Gonadotropin Therapy

Background

Gonadotropins are protein hormones produced by the pituitary gland by men and women. They are Follicle  Stimulating Hormone (FSH) and Luteinizing Hormone (LH). In the Female, FSH promotes the maturation of ovarian follicles and the eggs that they contain. The cells, which line each follicle, produce estrogen, which in turn promotes the growth of the uterine lining (endometrium) so as to create a favorable environment for embryo implantation. Estrogen also stimulates the cervical glands to produce clear mucus, through which sperm must pass, in transit to the awaiting egg in the distal end of the fallopian tube. LH is released, in small amounts, in a pulsitile manner up until the time of ovulation when a large amount is released (LH surge). Low concentrations of LH help to promote and sustain the development of the early corpus luteum which is formed from the collapsed follicle following ovulation.

Methodology

Prior to selecting the most appropriate regimen of gonadotropin therapy, the hormones FSH, LH and estradiol are measured between the 2nd and 4th days of a menstrual cycle. This enables the doctor to select the most ideal regimen and dosage likely to achieve optimal stimulation.

What are the side effects?

According to the American Society of Reproductive Medicine, the main side effects are as follows:

Ovarian Hyperstimulation (OHSS) - Ocurring in 1 to 5 percent of cycles, the chance of OHSS is increased in women with polycystic ovarian syndrome and in conception cycles. When severe, it can result in blood clots, kidney damage, ovarian twisting and chest and abdominal fluid collection. In severe cases, hospitalization is required to monitoring fluid intake and output and instituting appropriate treatment. While not totally preventable, careful monitoring of patients undergoing follicular stimulation should minimize this potentially serious complication. Those patients with grossly exaggerated responses will have their cycles cancelled prior to hCG administration.

  • Multiple Gestation - up to 30% of pregnancies resulting from gonadotropins are multiple, in contrast to a rate of 1 to 2 percent of the general population.

  • Ectopic (Tubal) Pregnancy - while ectopic pregnancies occur 1 to 2 percent of the time, in gonadotropin cycles the rate is slightly increased at 1 to 3 percent.

  • Adnexal Torsion - less than 1 % of the time, the stimulated ovary can twist on itself, cutting off its own blood supply.

Long Term Risks

According to the American Society for Reproductive Medicine, some studies suggested a possible link between ovarian cancer and the use of drugs that induce ovulation. Although the data does suggest that infertile women and in particular, women who take infertility drugs, do have a higher risk of ovarian cancer, it is not known whether the drugs themselves are the cause of the increased risk. It is the Center's feeling that all fertility drugs need to be used prudently with suitable monitoring, for limited periods of time.

Insurance questions

Our administratitive staff will be happy to assist you in determining your level of coverage for your indicated treatment cycle. We strongly recommend that you contact your insurance company for clarification of benefits prior to initiating treatment.

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Endometrial Biopsy

What is an Endometrial Biopsy?

An endometrial biopsy is a test that evaluates the endometrial tissue that lines the inside walls of your uterus. Around the time you ovulate (release an egg from your ovary), your endometrium (inside lining of your uterus) grows thick with blood vessels, glands, and stored nutrients to allow a fertilized egg to implant and grow. If fertilization does not occur, the endometrial tissue sheds as menstrual flow to mark the beginning of your next cycle. Progesterone and Estrogen control growth and stabilization of the endometrial tissue. If your body doesn't produce enough of these hormones, your uterus may not be able to maintain a pregnancy. An endometrial biopsy is taken by your doctor and then sent to a pathologist who will examine the sample of your endometrial tissue under a microscope. Your doctor can tell if your body is producing enough of these hormones by its thickness and pattern. If your body is not producing enough hormones, medications may be prescribed to regulate them.

How is this test performed?

Your doctor will place a speculum inside your vagina, insert a small catheter through your cervix into your uterus, and remove a small sample of the endometrial lining. It usually takes just a few seconds. You may feel a pinch or some cramping.

What can I expect after the procedure?

You may have a mild cramps an hour of so after the procedure and you may also have vaginal spotting. Light bleeding and spotting can last until you have your period.

When will I receive the results of this test?

Results for this test will be reviewed and discussed with you during your follow up consult with your doctor.

Does this test have to be done on a specific day of my cycle?

Yes. This test is usually done 1 to 3 days before you expect your period or between cycle days 22 and 26. Your endometrium should be very thick at this time in your menstrual cycle. You will need to let your doctor know when your period actually begins. Your doctor will compare the date your period actually started with the date it should have started, based on the thickness and pattern of the tissue sample. If there is a big difference between these dates, it may mean that your endometrium is not sufficient to support a pregnancy.

What are the risks of this procedure?

There is a slight chance that the biopsy may disrupt an early pregnancy if you happen to be pregnant when the test is performed. To avoid this potential problem, your doctor may want you to avoid pregnancy during the month you are taking this test. You will have a urine pregnancy test before you have the biopsy to make sure you are not pregnant.

Insurance questions

Most commonly an endometrial biopsy is considered a diagnostic evaluation. Our administration staff will be happy to assist you in your coverage and patient responsibility.



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Hysterosalpingogram

Why is an HSG performed?


Damage to the fallopian tubes and /or the uterus can interfere with the passage of sperm, eggs and embryos, thus hindering the establishment of pregnancy. An HSG is a diagnostic procedure, which allows the physician to identify any blockage in the fallopian tubes. Also, obvious defects of the uterus such as scarring, fibroids or developmental abnormalities can be detected.


What is involved?


The radiologist will inject a small amount of dye into the uterus by passing an instrument through the cervix. X-rays can display the dye. Enough dye will be injected to permit the visualization of the uterine cavity and the pathways through the fallopian tubes. Spillage of the dye from each fallopian tube should be observed if the tubes are patent. Blockage of either or both tubes can be confirmed by failure to pass the dye. The procedure may cause some discomfort and spotting can occur afterwards.

How to prepare for an HSG


Your HSG will be scheduled at the time between the complete cessation of menstrual flow and expected ovulation. You are advised not to have unprotected intercourse from the first day of your menstrual flow until after the procedure date.

On the day of the procedure you may have meals. but eat lightly. Approximately 30 minutes before the procedure take 600-800 mgs of either Advil, Motrin or 440 mg of Anaprox.

Normally you will be able to return to work after the procedure.

 

Where is the procedure performed?


You will need to collect a prescription from our office and then report to Patient Registration of the Hospital or Diagnostic Center at least 15 minutes prior to scheduled procedure time. Please confirm with our reception staff where to attend.


Things to remember


Please notify us if you suffer from asthma or have been diagnosed with Mitral Valve Prolapse. You may have to be medicated prior to your HSG. Please notify us of any allergies you may have.


Insurance questions


An HSG is considered a diagnostic evaluation. Our administration staff will be happy to assist you in clarifying you coverage and patient responsibility.



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Clomiphine Citrate

Background

Clomiphine citrate has been used for ovulation induction for many years. It acts by functioning as an antiestrogen, blocking the normal feedback response between the ovary and the hypothalmic pituitary axis. By blocking the estrogen receptor the pituitary gland receives less estrogen being present and releases an increased amount of FSH to stimulate the ovary. This results in the recruitment and continued development of an oocyte and eventual ovulation.

The antiestrogenic effect of Clomiphine can also affect the priming effect of estrogen on the endometrial lining as well as the production of cervical mucous. The ultimate effect on these target organs is usually a balance between the increased estrogen produced as a result of ovarian stimulation and the antiestrogenic effect of the Clomiphine.


Indications

Clomiphine Citrate is indicated for the treatment of ovarian dysfunction. This includes patients with anovulation, oligo-ovulation, luteal phase defect and those requiring timing of inseminations for the treatment of male factor or donor inseminations.

Clomiphine Citrate is usually commenced between the 3rd and 5th day of the menstrual cycle, counting the first day of full flow as day 1. The medication is usually taken in the evening, in tablet form, for 5 days. Most patients respond to either 1 or 2 tablets daily (50-100mgs). Occasionally dosages of up to 250 mgs are required to achieve ovulation. The response to Clomiphine therapy should be monitored to insure that an appropriate effect is being achieved. Normally, it is our practice to start Clomiphine Citrate between cycle days 3-5 with the patient using an LH kit from cycle day 12.

An ultrasound and serum estradiol is often obtained on cycle day 14 and if an adequate dominate follicle exists in the presence of an adequate estradiol level and a good biological effect on the endometrial lining, hCG is administrated intramuscularly. The latter agent substitute for the body's natural LH surge. Most commonly, ovulation will occur in 30-50 hours following this injection.


What are the side effects?

The multiple birth rate with Clomiphine Citrate is estimated between 6-8%. The majority of these multiple gestations are twins. Other side effects such as moodiness, hot flashes, headaches, and blurred vision have been described.




Does Clomiphine Citrate increase risks of birth defects?

According to the American Society for Reproductive Medicine, doctors can advise patients that ovulation induction agents are not associated with an increased risk of birth defects.

 

Long term risks 

Several studies suggested a possible association between ovarian cancer and the use of drugs that induce ovulation. Although the data does suggest that infertile women, and in particular, women who take infertility drugs, do have a higher risk of ovarian cancer, it is not known whether or not the drugs themselves are the cause for the increased risk. It is important that women considering the use of ovulation induction agents discuss the potential benefits and risks with the Doctor. It is the Center's feeling that all fertility drugs need to be used prudently with suitable monitoring for a limited period of time.

 

Insurance questions 

Most commonly an endometrial biopsy is considered a diagnostic evaluation. Our administrative staff will be happy to assist you in evaluate your coverage and patient responsibility. We strongly recommend you to call your insurance company to find out about benefits of your policy.


 

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Hysteroscopy


Why is Hysteroscopy performed?

A hysteroscope is a lighted flexible telescope, which has been scaled to size so passage through the cervix into the uterus occurs relatively easily. Hysteroscopy is a diagnostic procedure, which allows the direct visualization of the cervical canal and internal uterine architecture. This may reveal defects, which may cause infertility problems (such as polyps, fibroids, tumors, bands of scar tissue or congenital abnormalities). Hysteroscopic findings complement the results of the Hysterosalpinogram (HSG) by providing medical details of any abnormalities detected.

When is a Hysteroscopy scheduled?

It is necessary to schedule the hysteroscopy at the time between the complete cessation of menstrual flow and before expected ovulation. You doctor will determine the most appropriate time for the hysteroscopy based on your menstrual cycle length.

Where is the procedure performed?

One of our physician performs the procedure in our office, in the comfort of our hysteroscopy suite. Hysteroscopy procedures are performed in our office and your visit will last approximately 30 minutes. The actual instrumentation usually takes only a few minutes.

What is involved?

The hysteroscopy entails placing a speculum in the vagina to allow access to the cervix. The vagina will be cleansed with an antibacterial solution. The flexible hysteroscope will then be channeled through the cervical canal. Small amounts of carbon dioxide gas or saline will be used as distending media to better visualize the uterine cavity. Occasionally, a grasping instrument is used on the cervix to immobilize it and straighten the cervical canal - local anesthesia is then utilized to minimize your discomfort.

After the procedure, the instruments will be removed. If necessary, a tampon may be placed in the vagina to contain the small amount of bleeding related to grasping of the cervix.

How to prepare for Hysteroscopy

On the day of the procedure, you may have meals, but eat lightly. Approximately 30 minutes before your appointment take 600-800 mgs of either Advil, Motrin or Anaprox 440mgs.

Please notify us if you have Mitral Valve Prolapse and require prophylactic antibiotics. You may need to take some antibiotics for this procedure, if you take them prior to dental procedures. Please notify us of any allergies.

Post Procedure Instructions

If a tampon has been inserted, please remove 2-3 hours after procedure. Avoid sexual intercourse for 24 hours or until spotting has stopped. Call the Doctor if there is excesive vaginal bleeding, fever or foul-smelling discharge. Remember it is common to have spotting for a day or two after the procedure.

Please do not hesitate to call our office if you have any questions about symptoms you are experiencing.

Insurance questions

Most commonly a hysteroscopy is considered a diagnostic evaluation. Our administrative staff will be happy to assist you in clarifying your coverage and patient responsibility.

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Información adicional