General Questions About Infertility

• Absence or reduced ovulation (less than 12-13 times a year)
• Blocked fallopian tubes
• Low egg number and quality

• Decrease in sperm count, movement or shape. In its most advanced form no sperm appears in the ejaculate (azospermia) due to decreased sperm production or obstruction.
• Inability to deposit sperm into the vagina e.g. erectile dysfunction.

Age is the most important factor impacting fertility. Age is associated with reduction in egg number and egg quality.

The number of eggs remaining in the ovary constantly diminishes from approximately 300,000 at puberty to 1,000 at the age of menopause.

For example by the age 35 the number of eggs remaining in the ovary is half those present at age 25. Hence it is important for women to seek consultation as early as possible.

In addition to reduced egg numbers, the quality of the eggs is also lower with advanced age. The most important aspect of egg quality is the chromosomal complement of the eggs. Abnormal eggs carry or lack a chromosome or piece of chromosome. For not well understood reasons, the number of abnormal eggs increases with advance in age.

Diminished in the number of quality eggs with age reduces the chance for natural conception, prolongs the time to achieve pregnancy and increases the risk for miscarriages, ectopic pregnancy and abnormal pregnancy outcomes.

Fertility treatment is less successful with advance in age even when IVF is employed. Age is also associated with increased risk for miscarriage after IVF. Success of egg freezing is also reduced when performed later in life >38-40 years.

Couples are encouraged to seek fertility evaluation and possibly treatment following one year of regular unprotected intercourse. Unprotected means relation without any method of birth control (pills, condom or others). Women 35 years or older should consider a consultation earlier e.g after 6 months. Couples or women should also seek care in the presence of a known infertility factor

• Women with a possible fertility issue e.g. irregular cycles or no menses indicating no ovulation, history of prior pelvic surgery or endometriosis
• Male partner known to have abnormal sperm analysis
• Individuals known to be a carrier of genetic disease to avoid the risk of transmission to future children e.g. chromosomal abnormality, sickle cell, BRCA mutations.
• Women seeking to extend their fertility through egg or embryo freezing (cryopreservation and storage)
• Women and men at risk for infertility because of disease or disease treatment e.g breast cancer, lupus.
• Same sex couples.
• Women with a medical problem or an issue that prevents them from carrying a baby in their own uterus.
• Recurrent pregnancy loss; two or more spontaneous miscarriages Remember there is no harm in early consultation but delayed consultation / referral can increase the risk of failure of fertility treatment if needed.

• Tests for ovarian function (ovarian reserve): cycle day 2 or 3 FSL, LH and estradiol. Anti-mullerian hormone levels (AMH)
• Test for fallopian tubes: hysterosalpingogram (HSG)
• Test for male factor: sperm analysis.
• Preconception labs for male and female to establish the safety of getting pregnant. These include genetic screening, infectious disease testing, screening for diabetes and thyroid gland abnormalities, screening for disorders of prolactin, blood count and type and immunity to rubella and chickenpox.
• Testing for the uterine cavity: saline sonography if a uterine abnormality distorting the cavity is suspected.
• Select additional tests are ordered if indicated e.g MRI of the uterus if congenital abnormalities of the uterus is suspected, CT scan for the pituitary gland if a pituitary tumor is suspected, a specific screening or sequencing of a gene in case of strong family history or affected relatives e.g BRCA1 and 2…

Recurrent pregnancy loss is one of the toughest spots for women that require extensive support and counseling. We start by asking the couple not to attempt pregnancy and use a birth control method till the workup is completed. We run both partners’ chromosomes, antiphospholipid antibodies and tests for excessive clotting (thrombophilia). We also investigate the shape of the uterus and exclude any abnormalities in its cavity. We refrain from ordering tests or recommending treatment of anecdotal or no proven relation to recurrent miscarriage.

After testing is completed, we convene with the couple to discuss 1. Test results and how to address any abnormality and 2. The odds for a delivery of a healthy newborn.

Women with specific abnormality e.g. clotting problems are treated with aspirin and heparin. Women with abnormalities in the uterus require surgical correction, mostly through hysteroscopy not major surgery. Women or men carrying a chromosomal abnormality as translocation are offered IVF with embryo biopsy followed by chromosomal analysis of the embryos and transfer of normal ones.

For women with no abnormalities, there is a 70% chance of delivering a viable baby if they continue to try using intercourse, IUI or IVF cycle.

Modern treatment of male factor infertility depends on results of initial evaluation. Men with 10 million motile sperms in their ejaculate can attempt ovarian stimulation and IUI. Men with less sperm or with multiple sperm abnormalities: reduced number, count and motility should undergo IVF sometimes with ICSI where a single sperm is injected in each egg. 

Men with no ejaculated sperm (azospermia) should be evaluated for surgical retrieval of sperm from the testes.

Men with severe male factor are at an increased risk for genetic abnormalities and this should be considered prior to treatment.

Men with erectile dysfunction can be assisted through medical treatment or vibratory devices and sperm can be used for IUI or IVF.

Once few normal sperm are obtained, successful pregnancy depends on the ovarian reserve of the female partner. Thus it is important to evaluate male and female partners prior to any procedures in any of them.

There is no strong evidence that repair of varicocele or medical treatment improves the odds for pregnancy in partners of men with male factor infertility.

Sometimes women do not conceive after multiple IVF attempts. These challenging situations require careful evaluation of past treatment. These include the specifics of ovarian stimulation protocol and ultrasound and hormone levels in every stimulation day. It also requires evaluation of the state of eggs and embryos after each cycle. Prior difficulty in embryo transfers is also investigated. Additional tests may be required such as Karyotype (Chromosome analysis of both partners), saline sonography to detect any abnormalities in the uterine cavity, endometrial biopsy to detect endometrial receptivity (ERA) and inflammation of the lining of the uterus and other tests. Review of ultrasound and hysterosalpingogram (HSG) may indicate a dilated fallopian tube (hydrosalpinx) that should be excised before treatment. We address any abnormality detected before initiating further treatment.

Our approach to repeat IVF failure in women with low ovarian reserve or advanced reproductive age is Modification of stimulation protocol: reduce dose, change timing of hCG injection. Many times modification of the way stimulation is done improves the number and quality of eggs. This may include pretreatment with estradiol and antagonist in the preceding cycle just before starting stimulation, the addition of oral agents e.g clomid or letrozole, reduced dose of gonadotropin and earlier administration of hCG injection.

Genetic testing of the embryos: This approach may be feasible in women producing large numbers of eggs and embryos but fail to achieve pregnancy. 

Genetic testing enables selection of the chromosomally normal embryos for transfer or for women and men with abnormal chromosome configuration.

If prior IVF failure takes place in women with high ovarian reserve with the production of many eggs but no pregnancy after transfer of good quality embryos changing the stimulation protocol may reduce the number of eggs produced, increase egg maturity and embryo quality. Mild stimulation protocols and adding an oral agent commonly achieve that goal and yield a successful pregnancy.

There are many steps you can take but by far the most important is early consultation with a qualified reproductive endocrinologist. This step allows for the study of various fertility factors especially ovarian reserve and directs you to the most successful plan of action.

Encourage your partner to seek care and advice from a urologist and a reproductive endocrinologist. Explain that he is not the only factor and there are always multiple factors cooperating together.

In a natural cycle, the ovaries usually produce one follicle that contains a single egg. Ovarian stimulation entails the production of more than one follicle and subsequently more than one egg. If the intention is IUI then the desired number of eggs should be small e.g. 1-3 eggs to minimize multiple pregnancies. In IVF, the aim is to produce a larger number of eggs because not all the eggs are mature, not all of them fertilize and not all the embryos are healthy and continue to grow. The desired outcome is to transfer one or more good quality embryos into the uterus while the rest are frozen for later use.

Stimulation is achieved through the administration of oral or injectable agents with monitoring of the response and modification of the dose.

It is the physical placement of embryos into the uterus. It is a delicate procedure that require careful attention and superb skills so that embryos are delivered into the middle of the cavity of the womb without damage to them and the lining of the uterus and without exciting contractions of the wall of the uterus

In its common form it indicates freezing of embryos or eggs at a young age then thawing them at later age to achieve pregnancy in women delaying child bearing for social or personal reasons (extending fertility).

Preservation of fertility in general means the application of medical, surgical and laboratory procedures to preserve the potential of conception with the individual own eggs or sperm in adults and children at risk of sterility during reproductive years.

Sperms are obtained usually through masturbation, prepared to concentrate sperm and remove fluids. The prepared sperm are loaded in a thin catheter and injected into the uterus. Sperm preparation concentrates sperm and increases their motility. IUI also bypasses any obstacles in the cervix like thick cervical mucus.

In vitro fertilization indicates that egg(s) are picked up from the ovary and incubated with sperm in the laboratory. Eggs are observed for fertilization then embryo development. One or more embryos are then transferred into the cavity of the womb 3 to 6 days after retrieval.

Ovulation induction is the initial treatment for women who do not ovulate (release an egg) on their own e.g. women with PCOS and women with hypothalamic amenorrhea. These women have many eggs in the ovary but cannot process these eggs to the point of maturity. A medicine is given to make these eggs mature inside the ovary then ovulate. Before employing this treatment the fallopian tube should be open and sperm parameters should be normal.

Weight loss improves ovulation in some women. Medications used to induce ovulation could be oral (clomid, letrozole) or injections. The aim is to produce 1-2 eggs to minimize the risk for multiple pregnancy.

Direct injection of a single sperm into the egg. A sperm is picked using a thin tube then the tube is pushed through the outer shell of the egg and the sperm is released. It is used in cases of male factor, prior unsuccessful fertilization with IVF alone and other conditions.

The outer shell of the egg is opened using a laser beam to facilitate implantation of the embryo. It is useful in older women and women with thick outer egg shell.

After egg retrieval the embryos can be cultured for 5 to 6 days. The blastocyst is an advanced embryo that is made up of hundreds of cell. Embryos that progress to blastocyst stage have higher potential to be healthy and to attach to the lining of the uterus. Extended culture of the embryo allows for better selection of the healthier embryo for transfer.

After the embryos reach the blastocyst stage, couples may opt to test the chromosomal makeup of the embryos prior to implantation. This entails taking a few cells out of each embryo ( biopsy of average 4 cells) and subsequently testing them for chromosomal number and some structural abnormalities. Also, PGT can identify single gene disorders and the embryo’s gender.

Instead of transferring 2 embryos into the uterus which carries a twin rate of about 30%, one embryo is transferred and the other is frozen. If pregnancy does not take place, the frozen embryo is thawed and transferred in the next cycle. This approach markedly minimizes twin pregnancy to 1% while maintaining a comparable chance for pregnancy.

Extra embryos that will not be transferred are frozen and stored to use later. They can be stored for a very long time. When desired, the embryo is thawed and transferred to the uterus after preparation of the lining of the uterus.

An embryo is a fertilized egg (already penetrated by a sperm). An egg is a cell that is not fertilized yet. Multiple eggs are retrieved after ovarian stimulation and stored after slow or rapid freezing for use later.

When desired, the egg is warmed and injected with a sperm. The resulting embryos are transferred into the uterus. It enables women to preserve their fertility and to use their eggs at a later time.

Egg donation is an option for women with low egg supply and underwent multiple unsuccessful fertility treatment cycles. A young woman is screened to become a donor. She undergoes stimulation and eggs are obtained from her ovary. Eggs are fertilized with partner or donor sperm. The mother’s uterus is prepared and some of the embryos are transferred to the uterus. The rest of the embryos are frozen. Donor eggs yield very high pregnancy rates and are generally a satisfactory experience for women and families.

The only proven long term risk for fertility treatment is multiple pregnancies. They should be avoided at each step of fertility treatment through careful stimulation and reducing the number of embryos that reach the cavity of the uterus. Multiple pregnancy can increase the risk of premature delivery requiring admission of the babies to the neonatal intensive care units and can be associated with long term health problems for children. If it takes place, fetal reduction should be considered.

There is no evidence that fertility treatment itself increases the risk of any cancer or congenital abnormalities.

Some issues are related to trying to conceive with IVF after the age of 35;

These issues include reduced chance for pregnancy compared to younger age (40% versus 50% in younger age), increased risk for miscarriage and increased risk for chromosomal abnormalities in the baby (compared to younger women). These are unrelated to IVF itself but rather to increased chromosomal abnormalities in the egg. Babies carrying chromosomal abnormalities are largely detected during early pregnancy

Additionally there is increased risk for medical problems during pregnancy e.g diabetes and also delivery by cesarean section. These are usually easy to manage during pregnancy under the supervision of qualified obstetricians.

An IVF cycle carries a high chance for success when the egg supply in the ovary is adequate, the quality of eggs are good, with good response to fertility medications. Male produces at least a few sperms; one or two good quality embryos are transferred smoothly into the uterus.

Ovarian stimulation requires an average of 12 to 14 days. Embryos are transferred 3 to 6 days later. A pregnancy test is performed 2 weeks after egg retrieval. Total 3 weeks (not including initial testing)

• Stimulation of the ovaries
• Retrieval of eggs
• Fertilization of eggs
• Culture of embryos
• Transfer of embryos to the womb

Sometimes women do not conceive after multiple IVF attempts. These challenging situations require careful evaluation of past treatment. These include the specifics of ovarian stimulation protocol and ultrasound and hormone levels in every stimulation day. It also requires evaluation of the state of eggs and embryos after each cycle. Prior difficulty in embryo transfers is also investigated. Additional tests may be required such as Karyotype (Chromosome analysis of both partners), saline sonography to detect any abnormalities in the uterine cavity, endometrial biopsy to detect endometrial receptivity and  inflammation of the lining of the uterus and other tests. Review of ultrasound and hysterosalpingogram (HSG) may indicate a dilated fallopian tube (hydrosalpinx) that should be excised before treatment. We address any abnormality detected before initiating further treatment Our approach to repeat IVF failure in women with low ovarian reserve or advanced reproductive age is

• Modification of stimulation protocol: reduce dose, change timing of hCG injection. Many times modification of the way stimulation is done improves the number and quality of eggs. This may include pretreatment with estradiol and antagonist in the preceding cycle just before starting stimulation, the addition of oral agents e.g clomid or letrozole, reduced dose of gonadotropin and earlier administration of hCG injection.
• Genetic testing of the embryos: This approach may be feasible in women producing large numbers of eggs and embryos but fail to achieve pregnancy. Genetic testing enables selection of the chromosomally normal embryos for transfer or for women and men with abnormal chromosome configuration.
• If prior IVF failure takes place in women with high ovarian reserve with the production of many eggs but no pregnancy after transfer of good quality embryos changing the stimulation protocol may reduce the number of eggs produced, increase egg maturity and embryo quality. Mild stimulation protocols and adding an oral agent commonly achieve that goal and yield a successful pregnancy.

No. IVF is a very robust treatment for infertility and is able to address many aspects of reproductive abnormalities. The majority of women, however, can be helped with simpler treatments as IUI or induction of ovulation and do not require IVF.

We recommend you go through two steps 1. Completed consultation with a qualified reproductive endocrinologist, initial fertility testing and preconception labs. If you received prior treatment these should also be discussed with your physician in details and 2. Understand your fertility issues and the treatment options available for you and their success rate.

You should then consider additional factors: time commitment, cost, risks of treatment e.g. multiple pregnancies, before making a final decision. Example if you do not ovulate and all other tests are normal initial treatment is induction of ovulation with medications with IUI. If this treatment significantly increase your risk for multiple pregnancy and you do not accept fetal reduction if that takes place you may want to consider IVF with single embryo transfer.

We recommend you go through two steps. The first would be a complete consultation with a qualified reproductive endocrinologist, initial fertility testing and preconception labs. If you received prior treatment these should also be discussed with your physician in details. The second would be to understand your fertility issues and the treatment options available for you and their success rate.

You should then consider additional factors: time commitment, cost, risks of treatment e.g. multiple pregnancies, before making a final decision. Example if you do not ovulate and all other tests are normal initial treatment is induction of ovulation with medications with IUI. If this treatment significantly increase your risk for multiple pregnancy and you do not accept fetal reduction if that takes place you may want to consider IVF with single embryo transfer.

During Consultation

A structured consultation with a reproductive endocrinologist consumes approximately 90 minutes. Components of encounter include

• History: to review information related to ovarian, tubal and male factors of infertility as well as medical, surgical and personal histories. Detailed family and genetic history is essential to identify and possibly test for risk factors of genetic disease in the newborn.
• Examination including general, abdominal and pelvic examination
• Pelvic ultrasound aiming at detecting abnormalities in the uterus, ovaries and the pelvis. Ultrasound is an excellent tool to estimate ovarian reserve-antral follicle count
• Explaining the required tests needed to investigate ovarian reserve, male and tubal factors as well as prenatal tests required of any woman attempting to conceive
• Outlining a provisional plan for investigation and treatment of infertility

All the required tests can be finalized within 2 to 3 weeks, enabling the person or couple to make informed decision about the next step in fertility treatment

After Consultation

Before making any treatment decisions concentrate on completing the required investigation including sperm analysis, test for tubal patency (HSG) and tests for ovarian reserve. Prenatal tests before attempting to conceive including reproductive hormone assay, infectious disease profile and genetic screening tests should also be obtained.

A second visit or phone call with your reproductive endocrinologists outlining the results of fertility tests is highly advisable. Based on theses tests, treatment plans are finalized.

Five points to consider before starting treatment

• Time commitment: Fertility treatment may require multiple visits over several months. Its important that visits are tailored around your schedule with minimal time off work
• Cost is also an important consideration as well as resources available to help you
• Potential undesired outcome especially multiple pregnancy. For example women desiring only a singleton pregnancy should lean towards IVF with single embryo transfer rather ovulation induction with gonadotropin injections
• Risk of pregnancy in older women and women with medical disorders
• Is surgery required before fertility enhancing treatment e.g. removal of polyps or fibroids

If you decide to pursue treatment you need to be advised of the schedule of treatment cycle, type and self administration of medication.

We offer many treatment options but above all counseling and advice that may help you conceive without medical intervention. Many times this is just enough to do the job. In fact only a minority of women are offered IVF at early stages. On the other hand we will not shy from offering IVF if we think it is the most appropriate treatment. Options we offer include:

• Ovulation monitoring
• Ovulation induction
• IUI
• IVF-ICSI
• Mild stimulation IVF
• Treatment for male factor infertility
• Preimplantation genetic Testing (PGT), sex selection
• Egg freezing
• Donor oocytes
• Fertility preservation
• In vitro maturation
• Laparoscopic and hysteroscopic surgery.

If you are looking for a fertility clinic that will give you all the time you need to understand your fertility issues and apply only as much science as is needed to achieve your fertility goals, NYCIVF is the place to come to. Care is centered on you, respects your time commitments and rendered by the same physician every time. We consistently maintain an excellent pregnancy rate while reducing the risk for multiple pregnancy and ovarian hyperstimulation syndrome.

Car: Fifth Avenue between 55th and 54th street.

Bus: M1,M2,M3, M4

Subway: E,M,N,Q,R,B,D,1,4,5,6,C

You can contact us for an appointment in several ways:

• E. mail : reception@nycivf.org
• Address : 693 Fifth avenue, Floor 7 , New York, NY 10022
• Phone : (800) 853-7595, (800) 915-1641
• Fax : (800) 780-6167

How Much Do The Different IVF Treatment Options Cost?

Cost is variable depending on

1. Amount and type of medication used
2. Additional procedures e.g embryo biopsy, genetic testing of the embryos, embryo freezing
3. Own or donor oocytes are used. Insurance may cover all or part of the treatment and medication. Please contact the office for a specific procedure cost.

Insurance may cover part or whole cost of treatment (visits, ultrasounds, lab work or medications). When you contact the office we will call your insurance for you and tell you what will your insurance cover.