very useful energy saving tool and source of encouragement for you and your partner. Continuous electronic fetal monitoring does limit your mobility regarding walking around. However, if you are able, sitting up in a chair or standing at the bedside are options to staying confined to lying in the bed.

Childless women 'could get womb transplants

Childless women 'could get womb transplants next year'

Womb transplants could be available as early as next year, which will enable childless women them to have babies, say scientists.

Following successful animal experiments, a team, led by Prof Mats Brannstrom of University of Gothenburg in Sweden, claims that doctors will be soon able implant childless women with healthy wombs from donors, the 'Daily Mail' reported.

The forecast will bring hope to the thousands of women of childbearing age who are born without a womb or have had it removed because of disease, say the scientists.

The team has succeeded in implanting donated wombs in mice, rats, sheep and pigs and are now hoping to achieve the same success in women, the findings of which have been published in the latest edition of the 'Journal of Obstetrics and Gynaecology Research'.

The only human womb transplant so far took place in Saudi Arabia in 2000, but the donated organ failed after four months. And, the Swedish scientists believe this was because of the complexity of connecting the new womb to the body's blood supply.

But Prof Brannstrom said: "During the last decade, there has been considerable progress in surgical techniques."

According to him, womb transplants could to be carried out as early as next year, at one of ten hospitals around the world. But, the transplant would only be temporary as the new womb may have to be removed after one or two pregnancies.

Meanwhile, a British team, from Hammersmith Hospital in London, has also been developing womb transplants and has carried out successful experiments on rabbits.

5 Signs That You Need to See a Urologist

5 Signs That You Need to See a Urologist 


Some symptoms of incontinence are obvious: Urine leaks out inappropriately, or you simply can't "hold it" long enough to reach a commode. But many adults with incontinence may be oblivious to bladder problems or in denial about how serious the underlying issue may be -- that is, if their behaviors are any indication, says urologist Adam Tierney of Dean Clinic in Madison, Wisconsin.

Here are five lifestyle signs that you should see a doctor. You might be then referred to a urologist (a doctor specializing in the urinary system) or a gynecologist (a doctor specializing in the female reproductive system, who also manages certain urinary problems).

Sign #1: You routinely wear sanitary pads -- and you're not menstruating.

Some women turn to sanitary pads intended for menstruation to absorb the occasional uncontrollable leakage that seeps out when they cough, laugh too hard, lift something, or exercise -- or for leakage that appears seemingly at random.

Why it's unnecessary: "It's very common to leak urine, but that doesn't mean it's normal -- or shameful," says Jill Rabin, coauthor of Mind Over Bladder and chief of ambulatory care and urogynecology at the Albert Einstein College of Medicine in Hyde Park, New York.

If you're postmenopausal and still buying pads, or if you've taken to wearing sanitary pads routinely even after your period to "catch" bursts of wetness, it may be urine and warrants checking out.

What you can do: Stress incontinence (when urine leaks due to a physical stressor, such as laughing or moving a certain way) can be fixed in many ways without surgery. These include physical therapy to strengthen the pelvic muscles, nerve stimulation, and biofeedback.

Losing weight has also been shown to slash stress incontinence symptoms in women who are overweight or obese to begin with. Shedding just 10 or 20 pounds can cut symptom frequency in half.

Sign #2: You keep a change of clothing stashed in your car or bag.

Preparing for disasters is one thing. But if your disaster-worry centers on the possibility that you might wet your pants or skirt, and it's no random nightmare -- it's actually happened to you before -- you needn't live in fear.

Why it's unnecessary: These random acts of incontinence aren't a normal part of aging. A doctor can help discover the underlying cause. Overflow incontinence, for example, is when something blocks normal urinary flow, making it harder to control output. (It's more common in men.) Urge incontinence is the sudden overwhelming need to empty your bladder. In some cases nothing is produced, or you can make it to a bathroom in time. But sometimes the urge comes too fast or with almost no warning. (Both men and women can experience this.)

What you can do: If a kidney stone or tumor is behind the blockage causing overflow incontinence, it can be removed. Urge incontinence treatments include medications, dietary changes, bladder retraining programs, biofeedback and electrical stimulation, and surgery. While treatments are underway, modern absorbent products also help you avoid costume changes.

Sign #3: Your social life has shrunk to the size of your home.

"It's very common to have your circle of interactions with others grow smaller and smaller because you're afraid of incontinence episodes," says Rabin. "Plenty of people become a prisoner of their own home." As someone with bladder symptoms grows wary of social outings, he or she starts turning down invitations; this snowballs over time into receiving fewer invites, because the person is perceived as not wanting others' company-- when the real cause for going Greta Garbo is a bad bladder, not a rude personality.

Variation on this theme: Planning your day around bathroom opportunities or feeling unable to relax in a new setting until you've first scoped out the location of the loo.

Why it's unnecessary: Avoiding life to avoid embarrassment is a drastic lifestyle cost, Tierney says. Ultimately, getting your body to a specialist is easier than adapting your lifestyle to your body.

What you can do: A thorough workup can usually pinpoint the cause of your incontinence episodes. Once you understand the cause, it's possible to live normally with a leaky bladder. Management tactics include monitoring fluid intake, avoiding foods that irritate the bladder, avoiding mental triggers for urination, and learning how to strengthen the pelvic floor.

Sign #4: You avoid sexual intercourse.

Obviously couples say, "Not tonight, dear" for many reasons, including those that originate in the head and heart, not just the body. But one physical reason that can embarrass both men and women to the point of avoidance is the inopportune appearance of urine.

Why it's unnecessary: The following common sex-stealers aren't normal.

For women, stress incontinence can cause small leakages at any time during sex play, especially during orgasm. Urge incontinence, the need to urinate immediately, can also be triggered by orgasm. Net result: inhibition.

For men, the need to urinate urgently and frequently -- known as overactive bladder -- can hamper what happens postarousal. According to a recent Pfizer study of 12,000 men, reported by the National Association for Continence, only half of men with overactive bladder are sexually active (compared to eight out of ten men with no urinary symptoms) -- and of these, one in four reported that their OAB symptoms were why they stopped having sex.

What you can do: All these forms of incontinence can be lessened with therapy, medication, or other interventions. Behavior modification techniques can help both men and women.

Sign #5: You lie down to relieve a constant, heavy pressure.

Urinary system troubles aren't always flagged by visible urine. A persistent heaviness or an annoying sensation of pressure near your plumbing -- urethra, vagina, vulva, kidneys -- is always worth having checked out, Rabin says. The discomfort often lifts when you lie down.

Why it's unnecessary: The cause of the discomfort may be prolapse, in which muscle weakness causes one or more organs to slip out of their usual positions. Common after childbirth or menopause, vaginal prolapse can also affect the bladder, urethra, uterus, bowel, and rectum. A heavy sensation may be the clue of a mass in the area that should be evaluated.

What you can do: The first line of defense is to strengthen the pelvic floor muscles through therapies and other measures, including vaginal weights and pessaries (devices worn in the vagina to strengthen musculature). Surgery is sometimes needed to correct prolapse.

If the source of the heaviness is found to be a mass or other blockage, you may need to have it removed surgically or biopsied for further evaluation.