Click here to see Dr. Ramirez speaking about infertility on The Heartbeat of America

Hormonal Evaluation

This is blood testing done to evaluate the ovarian hormones, thyroid function and pituitary function. This test must be done on the 2 nd or 3 rd day of the menstrual cycle (the day that the period begins is cycle day # 1) in order to be valid. The ovarian hormones test for Ovarian Reserve, which is an evaluation of how the ovarian is functioning. It will indicate of the ovaries are resistant to FSH hormone, in the perimenopausal stage or in the menopause. This gives us an indication of whether or not the ovary would respond to stimulation with any of the fertility drugs. It also gives us an indication of whether or not there is urgency in choosing a more aggressive treatment. Ovarian resistance is usually encountered in women over the age of 36 years old but can be at any age.

Hysterosalpingogram

This is a non-invasive test whereby a small catheter with a balloon is inserted into the uterine cavity. The balloon is then inflated to close off the cervix. Radio-opaque dye is then injected and x-rays are then taken at various stages. The purpose of this test is to determine if the tubes are open or not and where the blockage may be. This test is done between cycle day # 5 and # 12 of the menstrual cycle.

Cervical Cultures

Cultures are taken from the cervix and vagina for various bacteria that might interfere with sperm survival, uterine environment or tubal patency. Sexually transmitted diseases are tested for as well. If found, then antibiotic treatment may be required.

Mid-Luteal phase Progesterone

This is a blood test done around the 21 st day of the menstrual cycle, to evaluate if there has been ovulation and whether or not there is adequate Progesterone hormone in the Luteal phase. Progesterone is a requirement of the Luteal phase for preparation of the endometrium for implantation of the embryo and for maintenance of the early pregnancy.

Semen Analysis with Cultures

Complete semen analysis is done to evaluate sperm count, the ability of the sperm to swin i.e. live sperm (motility) and the anatomy of the sperm (morphology). In addition, cultures are done on the semen for sexually transmitted diseases and other bacteria that might interfere with sperm viability or function.

Pelvic Ultrasound

This is a noninvasive method for evaluating the uterus and ovaries by using high frequency sound waves rather than x-rays to show what is inside your body. Because the body contains over 90% water, sound can be used just as sonar is used in the ocean. Each time the sound hits a tissue interface, like a blood vessel, an echo is sent back. Sophisticated, high-speed computers can use these echoes to create a picture of your internal organs. Ultrasound carries little risk or discomfort while producing clear images that enable the physician to count any mature follicles present and examine the endometrium. Fibroid tumors and ovarian cysts can be diagnosed as well.

Endometrial Biopsy

A procedure by which a sample is taken of the endometrial lining of the uterus, shows evidence of ovulation and degree of maturation of the uterine lining, and can reveal uterine cancer, uterine fibroids, uterine polyps, and adenomyosis. This test also reveals if the woman has a luteal phase defect - a hormonal imbalance which prevents a woman from sustaining a pregnancy because not enough progesterone is produced. The test is typically performed 1-3 days before onset of woman's menstrual flow.

Hysteroscopy

This is a procedure that involves insertion of a narrow telescope-like instrument through the vagina and cervix into the cavity of the uterus (endometrial cavity). The uterine cavity is then distended with fluid and visualized. This procedure allows us to determine whether there are any defects such as Fibroid tumors, polyps, scar tissue, a uterine septum, or other uterine problems inside the cavity. In our center, this is done in the office with a very small flexible video scope. It is a quick procedure taking 5-15 minutes and generally painless. No medication of any sort is required for the procedure. Some offices will do this procedure in the operating room of an Outpatient surgery center under General Anesthesia. This makes the procedure more expensive.

Laparoscopy

About 40% of infertile women whose initial Fertility work-up is unrevealing will demonstrate abnormal tubal or uterine findings on a laparoscopic examination. Laparoscopy requires two small incisions (one at the navel and one above the pubic bone). Carbon dioxide gas is injected into the abdomen, distending it and pushing the bowel away. The laparoscope, a hollow tube equipped with a tiny camera, lenses, and a fiberoptic light source, is inserted through the umbilical incision. A probe is then inserted through the second incision allowing the physician to directly view the outside surface of the uterus, fallopian tubes, and ovaries. Endometriosis, pelvic scar tissue, and blockage at the ends of the fallopian tubes can all be identified using laparoscopy. Some of these conditions can be corrected during the procedure by cutting away any scar tissue that may be binding organs together or by destroying endometrial implants. The procedure is usually done under general anesthetic and the wound itself is minimally painful.

In order to prepare for AI, a woman usually takes Fertility drugs in advance. The man must produce sperm at the time the woman is ovulating. The sperm are then "washed", using high-tech laboratory procedures and are then inserted into the uterine cavity through a long, thin catheter. To reduce the risk of multiple births, the amount of the drug and the response to it is carefully monitored with several ultrasounds and blood tests for estrogen levels.

Microscopic Tubal Reconstructive Surgery

Treatment for reversal of tubal ligation or tubal obstruction. Tubal ligation reversal (reanastomosis) is a surgical procedure, which can restore the function of fallopian tubes, which have been blocked by a previous sterilization operation. Reversal operations are performed using microsurgical techniques, in which microscopes or loupes are used to visualize and bring together the very narrow hollow center portion of the fallopian tubes. Microsurgery also uses very thin suture materials, the smallest possible incisions, specially designed instruments and non-traumatic tissue handling techniques. Patients go home the same day. This would allow the patient to attempt pregnancy naturally, but in general, pregnancy rates are not as good as a normal tube and are age dependent.

Ovulation Induction

Treatment for women who do not ovulate or to increase the number of eggs that ovulation (super-ovulation). This treatment requires the use of ovulation-inducing drugs such as Clomiphene, Letrezole, Gonal-f, Repronex, Cetrotide, or Ovidrel. Monitoring involves follicular sonograms and serum hormonal tests.

Advanced Laparoscopic Surgery

Treatment for tubal obstruction, pelvic Endometriosis and/or adhesions; ovarian cysts, ectopic pregnancy. Involves a small surgical incision through the naval. This procedure is done in an outpatient surgery center under general anesthesia.

Advanced Hysteroscopic Surgery

Treatment for intrauterine insemination adhesions, polyps, fibroids, and uterine septum; tubal catherization for tubal obstruction. Involves the insertion of a small scope through the vagina and cervix. This procedure uses a larger scope with an operating channel. Therefore, it is done in an outpatient surgery center under general anesthesia.

IVF - In Vitro Fertilization