Fellowship training focuses on the diagnosis and treatment of infertility and related disorders. This training includes experience in microsurgery, laparoscopic and hysteroscopic surgery, in vitro fertilization-embryo transfer, sonography, and ovulation induction. In addition, the physician spends a significant amount of time performing clinical or laboratory research.

Upon completion of a Fellowship in Reproductive Endocrinology, a specialist seeks Board certification, a multi-step process. To become Board certified in Reproductive Endocrinology, the physician must first obtain Board certification in Obstetrics and Gynecology. This requires successful completion of both a written and an oral examination. Board certification in Reproductive Endocrinology requires successful completion of additional written and oral examinations.

The entire certification process takes several years to complete. Only a physician who has successfully completed a Fellowship in Reproductive Endocrinology and passed the examinations can become Board certified as an infertility specialist.

High FSH levels
Reference ranges for luteinizing hormone and follicle-stimulating hormone in the menstrual cycle, expressed in international units. The scale is logarithmic.

The most common reason for high serum FSH concentration is in a female who is undergoing or has recently undergone menopause. High levels of Follicle-Stimulating Hormone indicate that the normal restricting feedback from the gonad is absent, leading to an unrestricted pituitary FSH production.

If high FSH levels occur during the reproductive years, it is abnormal. It may be a sign of:

1. Premature menopause also known as Premature Ovarian Failure
2. Poor ovarian reserve also known as Premature Ovarian Aging
3. Gonadal dysgenesis, Turner syndrome
4. Castration
5. Swyer syndrome
6. Certain forms of CAH
7. Testicular failure.

FSH is available mixed with LH activity in various menotropins including more purified forms of urinary gonadotropins such as Menopur, as well as without LH activity as recombinant FSH (Gonal F, Follistim). It is used commonly in infertility therapy to stimulate follicular development, notably in IVF therapy, as well as with interuterine insemination (IUI). (See Gonadotropin Preparations.)

* Injectable (Follistim™, Gonal-F™, Repronex™, Bravelle™): highly purified preparations of follicle stimulating hormone (FSH) and/or luteinizing hormone (LH) which are taken as subcutaneous injections. These medications provide for a much more potent stimulation than the oral ovulation medications, and as such require much more frequent monitoring.

* Oral (Clomiphene Citrate, Clomid™, Serophene™): oral tablets which function as mixed estrogen agonists and antagonists depending on the tissue (i.e. compete with estrogen for receptor sites). Use of this medication can lead to monthly ovulation for those women who normally do not ovulate on their own, ovulation of more than one egg for those women who do ovulate on their own, and better synchronization of the uterine lining.

Recurrent miscarriages

The evaluation and treatment of recurrent miscarriage involves seeking uterine, genetic, immune, or hormonal factors that explain miscarriages to form a basis for treatment to improve the chance of successful pregnancy. The Center sees many couples with these problems and often collaborates with other specialists in the Department to establish a diagnosis and plan for treatment.

In 2002 about 28% of cycles in the United States in which women underwent IVF and embryo transfer with their own eggs resulted in the live birth of at least one infant. Since 2002 we have seen this number slowly creep up! So good news the odds are about 1 in 3. Now, there is a HUGE but in this number for IVF success. The facts are enormous that effect the outcome of IVF.

Success varies with many factors. The age of the woman is the most important factor, when women are using their own eggs. Success rates decline as women age, and success rates drop off even more dramatically after about age 37. Part of this decline is due to a lower chance of getting pregnant from ART, and part is due to a higher risk of miscarriage with increasing age, especially over age 40. There is, however, no evidence that the risk of birth defects or chromosome abnormalities (such as Down’s syndrome) is any different with ART than with natural conception.

This age related decrease in success begins to accelerate after age 35 and even quicker after 40. Overall, 37% of cycles started in 2003 among women younger than 35 resulted in live births. This percentage dropped to 30% among women 35–37 years of age, 20% among women 38–40, 11% among women 41–42, and 4% among women older than 42.

Each year we are seeing the odds tick up which is great news for all of those who are interested in entering the IVF program.

Analisis de semen
Examen microscopico del liquido eyaculado pare determiner el numero de espermios, su forma, y su habilidad pare moverse.

Anovulacion
Falla o ausencia de ovulacion.

Biopsia de endometrio
Es la extraccion de un pequeflo trozo de tejido del endometrio (revestimiento inferno del utero), pare ser examinado bajo el microscopio. Los resultados indican si el endometrio esta o no en la fase adecuada pare la implantacion de un huevo fertilizado.

Cuello del utero (Cerviz)
Parte angosta, mas baja del Ctero, que se abre hacia la vagina El canal cervical pasa a traves del cuello del utero y conecta la vagina con la cavidad uterine. El cuello del utero produce moco a traves del cual deben nadar los espermios antes de entrar a la cavidad uterine y pasar de ahi a las trompas de Falopio.

Defecto de fase lutea
Es la condicion que se presenta cuando el revestimiento inferno del utero no madura adecuadamente en respuesta a la secrecion de progesterone producida por el ovario despues de la ovulacion.

Endometriosis
La presencia de tejido similar al del endometrio en localizaciones anormales como ovarios, trompas de Falopio, y cavidad abdominal. La endometriosis puede asociarse a dolor pelvico e infertilidad.

Fertilizacion in vitro (IVF en ingles)
Metodo de reproduccion asistida que involucra la remocion quirurgica de huevos desde los ovarios de la mujer, los cuales son combinados con los espermios, en el laboratorio. Si se produce la fertilizacion, el embrion resultante es puesto en el utero de la mujer.

Foliculo
Saco lleno de liquido ubicado justo por debajo de la superficie ovarica y que contiene el huevo inmaduro (oocito).

Histeroscopia
Procedimiento diagnostico en el cual un visor con luz propia (histeroscopio), es introducido a traves del cuello del utero haste el utero. Io que perrnite al medico visualizer el interior del utero.

Histerosalpingograma
Procedimiento radiol6gico en el cual un medio especial de contraste (tintura), es inyectado dentro del utero pare definir su contorno inferno, y el grado de aperture (permeabilidad) de las trompas de Falopio.

Hormona luteinizante (LH)
Hormona que produce la ovulacion, y estimula al cuerpo luteo pare que secrete progesterone.

Laparoscopio
Instrumento visor delgado, con luz propia, equipado con un lente telescopico.

Laparoscopia
Procedimiento diagnostico en el que el cirujano introduce un laparoscopio a traves de una pequefla incision bajo el ombligo, e inspecciona visualmente el utero, los ligamentos uterinos, las trompas de Falopio, los ovarios y los organos abdominales. Puede ser necesario realizer otras incisiones, a traves de las cuales se puede introducir y manipular instrumentos adicionales, pare facilitar el diagnostico y tratamiento de la enfermedad pelvica.

Micromanipulacion
Grupo de procedimientos en los cuales el huevo (oocito) y los espermios son manipulados pare ayudar a la fertilizacion.

Ovulacion
Liberacion de un huevo maduro desde su foliculo ubicado en la cape externa del ovario. La ovulaci6n generalmente ocurre en el die 14 o 15 de un ciclo de 28 dies, o 14 dies antes del primer die de la proxima menstruacion.

Peritoneo
Revestimiento de la cavidad abdominal.

Progesterona
Hormona femenina secretada por el ovario durante la segunda mitad del ciclo menstrual. La progesterone prepare el revestimiento inferno del utero pare la implantacion del huevo fertilizado.

Temperatura corporal basal (TCB)
Temperatura del cuerpo en reposo. Se tome la temperature oral cada maflana, inmediatamente despues de despertar, y se lleva un registro en una hoja de TCB. Los registros son estudiados pare ayudar a identificar la ovulacion, que ocurre aproximadamente al mismo tiempo que el alza de la TCB.

Test postcoital (TPC)
Analisis microscopico de una muestra de moco cervical, tomada habitualmente dentro de las 18 horas posteriores al coito. Este test determine la madurez del moco cervical y la habilidad de los espermios pare entrar y penetrar el mucus.

Transferencia de embrion por ovodonacion
Transferencia a una receptora infertil de un embrion resultante del huevo de una donante voluntaria.

Transferencia intratubaria de gametos (GIFT en ingles)
Metodo de reproduccion asistida que involucra la remocion quirurgica de huevos desde el ovario de una mujer, los cuales son combinados con espermios , siedo ambos inmediatamente inyectados a la trompa de Falopio. La fertilizacion se produce dentro de la trompa de Falopio. Transferencia intratubaria de cigoto (ZIFT en ingles). Los huevos son recolectados y fertilizados, y el cigoto resultante es transferido a la trompa de Falopio.

Reputable IVF clinics will usually provide a synopsis of their pregnancy success rates and their data are submitted to the Centers for Disease Control (CDC) each year. However, the CDC data is usually “dated” by two years. Most highly successful IVF clinics also submit their data to the Society of Assisted Reproductive Technology (SART) which is usually “dated” by only one year. Our infertility clinic success rates are reported regularly to the CDC and SART and are available on our Web site (IVF success rates.)

“In vitro” literally translated means “fertilization outside of the body” which is where fertilization occurs in an IVF cycle. Eggs are retrieved from the ovarian follicles and combined with sperm in a Petri dish.

IVF consists of many stages and is performed by our highly trained team of professionals including infertility specialists, embryologists, nurses, and associated staff members. Our Salt Lake City Utah IVF clinic team has extensive experience performing IVF and its associated procedures such as intracytoplasmic sperm injection (ICSI), assisted hatching, preimplantation genetic diagnosis (PGD), egg freezing, and others.

The first step of the IVF process is ovarian stimulation with injectable follicle stimulating hormone (FSH). FSH stimulates the ovaries to develop numerous follicles, each of which usually contains an egg. This process occurs naturally in each ovulatory cycle when the pituitary, under the influence of the hypothalamus, releases FSH to stimulate egg recruitment.

In an IVF cycle, ovulation induction is initiated using standard treatment protocols and dosages are adjusted based upon each patient’s individual response. IVF patients are carefully monitored at our IVF clinic using estradiol hormone levels, vaginal probe ultrasound, and physical examination. FSH should only be administered by a fertility specialist thoroughly trained, and experienced in its use to avoid potential serious side effects.

As healthy follicles mature they produce estrogen, and along with progesterone, these hormones cause the endometrium to thicken and become more vascular. This development is necessary to support a developing embryo.

IVF patients receive either a GnRH agonist such as leuprolide acetate (such as Lupron®) or a GnRH antagonist (such as Antagon® [Ganirelix acetate] or Cetrotide® [Cetrorelix acetate]) to control ovulation. These products can a block the production or release of hormones, such as FSH and LH. Ovulation cannot occur while a patient is receiving proper doses of one of these drugs. Otherwise, ovulation might occur before the eggs can be retrieved resulting in the “loss” of the ovarian stimulation cycle for IVF.

Once the eggs are mature, an injection of human chorionic gonadotropin (hCG) is administered and egg retrieval is scheduled at our IVF clinic. In a natural cycle, ovulation is stimulated by a surge of luteinizing hormone (LH). Ovulation is triggered with hCG in the same manner as LH. We discuss hCG and LH products in the fertility drugs section.

Egg retrieval is performed at our Utah IVF clinic under light sedation using ultrasound guided transvaginal egg retrieval. A small “needle” is passed through the back of the vagina and into the follicle on the ovary. The egg is gently “suctioned” and retrieved in its follicular fluid. Once retrieved the “solution” is immediately passed to the embryologist who identifies and separates the eggs and places them in specially prepared media.

The remaining “follicular structure” is known as the corpus luteum. The corpus luteum produces progesterone to help complete endometrial development. After the embryo implants in the endometrium, the placenta also produces progesterone. IVF patients receive progesterone medication to offset the effects of the GnRH agonist or the GnRH antagonist.

The male usually provides sperm by masturbation and it is washed and specially prepared for exposure to the eggs. In cases where there is a male infertility component, procedures such as intracytoplasmic sperm injection (ICSI) are performed at this point. In ICSI, a single sperm is injected directly into the egg. If there are no sperm in the ejaculate, they can often be taken directly from the testicles or the reproductive tract. This is discussed in detail in the ICSI and male infertility sections.

After fertilization, the embryos are placed in an incubator which tightly controls temperature, atmosphere, pH, and other environmental factors. The embryos remain in the incubators at our IVF clinic until mature, usually three to five days. Five day embryos have usually developed to the blastocyst stage, which is discussed on a separate Web page.

Once the embryos mature, the embryo transfer is scheduled at our Salt Lake City Utah IVF clinic. This is a painless procedure usually requiring less than ten minutes and is similar to IUI. The embryo is gently placed directly into the uterus. Patients are advised when to return for a pregnancy test (usually two weeks later).

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