treat some of these problems by cauterizing or burning endometriosis (either electrically or with laser), or by cutting and removing scar tissue (lysis of adhesions). Laparoscopy can also be used during in vitro fertilization or the GIFT procedure to aspirate and remove the eggs from the ovaries. The use of laparoscopy to help diagnose and treat gynecological disorders has greatly reduced the need for major surgery. In the past, without this procedure, we would need to perform a laparotomy (major abdominal surgery) in order to determine what was wrong in the pelvis. Today, the patient can go home the same day and return to work within forty-eight hours.

What to expect in the hospital
You arrive at the hospital the same morning of surgery. The laparoscopy is usually performed under general anesthesia. Once you are asleep, a small incision or cut (less than half an inch) is made in your navel (belly button). A large needle is placed through this incision and your abdomen is filled with carbon dioxide gas. This allows us to examine your pelvis. The laparoscope (a thin telescope) is then placed into the abdomen through the same navel incision. A second small cut may be made above your pubic bone in order for us to move the pelvic organs and better examine them. We also need to put some small instruments in your vagina in order to hold the uterus. For this reason, you may notice some light spotting after the surgery.

The procedure takes about 45 minutes to 1 1/2 hours. You generally will go home that same evening. After surgery you may have some soreness in your abdomen and some pain in your shoulders and chest. This is secondary to irritation from some gas that still remains inside. Your urine may be slightly greenish which is due to the color of dye we use to test the tubes. You may also feel light-headed, "hung over", or nauseated from the anesthesia. This should wear off within twelve hours. You should be able to shower and proceed with your usual activities the following day. Most patients return to work within 48 hours. You should return to see us within two weeks after the procedure to discuss the surgical findings and to examine your navel incision.

Risks of the procedure
Major complications of laparoscopy are rare, occurring a little less than one in a hundred patients operated on. The major surgical risk is that of damaging the bowel, bladder, or a major blood vessel. This is because the large needle and the laparoscope are placed into the abdomen before we can fully see what organs are behind. If a major blood vessel was injured you may also have bleeding inside your abdomen. If a major complication were to occur at laparoscopy, we may need to perform major surgery to fix the organs.

Another risk is that of infection, especially if dye is injected into the tubes. Although we clean your cervix, we cannot kill all the bacteria in the vagina. The dye may carry some of these bacteria from your cervix and vagina up into the tubes, which can cause an infection. If you notice increasing abdominal pain or fever 2 or 3 days after the laparoscopy, please notify your nurse.

You may also have an allergic reaction to any of the medications that are used during a laparoscopy, but generally this is very difficult to predict.

The risk of death a laparoscopy is extremely rare and is usually due to anesthetic problems. The risk is about one in ten thousand, or about half the risk of being killed in a car accident on your way home today.

Financial aspects
Most insurance carriers will pay for the laparoscopy but policies are highly individualized. We encourage you to contact your insurance carrier to determine whether they will pay for this procedure. Janet Riso, who is responsible for billing and collections, will be happy to discuss any financial questions any time (Telephone 569-6979).

What will happen upon my arrival at the hospital?
You should first report to the Admitting Office to review personal and insurance information. Make sure that you have all necessary insurance information with you. You will then be tagged with a hospital ID bracelet containing your name and hospital identification number. You will be brought to the Day Accommodation Room assigned to you and be instructed to change into a hospital gown. Your vital signs will be taken (temperature, blood pressure and pulse) and you will be in your room)

What type of anesthesia is used?
General anesthesia, in most cases, is used. It is, therefore, imperative that you do not have anything to eat or drink, INCLUDING WATER, from midnight prior to surgery.

How long will the surgery last?
This depends upon what type of surgery you are having and what the doctor may find during the Laparoscopy. A Laparoscopy will last approximately 1 1/2 - 2 hours. A Laparotomy is more involved and can last up to 3 hours.

How long will I be in the hospital?
If you have a Laparoscopy, you will be in DAR for several hours (4-6 depending upon the individual). Conditions for release depend upon your vital sign, how you are generally feeling, and whether or not you are able to void on your own. If you have a Laparotomy, you can expect to be hospitalized approximately 3-4 days.

How can I expect to feel after surgery?
Pain/soreness should be expected after surgery, the degree depending upon the patient. Usually shoulder pain is common due to the anesthesia. The gas from this should dissipate over the course of several days. An intubation tube will be inserted down your throat once you have been anesthetized, therefore, you may experience a sore throat following surgery. You will fee fatigue and should plan to rest for several days following a Laparoscopy. Recovery time for a Laparotomy is several weeks. Absolutely no exercise of any kind (except slow walking) should be done following surgery until you come in for your post-op visit. Medication for pain will be prescribed by the doctor. Do not hesitate to take this medication or call the office if it is not helping you.

Will I have stitches?
If you are having a Laparoscopy, several stitches are put internally. If you have Laparotomy the number of stitches will depend upon the size of the incision and the patient. The stitches are dissolvable.

What are the risks of anesthesia?
Aspiration from vomiting during the procedure is the most common but rarely happens. This is the reason why it is important for you to follow your pre-op instructions. You may also experience nausea and/or vomiting following the procedure.

What happens post-op in the DAR?
Your vital signs will be monitored. Your nurse will check on you frequently for alertness, pain, medication, and any other needs you may have. She will also check to make sure you are not having any difficulty voiding. You may be given liquids and be allowed up after several hours.

When will I be able to eat normally?
In the case of a Laparoscopy, you should be able to eat once your IV is removed and liquid is well tolerated. If you have a Laparotomy then you may usually be able to tolerate food the day following surgery.

Will I have a bowel or bladder problem following surgery?
Some patients experience difficulty voiding after surgery. In both types of surgery (laparoscopy/laparotomy) a catheter will be inserted after anesthesia is induced. If you have a laparoscopy the catheter will be removed once the surgery has been completed or shortly thereafter. If a laparotomy has been done, the catheter will stay inserted for approximately 24 hours. You will also have an IV inserted, usually in the OR for both types of surgery.

If you do experience bowel problems (most commonly constipation) warm prune juice with lemon help. If you experience diarrhea, this is not uncommon either since there is some manipulation of the bowel during surgery. If either problem persists without relief, do not hesitate to call the office.

When can I expect normal menstruation to return?
This again varies with each individual patient. You may get an expected period shortly following surgery, or your cycle may be slightly off. You may also experience heavier bleeding during your first or several periods following surgery. We consider bleeding to be abnormal when you start going thru 4-5 pads an hour. This should be immediately reported to Dr. Lesorgen.

How long will the recovery process take?
The recovery process should take several days in the case of a laparoscopy. If a laparotomy has been performed, then figure on several weeks. This, again, depends upon the individual patient and circumstances. Dr Lesorgen advises against returning to work for several days following a laparoscopy. In the case of a laparotomy, Dr. Lesorgen will determine the length of disability. Your post-op visit will be scheduled for 3 weeks after surgery. Again, no exercise, heavy lifting etc. should be done until your post-op visit.

What will determine if a Laparotomy needs to be done?
Major surgery is avoided as much as possible. Various factors, however, are taken into consideration such as fibroids and their size/location, extensive adhesions, etc. If you have further questions please speak to Dr. Lesorgen prior to surgery.

Click here to go back to the top

Intrauterine Insemination

Intrauterine insemination (IUI) is used for women who either do not produce adequate or sufficient cervical mucous at the time of ovulation, or whose husband's sperm is of low count and motility, or in some cases of unexplained infertility. In the case of poor cervical mucus, by injecting the sperm directly into the uterine cavity, the poor mucus, and cervix are bypassed. In the case of low male sperm count or motility, placing the sperm directly into the uterus increases the number of sperm available for conception.

Instructions
Generally, one or two, well-timed inseminations are performed each cycle. Therefore, the timing with respect ovulation is of utmost importance. You will be asked to monitor your cycle with a urinary LH (ovulation prediction) kit. We recommend OvuGen or Ovu-Quick kits to be used. Most pharmacies do not stock these particular kits, but you may purchase them in our office.

Your nurse will tell you exactly what day to begin using your ovulation prediction kit, this is generally three to four days before the anticipated day of ovulation. You must call your nurse on the day that you begin using the kit so that she may make arrangements for your insemination.

Test your urine each day between 8:00 a.m. and 10:00 a.m. Notify your nurse again on the day of your LH surge. Your insemination will be performed on the day after the LH surge, which should be the day of ovulation.

We ask you not to have relations two-three days before the procedure is to be done. On the day of your insemination, your husband will be asked to obtain a semen sample by masturbating into a sterile plastic container, which is provided by our office. The semen sample must be received in the laboratory within 2 hours after collection. We recommend keeping the specimen close to your body in a pocket or shirt to maintain body temperature, for maximum survivability of the sperm.

Once received in the laboratory, the sperm will be washed and concentrated. This generally takes between 20 minutes to 1 hour, depending on the type of sperm preparation procedure.

The actual procedure for the insemination is simple. A speculum is inserted into your vagina, and a small plastic tube is threaded through your cervix into the uterine cavity. There is usually only minimal discomfort with this procedure, and you may leave the office soon after the procedure is performed.

If you develop severe abdominal pain, severe cramping, fever or other problems following your intrauterine insemination, please notify your nurse.

Click here to go back to the top

Hysterosalpingography

The hysterosalpingogram, or HSG, is an x-ray of the uterus and fallopian tubes. The procedure involves the introduction of radiopaque dye into the uterus through a special instrument placed through the vagina and into the cervix. X-ray pictures are then taken as the dye passes through the uterus and out the ends of the tube. The test helps to determine that the tubes are open and the uterus is normally shaped. It is a short procedure and usually takes 10 to 15 minutes. Expect to spend about an hour in the hospital. Most of this involves patient registration and filling out paperwork. HSG's are usually done in the late afternoon and are scheduled in the x-ray department of the hospital. Dr. Lesorgen will meet you there and perform the procedure personally. The test is not as bad as your friends would have you believe.

During the procedure, you may experience some mild cramping and you may also feel slightly dizzy. You may have cramping along with light bleeding for a day or so after the procedure. These symptoms are to be expected and should not be cause for alarm. You may take analgesics such as Tylenol, Motrin, or Anaprox before and after the procedure for the cramping.

The main risks of an HSG are infection, allergic reaction to the dye, and flow of dye into blood vessels (vascular extravasation). The infection of the uterus and tubes is caused by organisms that are already present in the vagina and flow upward when the dye is injected. A special solution is used to clean the vagina. However, you should understand that it is not normal to experience acute abdominal pain, heavy bleeding, or fever in the first few days after the procedure, and you should notify your nurse if any of these symptoms occur.

If you are allergic to previous x-ray dyes used, or to crabs or shellfish, please let us know, as you may be allergic to the dye that is used for the HSG. If you develop hives, shortness of breath, or a rash, you should notify the nurse as soon as possible. On occasion, the dye may, as it enters into the uterus, flow into blood vessels. Very rarely this may become life threatening.

Since we do not want to interrupt a pregnancy, most HSG's are performed before the middle of the cycle on days 7 through 14. To schedule the HSG, you should call your nurse as soon as your period starts, and the x-ray will be scheduled with the department of radiology.

Click here to go back to the top

Endometriosis

The name endometriosis comes from the word “endometrium”, which is the tissue that lines the inside of the uterus. If a woman is not pregnant, this tissue builds up and is shed each month when she has her period. In a woman with endometriosis, tissue that looks and acts like endometrial tissue is found outside the uterus, usually inside the abdominal cavity.

Endometrial tissue that is found outside the uterus responds to the menstrual cycle in much the same way as the endometrium in the uterus responds. At the end of every cycle, when hormones cause the uterus to shed its endometrial lining, endometrial tissue growing outside the uterus will break apart and bleed. However, unlike menstrual fluid from the uterus, which is discharged from the body during menstruation, blood from the misplaced tissue has no place to go. Tissues surrounding the area of endometriosis may become inflamed or swollen. The inflammation may produce scar tissue around the area of endometriosis. These endometrial tissue sites may develop into what are called “lesions,” “implants,” nodules,” or “growths.”

Mild forms of endometriosis are common and may not require treatment. But, endometriosis can make it difficult for a woman to become pregnant.

What causes endometriosis?
The cause of endometriosis is unknown. Some experts believe that pieces of endometrium travel back through the fallopian tubes and pass out into the pelvic cavity (space inside the pelvis that holds the reproductive organs). Tiny pieces of tissue may lodge on surfaces of the reproductive organs. During menstruation, the tissue bleeds, just like the endometrium inside the uterus. Blood from the misplaced tissue gets trapped. Surrounding tissue may become swollen and inflamed. Over time, scar tissue and cysts can form.

What are the symptoms of endometriosis?
Many times, endometriosis has no symptoms. When symptoms are present, they may include:

• Abdominal cramps or back pain during menstruation
• Very painful menstrual cramps
• Painful bowel movements
• Painful urination, especially during menstruation
• Abnormal or heavy bleeding during periods
• Painful sex
• Difficulty becoming pregnant

• Gonadotropin-releasing hormone (GnRH) agonist, (Lupron, Synarel)
• Progesterone (progestins)
• Danazol (Danocrine)—a synthetic hormone that reduces the size of abnormal tissues. Danazol can cause birth defects. Women using this drug need to use a barrier form of birth control to prevent pregnancy. This medication is rarely used today.

Medications to reduce painful cramps include:

• Birth control pills
• Motrin
• Anaprox

Medications are not successful in treating the infertility caused by endometriosis.

Surgery

For more severe cases of endometriosis, scar tissue may be removed during laparoscopy. This appears to improve pain symptoms and may increase the chances of pregnancy. Alternatively, a hysterectomy to remove the ovaries and uterus can be performed, although this approach is considered radical.

Will I be able to have children if I have endometriosis?

A Most women with endometriosis can have children. If you have endometriosis, your chances for getting pregnant will depend on how severe your condition is and how well it responds to treatment. Usually a period of observation without treatment is advised before proceeding to surgical treatments.

Click here to go back to the top

Endometrial Biopsy

An endometrial biopsy (EB) is a single test that is performed in the doctor's office.

This test is used to determine:

• Whether ovulation has occurred.

• Whether an adequate amount of the hormone progesterone is being produced to prepare the uterine lining for implantation.

• Whether or not the lining of the uterus is infected or inflamed

Timing of this test is extremely important. It is performed approximately 1 to 3 days before your expected period. We use your past menstrual history to help us schedule this test. For example, if you historically have a 28-day cycle - we would schedule the test on day 25. To help all of us, call when you have your period and we can count the days and schedule the EB.

The preparation for the test is simple. You can take a Motrin or Advil about 1 hour before the test. When you come to the office you will be taken into the exam room and positioned as for a pelvic exam. A thin tube will be inserted through the cervix into the uterus and a small piece of the uterine lining will be suctioned into the tube. You will experience a small amount of cramping at this time.

After the test, you may continue to experience cramping. Tylenol or Advil will help to alleviate the cramping. You may also experience some spotting which may continue until you get your period. You may return to work after the test and resume your normal daily activities. Do not have intercourse for 36 hours after the test. Once your period begins call the office so the exact "dating" of the tissue can be done.

The tissue that was obtained will be sent to the lab and examined under the microscope. It takes 7 to 10 working days before the results of the tests are available. Once we receive the results and the doctor reviews them, we will contact you.

* * * Important * * *
If you are pregnant, the test almost never causes a problem. However, each client receives a pregnancy test before the biopsy is done. You will be required to come in for a blood test for pregnancy one or two days prior to the biopsy. The charge for this blood test is $55.00.

Our charge for the procedure is $225.00. There will also be an additional lab fee.

Click here to go back to the top

Clomiphene Citrate (Clomid, Serophene)

Clomiphene citrate (Clomid, Serophene) is a drug commonly used to treat ovulatory problems. It acts by signaling the brain to trigger the release of the hormones responsible for development and release of the egg. This medication does NOT improve the fertility of normally ovulatory women.

Dosage
Clomiphene citrate is taken by mouth for five days, usually from the fifth to the ninth day of the cycle. The dosage is generally started at one pill (50 mg) per day, and is increased, if necessary, by the physician. For your own safety, it is necessary that you come in for an exam at the end of each cycle (prior to starting your next cycle of Clomiphene). This is done to evaluate the size of the ovaries and to make certain that a cyst has not developed with the Clomiphene stimulation. PLEASE CALL FOR AN APPOINTMENT AS SOON AS YOU START YOUR PERIOD.

Side-Effects
The side-effects associated with Clomiphene citrate are generally minimal.

The following side-effects are not serious and should not be cause for alarm:

• Mild abdominal distention

• Abdominal bloating

• Breast tenderness

• Hot flashes

• Headache

• Nausea

• Visual disturbances

Take Clomiphene with a meal and/or large glass of milk to minimize abdominal side effects.

Side-effects that SHOULD be reported to your physician are:

• Significant abdominal pain

On Clomiphene there is a slight increase in the multiple birth rate (usually twins). When taken prior to ovulation, Clomiphene does not increase the risk of birth defects.

If you have any questions or problems regarding your medication, please call the office.

Click here to go back to the top

Parlodel

Parlodel (Bromocriptine) is a drug used to inhibit the secretion of prolactin, the milk-producing hormone. When prolactin levels are higher than normal, there may be interference with the egg release mechanism. This may result in faulty ovulation and irregular cycles, or absence of ovulation and no menstrual periods. Additionally, many women with high prolactin levels produce milk from one or both breasts.

The causes of elevated prolactin levels vary, but may include certain drugs, thyroid disorders, and benign tumors of the pituitary, a small gland at the base of the brain. After the cause has been identified, your physician may prescribe Parlodel as treatment. Parlodel acts by inhibiting prolactin secretion at the level of the pituitary. It has also been found to reduce the size of prolactin secreting pituitary tumors.


Dosage
The dosage of Parlodel may vary depending upon the cause of the prolactin elevation and the degree of elevation. Generally, the dosage starts at 1/2 tablet twice a day and is then increased weekly to a specific dosage schedule to follows. Periodic prolactin levels will be drawn to evaluate your response to the drug.

If you are attempting pregnancy, Parlodel may act to improve fertility by restoring ovulation. You will be asked to keep a temperature chart while you are on drug therapy, so that the medication can be stopped as soon as conception occurs. Nevertheless, no birth defects have been reported in women who continue to take Parlodel while pregnant.

If you do not desire pregnancy, you should use a reliable form of contraception. Remember that Parlodel restores ovulation and may increase your chances of pregnancy.

The following are common side-effects of Parlodel, which are generally not serious and improve with lower dosages and time:

• Nausea

• Vomiting

• Dizziness

• Nasal Congestion

• Approximately 2% of patients faint when taking their first dose of Parlodel. You should be prepared for this.

Side-effects that SHOULD be reported to your physician or nurse are:

• Significant or persistent dizziness

• Fainting

• Significant weakness

• Persistent vomiting

Click here to go back to the top

Gonal-F (Pergonal/Humegon)

Personal/Humegon is an injectable drug used to induce ovulation. It contains the hormones FSH and LH, which are responsible for stimulating growth and maturation of the egg. It is a powerful drug, which directly stimulates the ovary. For this reason you will be carefully monitored with sonography and blood tests.

The main risks are:

• Hyperstimulation syndrome and multiple pregnancies

Dosage and Procedure
Pergonal/Humegon injections are usually started between days 3 and 6 of your menstrual cycle. You should call your nurse on the first day of your period. On the days instructed by your nurse, you will need to be in the office by 9:30 a.m. to have blood drawn for an estrogen level. You may also have a sonogram (picture by ultrasound) to observe the development of the egg (follicle). A pelvic examination may also be done to evaluate changes in the cervix as well as the size of the ovaries. The estrogen results are reported late in the afternoon. At that time your doctor will review these results with your nurse. Your nurse will then contact you regarding how much medication you are to receive and when you should return for additional monitoring. There is no way to accurately predict exactly how much drug you will require. Therefore, it is necessary that you be able to come in by 9:30 a.m. for blood work, and possibly return in the afternoons, on an unknown number of days.

The follicles (eggs) become mature when the estrogen has reached the appropriate level. This level is highly individualized. At this time you may notice an increase in vaginal discharge, which is normal. You will receive a drug called HCG (Human Chorioic Gonadotropin) 24 to 48 hours after your last Pergonal injection. You should expect to ovulate approximately 36 hours after your HCG injection. You should have intercourse the day of the injection. If you are having intrauterine insemination, this will be scheduled approximately 24 - 36 hours after your HCG injection.

The following are frequent symptoms associated with Pergonal which are not generally serious:

• Breast tenderness

• Swelling

• Abdominal bloating

• Mood Swings

• Slight abdominal discomfort or twinges

The following could be signs of the hyperstimulation syndrome and should be reported to your nurse as soon as possible:

• Significant abdominal pain

• Significant abdominal bloating

• Dizziness or weakness

Click here to go back to the top

Post-Coital Test

The post-coital test (PK) is used to evaluate your cervical mucus. The test also evaluates the way your partner's sperm swims within your mucus. When a male ejaculates during intercourse, the sperm must swim through the cervical mucus up to the uterus, to the fallopian tubes to meet the egg.

The timing of this test is extremely important. Your body will manufacture the clear, thin, watery mucus during ovulation. The doctor may ask you to determine ovulation by using a urine ovulation prediction kit. If you use the urine kit, call the office when you surge so an appointment for the PK may be made. If you do not use a urine kit, call the office when you get your period so the PK can be scheduled between day 12 to 14 of your cycle.

You will be asked to have intercourse 2 to 12 hours before appointment time. It is ok to shower after but you MUST NOT douche or take a tub bath.

For the PK, the doctor will perform a pelvic exam and obtain a small sample of the mucus. The mucus sample will be examined under the microscope. Occasionally, the PK may need to be repeated in the same cycle or a later cycle. There is no pain or discomfort involved with this test. The results will be discussed with you after the doctor has reviewed the slide.

The cost for the test is $150.00.

Click here to go back to the top

In Vitro Fertilization

Introduction
In vitro fertilization and embryo transfer (IVF-ET) was first successfully used in humans over 25 years ago; since then, more than one million children have been conceived using this technology. IVF is a procedure designed to enhance the likelihood of conception in couples for whom other fertility therapies have been unsuccessful or are not possible. It is a complex process and involves multiple steps resulting in the insemination and fertilization of oocytes (eggs) in our laboratory. The embryos created in this process are then placed into the uterus for potential implantation. Each stage of the procedure is associated with specific risks, as outlined below.

Benefit of Therapy

• IVF is an elective medical treatment. IVF may provide a couple who has been otherwise unable to conceive with a chance to establish a pregnancy.

Risks of Therapy

• Superovulation Stimulates Egg Development
  The controlled "superovulation" techniques used in IVF are designed to stimulate the ovaries to produce several eggs (oocytes) rather than the usual single egg as in a natural cycle. Multiple eggs increase the potential availability of multiple embryos (fertilized eggs) for transfer and ultimately increase the probability of conception.
  
  The medications required to boost egg production may include, but are not limited to the following: Lupron (gonadotropin releasing hormone-agonist), Antagon or Cetrotide (gonadotropin releasing hormone-antagonist), Follistim, Bravelle or Gonal-F (FSH, follicle stimulating hormone), Repronex, Menopur (combination of FSH and LH, luteinizing hormone), and Pregnyl or Novarel (hCG, human chorionic gonadotropin). Each is administered by injection only. Most medications are given subcutaneously (beneath the skin), though some are intramuscular injections (into the muscle). Risks associated with injectable fertility medications may include but are not limited to, tenderness, infection, hematoma, and swelling or bruising at the injection site.
  
  Risks associated with the medications may include, but are not limited to, allergic reactions, hyperstimulation of the ovaries (mild, moderate or severe), failure of the ovaries to respond and cancellation of the treatment cycle.
  
  There are situations that can occur during a stimulation that may necessitate canceling your IVF cycle and stopping treatment for a period of time. This occurs because the ovaries produce either too many or too few eggs in response to drug stimulation protocol. Although we realize that this can be a big disappointment, at times it is necessary to discontinue the use of the medications to avoid the possibility of complications and to afford you the best chance of future success. If canceling the cycle becomes necessary, you will be told to stop your injections. No hCG injection will be given and no egg retrieval will occur. You will be asked to schedule an appointment with Dr. Lesorgen to make decisions regarding future treatment cycles.
  
  When ovulation induction medications are used in fertility therapy, the ovaries are coaxed to produce more than one egg to the point of maturity. Consequently, hormone levels of estrogen and progesterone reach much higher than normal values. When the estrogen level becomes mildly to moderately elevated, side effects that may be experienced include, but are not limited to, fluid retention with slight transient weight gain, nausea, diarrhea, pelvic discomfort due to enlarged cystic ovaries, breast tenderness, mood swings, headache and fatigue.
   

• Ovarian Hyperstimulation Syndrome (OHSS)
  If the estrogen level rises excessively and hCG is administered to trigger final maturation of the eggs, the following more serious complications may result:
   

  1. Excessive fluid retention with fluid in the abdomen and/or chest cavity;

  2. Thrombosis of arteries and/or veins (formation of blood clots) which may lead to stroke, embolus, or potentially fatal complications;

  3. Abnormally enlarged ovaries, which have the possibility of rupturing or twisting (a surgical emergency)

  Any of the three problems listed above may require prolonged hospitalization.
  
  Given the potential for such severe complications, it is important that we carefully monitor your response to these medications. This monitoring also allows your physician to determine when the eggs are ready for the next stage, oocyte (egg) retrieval. Monitoring includes frequent blood drawing for estradiol (estrogen) and possibly progesterone, LH and FSH levels. These blood tests will take place over approximately a twelve-day period. Risks associated with blood drawing may include, but are not limited to:
   

  1. Pain at the site of needle stick

  2. Tenderness or infection of the skin

  3. Bruising or scarring of the site of blood draw

  4. Development of a blood clot in the vein (thrombosis, thrombophlebitis)

  The second portion of the monitoring phase in IVF involves the use of intravaginal ultrasound to track follicular growth. The eggs develop inside fluid-filled cysts of the ovaries called follicles, which enlarge as the eggs mature. Ultrasound studies usually begin after an estrogen response has been measured and continue on a frequent basis until oocyte (egg) retrieval. The ultrasound studies are performed using a vaginal probe. Vaginal sonograms carry no appreciable risk but may cause slight discomfort, particularly as you near the point of ovulation.
  
  Ovarian stimulation with the fertility medications causes multiple follicles to develop. This is desirable in IVF because as the number of eggs increases, the chance for success increases. Multiple embryos can also increase the risk of multiple pregnancy. Approximately 20-25% of pregnancies with IVF will be multiple. Most of these will be twins, but triplets, quadruplets or even greater multiple pregnancies can occur. A procedure called "selective reduction of pregnancy" has been performed in several medical centers across the country in selected cases of triplets or more. Selective reduction is not offered on site. More information on this procedure and recommended centers is available on request.

Retrieving the Oocytes (egg retrieval)
For IVF, collection of eggs is usually performed under transvaginal ultrasound guidance. To accomplish this, a needle is inserted (under IV sedation) through the vaginal wall into the ovaries using ultrasound to locate each follicle. The follicular fluid is drawn up into a test tube to obtain the eggs. Although patients are given pain medications intravenously and are carefully monitored by an anesthesiology staff, some women may experience some discomfort during the procedure. Generally, the oocyte (egg) retrieval takes 20-30 minutes. Patients are usually discharged home within hours after the retrieval. Risks of oocyte (egg) retrieval may include, but are not limited to, the following:

1. Potential reactions from the drugs and procedures used in the administration of anesthesia.

2. Risks associated with the passage of the needle through the vagina into the ovaries (including infection, bleeding, inadvertent damage to adjacent structures including, but not limited to, the bowel, bladder, blood vessels, ureter, uterus or ovary(ies), and adhesion formation (internal scarring) following the procedure. Although uncommon, significant bleeding or damage to the bowel may occur, and surgery may be required to repair such damage; this is a very uncommon event. Rarely, infection may become severe enough to require hysterectomy and/or removal of one or both ovaries.

Collecting and Preparing the Sperm
A semen sample will be obtained from the partner by masturbation on the day of the oocyte (egg) retrieval. This is usually obtained while the retrieval is being performed. Abstinence from ejaculation for two to five days prior to providing this semen specimen is recommended. After the specimen is produced, the sperm will be prepared for inseminating the collected eggs in our laboratory. Because this can be a stressful time period for men, the man/partner may be unable to produce a specimen when needed. Men who feel that they may have difficulty producing a semen specimen have the opportunity to have their specimens frozen by our laboratory ahead of time for use in this situation. Testicular biopsy can also be performed as a method to extract sperm for IVF.

Insemination of Eggs and Embryo Culture
Following egg retrieval, the follicular fluid is immediately transferred to the adjacent laboratory for identification of eggs, evaluation, and preparation for insemination. In the process of collecting the follicular fluid, it is possible that a large number of eggs may be retrieved. It is strongly recommended that all of these eggs be inseminated to maximize the number of embryos available for subsequent transfer. Any objection(s) to this policy should be stated in writing and attached to the IVF-ET consent form with the understanding that pregnancy success may be reduced. Otherwise, the prepared sperm will be added to each egg and they will be allowed to incubate overnight under controlled laboratory conditions. The next day, each egg is evaluated for evidence of fertilization. However, it is possible that no eggs are fertilized. If this happens, the laboratory staff will re-inseminate the eggs or perform intracytoplasmic sperm injection (ICSI) in hopes of obtaining embryos for transfer. If fertilization still does not occur, the eggs will be discarded and the remainder of the procedure will be cancelled. In the case of severe male factor, the couple may be asked to consider the option of using anonymous donor sperm (obtained through a licensed sperm bank for use as a "backup" or secondary sperm source) if it is not possible to obtain sufficient sperm from the partner at the time of fertilization.
The eggs that have fertilized will be allowed to develop for two or more additional days under controlled laboratory conditions before they are placed inside the woman's uterus. Depending upon the couple's wishes, some fertilized eggs/ embryos may be frozen and stored for future use.

After the embryos are transferred to the womb, the woman will continue progesterone supplementation that begins on the evening of your egg retrieval procedure. Progesterone can be taken as a combination of oral troches and rectal/vaginal suppositories or by injections. Administration of these medications after egg collection has been shown to create a more favorable uterine environment for the embryos, which therefore increases pregnancy rates. Side effects of progesterone may include, but are not limited to the following:

1. 1. Vaginal dryness

2. Bloating, breast tenderness

3. Depression, mood swings

4. Delay of menses.

Synthetic progesterone-like medications have been associated with certain birth defects. By using only natural progesterone, the risk of drug-induced birth defects is significantly reduced. It is important to note, however, that birth defects occur in approximately 3% of spontaneously-conceived pregnancies in the USA. Therefore, use of natural progesterone does not guarantee a child without a birth defect.

Transferring Embryos to the Uterus
Embryos are transferred on either day three or day five of development. The embryologists are highly-skilled in identifying "healthy" embryos and in some cases will recommend that a patient extend embryo development to day five, known as the blastocyst stage. Blastocyst transfer has become quite common in IVF cycles as it can increase chances for success while decreasing the likelihood of multiples. Dr. Lesorgen will work closely with the embryologists to determine if a day three or day five transfer would be ideal for your cycle.

Embryos are transferred to the uterus through a small tube (catheter). This procedure is much like a pap smear and does not require any anesthesia and is usually painless. The embryos are placed in a small amount of fluid inside the catheter, which is passed through the cervix at the time of a speculum examination. The embryos are placed in a manner so they reach the top part of the uterus. The number of embryos transferred depends on individual circumstances of the couple, and this decision will be made collectively by you, your physicians and the embryologist. Typically, two to four embryos are be transferred in one treatment cycle.

Embryo transfer can cause mild cramping. Although unlikely, during the embryo transfer the embryo(s) may be displaced through the cervix (causing loss of embryos) or into the fallopian tubes (causing possible tubal pregnancy). There is a small risk of bleeding or infection as a result of the transfer procedure.

After transfer, the woman may get dressed and leave after a brief recovery period. A pregnancy test will be done twelve to fourteen days after the transfer, regardless of the occurrence of any uterine bleeding.

The transfer of several embryos increases the probability of success. A multiple embryo transfer also increases the risk of a multiple pregnancy. Any multiple pregnancy carries an increased risk of miscarriage(s), premature labor and premature birth as well as an increased financial and emotional cost. Pregnancy-induced high blood pressure and diabetes are more common in women pregnant with more than one fetus. Prolonged hospitalization may be necessary for these pregnant women and for the mother and babies after delivery. Tubal (ectopic) pregnancy is also possible, and a combination of normal pregnancy and ectopic pregnancy may occur. A tubal pregnancy is a condition that may require laparoscopy or major surgery for treatment. Like spontaneous (natural) conceptions, pregnancies that arise through IVF may result in miscarriage. In the event of a miscarriage, a dilatation and curettage (D&C) may be necessary.

Couples going through therapy must choose and formalize their choice in the appropriate consent form by indicating one of the following options for handling of any remaining embryos:

1. Freezing (cryopreservation) of remaining embryos for use by the couple in future treatment cycles.

2. Allowing the embryos to develop in the laboratory until they perish, at which time they would be disposed of in a manner consistent with professional ethical standards and applicable legal requirements (This usually occurs within six to eight days after egg collection)

Other Issues:
Any assisted reproduction process or technique can be psychologically stressful. Significant anxiety and disappointment may occur. We encourage you to consider short-term supportive counseling during this time and we are happy to provide you with a list of psychiatrists, psychologists, counselors and social workers who may help you through this difficult time.

A substantial time commitment is required by both partners to complete an entire course of IVF therapy. It will be necessary for couples to adjust their schedules to undergo the required testing and therapies associated with IVF-ET. It is the responsibility of the woman to report to our office as scheduled for repeated ultrasound examinations and blood tests over several days or weeks before and after the expected time of egg collection. It is the responsibility of the man to be available at the time identified by the physician to provide sperm.

Theoretical Concerns & Potential for Success:
Unfortunately, neither conception nor a successful outcome of pregnancy is guaranteed by the IVF-ET procedure. There are many reasons why pregnancy may not occur with the IVF-ET procedure. In fact, there are complex and largely unknown factors that limit pregnancy rates following assisted reproductive techniques. Some of the known reasons for failure may include, but are not limited to:

1. There may be a failure to recover an egg because:

   1. follicles that contain mature eggs may not develop in the treatment cycle

   2. ovulation has occurred before time of egg recovery

   3. one or more eggs cannot be recovered

   4. pre-existing pelvic scarring and/or technical difficulties prevent safe egg recovery.

2. The eggs that are recovered may not be normal;

3. There may be insufficient semen to attempt fertilization of the recovered eggs because the man is unable to produce a semen specimen, because the specimen contains an insufficient number of sperm to attempt fertilization, because the laboratory is unable to adequately process the specimen provided, or because the option to use a donor sperm as a "backup" was declined;

4. Fertilization of the eggs to form embryos may fail even when the egg(s) and sperm are normal;

5. The embryos may not develop normally or may not develop at all. Embryos that display any abnormal development will not be transferred;

6. Embryo transfer into the uterus may be difficult/impossible, or implantation(s) may not occur after transfer, or the embryo(s) may not grow or develop normally after implantation;

7. Any step in the IVF-ET process may be complicated by unforeseen events, such as hazardous or catastrophic weather, equipment failure, laboratory conditions, infection, human error and the like.

In the event the couple should die before embryo transfer, the embryo(s) will be discarded unless other provisions are made in writing.

When pregnancy occurs following IVF, it will typically be a normal pregnancy. However, there is always a risk of abnormal pregnancy, miscarriage, blighted ovum, ectopic pregnancy or premature delivery. This is because the process of IVF-ET does not protect against such normal occurrences. Congenital abnormalities, genetic abnormalities, mental retardation or other birth defects which occur in approximately 3% of spontaneously-conceived pregnancies may still occur in children born following assisted reproductive techniques. A large review of a subset of children born following assisted reproductive procedures found the incidence of developmental anomalies similar to a control group of children spontaneously conceived. Women with multiple pregnancies have a much higher risk of complicated pregnancies, which may include the following: toxemia, pre-eclampsia, miscarriage, premature labor and delivery, stillbirth, birth defects, and other complications.

Alternatives to IVF-ET:
Depending upon the individual and unique cause(s) of infertility for each couple, the chance of conception through alternative means, including intrauterine insemination (IUI) and medicinal therapy, other than IVF-ET may or may not exist. Possible success rates of these alternatives may vary depending upon the type and severity of the cause of the infertility. For some couples, it may even be possible to conceive spontaneously without a physician's help. You should discuss these alternative treatment methods with your physician before you proceed with IVF-ET therapy.

Click here to go back to the top