The initial approach consists of a consultation, physical examination and ultrasound. The problem of infertility is discussed with specific reference to causes, treatment options and lifestyle changes, which can improve the prognosis for a pregnancy. Patients and their partners are encouraged to ask questions. Planning is done regarding further investigation, which usually involves taking some blood samples and possibly a semen analysis, if not done before.
Ovulation Induction & Timed Intercourse
This is the most basic form of treatment. To consider this there should not be a severe male factor or a tubal factor present. Ovulation induction is done using oral medication or a combination of oral medication and injections. The aim is to ensure ovulation and possibly aim for two to three follicles per cycle in order to improve success rates. The follicles are monitored with ultrasound scans from day eight of the cycle. When the follicles have reached the ideal size, ovulation is either triggered with HCG injection or blood is taken to determine the LH peak.
Once a patient's response has been determined in a cycle and the ovulation has been pinpointed the patient can follow this 'recipe' at home for two to three months.
The success rates for timed intercourse are 5-8% pregnancy rate per cycle.
Artificial Insemination
This is a step up from timed intercourse. Again to consider this there should not be a severe male factor or a tubal factor present. Ovulation induction is done using oral medication or a combination of oral medication and injections. The aim is to ensure ovulation and possibly aim for two to three follicles per cycle in order to improve success rates. The follicles are monitored with ultrasound scans from day eight of the cycle. When the follicles have reached the ideal size ovulation is triggered with HCG injection.
Thirty-six hours after the trigger the patient should ovulate and the insemination is done on that day. The male partner takes his sample to the fertility laboratory where it is prepared. The preparation takes approximately 2 hours. The prepared sample is brought to Dr. Slabbert's rooms and the insemination is done. A small catheter is put into the uterine cavity, which allows the sperm sample to be deposited in the cavity. The patient remains supine for 30 minutes.
Artificial insemination can be repeated for up to nine cycles. The success rates are 15% pregnancy rate per cycle.
In Vitro Fertilisation (IVF)
In Vitro Fertilisation or IVF as it is commonly referred to is a technique where fertilization takes place in the laboratory. The patient is stimulated with follicle stimulating hormone (FSH) and /or luteinizing hormone (LH) in the form of injections. The stimulation is more intensive and aims at producing 8-10 follicles and in some cases even more. The follicles again are monitored using ultrasound. When the follicles reach the required size an HCG injection triggers the final maturation of the oocytes and aspiration is scheduled before ovulation takes place.
The follicles are aspirated under a light anesthetic in a small theatre adjacent to the IVF lab. The embryologist picks up the oocytes from the follicular fluid. The male partner's semen is prepared in much the same way as for artificial insemination and then added to the oocytes in the lab. On day one fertilization is seen and from day two the embryo divides and can be evaluated in terms of the quality.
The transfer of embryos is possible from day two. If there is a lot of embryos transfer is postponed to try and determine which embryos are the best quality and, therefore will give the best possible pregnancy rate.
The success rate of IVF can be as high as 40% depending on factors such as the age of the patient and the number of follicles.
ICSI
Intracytoplasmic sperm injection (ICSI) is used in patients where there is a severe male factor or recurrent non-fertilisation in previous cycles.
The process is similar to IVF. The only difference is that instead of allowing the sperm to fertilise the oocytes in much the same way as it would happen in the tube, with ICSI for each oocyte a normal looking sperm is selected and injected into the oocyte. In this way the fertilization rate is improved.
The success rate is similar to IVF, can be as high as 40% depending on factors such as the age of the patient and the number of follicles. |
Laparoscopy
Laparoscopy is used to evaluate tubal patency and treat a wide spectrum of conditions such as endometriosis, fibroids and adhesions. It is performed under general anesthetic in theater. A small incision is made in the umbilicus. A needle is inserted to allow for gas to be pumped into the abdominal cavity. Once the pressure in the cavity is at approximately 25mmHg a larger trocar is put through the umbilicus to allow a telescope into the abdomen.The telescope is connected to a light source and a camera. Two to three further ports are placed in the abdominal wall to allow access for instruments. Patients usually stay one night in hospital, but may well be discharged on the same day or stay an extra night should it be necessary.
The benefits of laparoscopic surgery are:
• Better vision for the surgeon
• Shorter hospital stay for the patients
• Less postoperative pain
• Better cosmetic result
Myomectomy
Fibroids or myomas are benign tumors of the smooth muscle of the wall of the uterus. Up to 50% of women at the age of 40 would have fibroids. They grow in response to oestrogen. They can lead to a wide spectrum of problems such as infertility, abnormal bleeding and anemia, constipation and bladder symptoms. A myomectomy is the surgical removal of fibroids. It can be done laparoscopically or through an open wound or hysteroscopically.
Endometriosis
Endometrial stroma and glands are tissue normally found in the uterine cavity and are discharged every cycle at menstruation. Endometriosis is a disease where endometrial stroma and glands are found in the abdominal cavity. They responds to the hormones in the same way, but at menstruation they remain in the abdomen and cause bleeding and inflammation. This leads to pain and scarring of the abdomen. The symptoms associated with endometriosis are infertility, painful menstruation and pain with sexual intercourse.
Endometriosis causes adhesions of the ovaries and fallopian tubes and large cysts in the ovaries, which can affect fertility. Endometriosis should preferably be treated laparoscopically by an expert surgeon. Laparoscopy allows for better visualization and reduces the trauma during surgery and therefore the postoperative adhesions.
Salpingolysis
Adhesions are formed as a result of injury, infection or conditions such as endometriosis. This can affect the free approximation of the fallopian tubes to the ovaries in order to pick up the oocyte at ovulation. Salpingolysis is the surgical procedure for the freeing of the fallopian tubes.
Salpingostomy
The fimbrial ends of the fallopian tubes are often blocked and therefore cause infertility. Salpingostomy is the opening of the ends of the tubes and securing them so that they will not merely become blocked again.
Salpingectomy
When the fallopian tubes have been damaged and are beyond repair fluid may collect in the damaged tubes. The fluid is toxic and if it leaks back into the uterine cavity it can damage healthy embryos in an IVF or ICSI cycle. Salpingectomy is the surgical removal of the tubes to prevent this from happening. The tubes are permanently removed which leaves no other option than IVF/ICSI for future pregnancy.
Reversal of Sterilisation
Patient's circumstances change and often there is a need for the reversal of sterilisation. This can be done laparoscopically or through open surgery. If patent tubes can be established the chances of pregnancy is 50% in the first year.
Hysteroscopy
Hysteroscopy is used to evaluate the uterine cavity and treat any abnormality of the cavity such as fibroids, adhesions and congenital uterine abnormalities. A small diameter telescope is used to pass through the vagina and the cervical canal and into the uterine cavity. Office hysteroscopy is now practiced throughout the world. This technique allows for hysteroscopy to be done without the need for an anesthetic. Hysteroscopy is an essential tool to evaluate the uterine cavity prior to assisted reproductive techniques.
Polypectomy
A polyp is a small growth of the endometrium in the uterine cavity. It is usually benign, but can impair fertility or cause abnormal bleeding. Polypectomy is when the polyp is removed using the hysteroscope. This is usually a day procedure and is associated with minimal pain. Patients can experience some vaginal bleeding for a week or two after the procedure.
A polyp as seen hysteroscopically before polypectomy
Annual Check up
The approach consists of a consultation, physical examination and ultrasound. Problems (challenges) are discussed with specific reference to causes, treatment options and lifestyle changes, which can improve the prognosis. Patients are encouraged to ask questions.
Menopausal Medicine
Patients in their menopause have specific needs and problems. Issues such hormone therapy, lifestyle changes and screening are addressed.
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