Dr. Eric Daiter writes the infertility tutorials offered by The New Jersey Center for Fertility and Reproductive Medicine in plain and simple language.

Each tutorial also includes several custom made drawings by Dr. Eric Daiter to illustrate difficult concepts.

Photographs taken by Dr. Eric Daiter (predominantly of gynecologic abnormalities identified and treated during one of his surgeries), radiologic studies (mostly ultrasounds, hysterosalpingogram films, and MRI films), and photographs taken through a microscope (including sperm cells, eggs and embryos at different stages of development, and tissues obtained at surgery) are also included in many of the tutorials.

Dr. Eric Daiter has compiled many frequently asked questions over the past 15 years in practice as a Reproductive Endocrinology and Infertility expert and hundreds of these FAQs are presented as anonymous case illustrations within the tutorials.

The information within these tutorials is intended to be solely educational. The knowledge and competence that the viewer may expect to develop within the complex medical field of infertility is not a substitute for the medical education that physicians obtain during their medical curriculum and training.

With this in mind, many couples are able to effectively use the knowledge that they gain about human reproduction to guide them through the difficult (and often expensive) process of obtaining medical (infertility) care.

Several different types of problems can cause pelvic pain, which can be intermittent or constant. When the pain is cyclic and seems to occur during certain specific times during the menstrual cycle, then the pain usually has a gynecological cause that can be treated if identified. If the pain seems to be primarily related to bowel movements, urination, certain types of movement, or a specific body position then other causes may also exist. When pelvic pain lasts for greater than 4 to 6 months, then the pain can become an illness in itself that is often referred to as "chronic pelvic pain."

In this pelvic pain tutorial, a large amount of information about the clinical evaluation for a woman with pelvic pain as well as the causes and treatments of pelvic pain are presented by Dr. Eric Daiter.

Click image to visit the Chronic Pain Tutorial site
for additional information.

The clinical evaluation that is performed to evaluate pelvic pain often determines whether the cause is found and therefore a careful and thorough approach is critically important. Dr. Daiter reviews the components of a complete evaluation, including the clinical history that is taken, the physical examination that is performed, laboratory testing that may be considered, and the role of minimally invasive surgical procedures like laparoscopy and hysteroscopy.

The sections on the various causes and treatments of pelvic pain provide Dr. Daiter's detailed descriptions of many of the common causes of pelvic pain. These causes may include gynecological problems like endometriosis, pelvic adhesions, pelvic cysts and fibroids; gastrointestinal problems like irritable bowel syndrome; genitourinary problems like interstitial cystitis; and musculoskeletal problems like fibromyalgia and myofascial trigger points.

Infertility care can be very expensive and a couple should be careful when deciding on a treatment plan that might challenge their budget.

Medical insurance often covers certain diagnostic testing or treatments, even when other treatments are not covered. If two different treatment options have reasonable potential for success and one is covered by a couple's medical insurance, then starting with the treatment option that is covered makes practical sense.

When you call The NJ Center for Fertility and Reproductive Medicine for an appointment with Dr. Eric Daiter, receptionists take your insurance information and contact your insurance company to determine your range of benefits. You will then receive a return telephone call prior to your initial visit to the office to discuss exactly what, if anything, you should expect to pay out of pocket. This helps you to decide on a management plan that fits your budget and your goals. Couples are often pleasantly surprised by how affordable infertility care can be when the infertility center considers your cost to be important and they help you develop a plan that fits your goals as well as your specific medical benefits.

For more information on the cost of care from Dr. Eric Daiter at The NJ Center for Fertility and Reproductive Medicine, click here.

Initially a couple should thoroughly discuss their own reproductive goals and their decision to expand their family. Once this decision is made, then the couple should create a plan to accomplish their goals.

If the couple runs into difficulty having children, then professional medical advice may be sought. Infertility physicians and practices do vary enormously in terms of their focus of interest, flexibility, cost, and ability to provide personalized care. It is possible that the same couple may receive completely different medical management plans from different Infertility Clinics, so it is important to select a program that "fits" you.

The traditional approach to infertility care initially focuses on diagnostic tests to identify problems with the reproductive system and then specific treatment plans are developed to correct or bypass these problems. The couple's unique goals and beliefs should be discussed and respected so that they can be taken into consideration when planning treatments. The rationales for several possible reasonable treatments should also be discussed along with relative costs so that the couple can participate in choosing a management plan that they are comfortable with. A traditional approach discourages the use of one particular treatment, such as In Vitro Fertilization (IVF), as a "universal cure" or panacea for all infertility problems.

The NJ Center for Fertility and Reproductive Medicine is a traditional program that focuses on developing a management plan that is effective and tailored to each patient couple. To learn more about this center and Dr. Eric Daiter, please click here.

Ectopic pregnancies are pregnancies that implant and grow outside the uterine cavity (womb). The likelihood of ectopic pregnancy is no longer uncommon and all ectopic pregnancies are very dangerous. Most ectopic pregnancies occur in the fallopian tube but they may also occur in the abdomen, cervix, or ovary. There have been tremendous advances in the diagnosis and treatment of ectopic pregnancy, which have often allowed a shift in clinical focus from "saving the woman's life" to "saving the woman's fertility."

In this ectopic pregnancy tutorial, the tests that may allow early detection of an ectopic pregnancy, risk factors for ectopic pregnancy, and treatment options for a known ectopic pregnancy are reviewed and discussed by Dr. Eric Daiter.

Click image to visit the Ectopic Pregnancy Tutorial site
for additional information.

General information about ectopic pregnancy includes the range of locations in which they occur and the likelihood of occurrence in these regions. Dr. Eric Daiter presents this information and the history of advances in medical treatments, including tests that allow earlier detection, use of aseptic techniques, antibiotics, anesthetic agents, availability of blood products, and refinement of surgical techniques.

Incidence rates and risk factors for ectopic pregnancy are fairly well known in the USA since ectopic pregnancies are reported to the national Centers for Disease Control (CDC). Dr. Daiter reviews the known risk factors, including the history of a prior ectopic pregnancy, prior surgery on the fallopian tubes, a history of pelvic infection, use of In Vitro Fertilization, IUD use, history of damage to the uterine cavity, exposure to DES in utero, chronic pelvic inflammation, and Salpingitis Isthmica Nodosa.

Early diagnosis of ectopic pregnancy largely determines the treatment alternatives that are appropriate and the prognosis of treatment in terms of preserving fertility. Dr. Daiter discusses the blood work and ultrasound examinations that can help to determine the likelihood of an ectopic pregnancy and allow for early intervention.

Treatment alternatives for ectopic pregnancy may appropriately include medical management, surgical management and conservative (expectant) management. Dr. Daiter presents a detailed description of the medical and surgical alternatives, including relative risks and benefits, and when conservative management is considered.

This website provides information written in plain language to couples who are struggling with infertility. The medical information may initially seem overwhelming. I suggest reading sections of interest at your own pace while referring to the drawings, photographs and case presentations whenever available.

You may expect a tremendous benefit after obtaining a basic understanding of the available infertility tests and treatments. Potential benefits include more effectively communicating with your physician, acceptance of a management plan that would otherwise seem undesirable, ability to propose and discuss alternative plans that would better serve your own unique goals, and regaining a sense of control by participating in decisions about your management.

Infertility can include an inability to become pregnant or a problem maintaining a normal pregnancy.

The three major events that must occur in order for a woman to become pregnant are (1) a mature (fertilization capable) egg must be created by and released from the ovary, (2) mature sperm must be created by and released from the testes, and (3) the mature sperm must be able to reach the egg for fertilization and the fertilized egg must then be able to find and implant into the uterine lining. The ovulation, sperm and pelvic factor infertility websites address these issues individually.

The tendency toward miscarriage, or recurrent pregnancy loss, is a very emotionally taxing form of infertility. The miscarriage website presents general information as well as diagnostic tests and treatment options.

A pregnancy that grows outside the uterine cavity is "out of place" or ectopic. These pregnancies are especially dangerous. The ectopic pregnancy website presents incidence rates and general information, tests for early diagnosis and treatment alternatives.

The infertility procedures website describes what to expect if you undergo some of the common infertility treatments.

For more information on infertility services provided at The NJ Center for Fertility and Reproductive Medicine by Dr. Eric Daiter, click here.

The process that results in the release of mature sperm is complex, can be disrupted by several disorders, and involves many different components. The known reasons for an abnormal semen analysis and poor sperm quality may become understood once you learn this material. Alternatively, you can focus more specifically on problems that your physician has addressed with you about the sperm.

In this sperm tutorial, a large amount of information about the production and release of sperm is presented by Dr. Eric Daiter.

Click image to visit the Male Factor Tutorial site
for additional information.

Many of the normal events that result in mature sperm production and release are currently understood. Dr. Daiter reviews these events, including the movement of the testes from the male abdomen to the scrotum prior to birth, the different types of cells that are found in a normal testis and their important and unique functions, the maturation process from an immature sperm cell to a highly specialized mature sperm cell, the modifications in a sperm cell's shape and motility during its storage in the epididymis, the physiologic mechanism that allows for the release of the mature sperm, and the final changes to the sperm hours after release that allow it to fertilize an egg.

The detection of normal sperm is limited since the semen analysis is basically a sperm and semen "appearance test" and there are no reliable sperm function tests. Dr. Daiter discusses the benefits and limitations of the semen analysis, the way in which a semen analysis is performed, and the reliability (positive and negative predictive values) of the various sperm function tests that are currently available.

There are several different possible causes for abnormal sperm and semen, each with their own treatment alternatives. Dr. Daiter categorizes and reviews these causes, including varicoceles (the dilatation of the testicular veins within the spermatic cord that is found in up to 15% of all healthy fertile men), antisperm antibodies (the types of antibodies, their detection, and their clinical significance for fertility), testicular causes (including exposure to excessive heat, testicular surgery, infections, radiation, trauma, substance abuse, testicular cancer, toxins, medications, chromosomal abnormalities and DES exposure in utero), pituitary causes (including pituitary tumors, elevated blood prolactin concentrations, pituitary damage, thyroid disease and hemochromatosis), and hypothalamic and central nervous system causes (structural lesions, Kallman's syndrome, and substance abuse).

The clinical evaluation of abnormal sperm or semen and the evaluation of a complete absence of sperm in semen (azoospermia) should involve several components. Dr. Daiter presents his usual evaluation, including a detailed fertility history, a detailed medical history, an expert physical examination (usually by a Urologist), and the initial laboratory evaluation.

The risks and benefits of available treatment alternatives for abnormal sperm largely depend on the cause for the disorder. Dr. Daiter reviews the clinically accepted treatments for specific known causes, the appropriate use of fertility medications, intrauterine inseminations for mild to moderate abnormalities, the more recent use of assisted fertilization (such as intracytoplasmic sperm injection or ICSI) and when to consider donor sperm.

About 20% of all human pregnancies are lost to miscarriage and this rate of loss does not change following a single miscarriage. If a couple suffers two consecutive pregnancy losses, then there is roughly a 35% chance that the next pregnancy will result in miscarriage. If a couple suffers three consecutive losses, then there is a 45-50% chance of miscarriage with the next pregnancy.

In this miscarriage tutorial, Dr. Eric Daiter reviews several different issues of significance with respect to miscarriage, including factors that increase the risk for a miscarriage and possible treatments to reduce these risks.

Click image to visit the Miscarriages Tutorial site
for additional information.

The grieving process that a couple goes through after they have a miscarriage is not well understood. Dr. Daiter presents some of the common psychological theories on grieving and cites literature that may be useful.

The incidence rate of miscarriage is uncertain since (1) many losses occur without any help from a physician and (2) physicians do not report pregnancy losses that they are aware of to any central agency. Dr. Daiter reviews the current understanding of pregnancy loss rates.

The causes of miscarriage can be categorized into two major groups: fetal causes (related to the embryo or baby) and maternal causes (related to the mother). A chromosomal problem with the fetus' genetic material (DNA) is the single most common cause for a pregnancy loss. Dr. Daiter provides an extensive review of the known causes for recurrent pregnancy loss and treatments that might be useful for these conditions.

The clinical evaluation for recurrent pregnancy loss is highly controversial and there are many "experimental" tests that are also available. Dr. Eric Daiter presents and discusses the clinically relevant tests that are available.

Many people learn more from listening to a presentation on a topic than after reading the same information in print. These narrated presentations provide you with the best of both worlds. You can listen to narrated presentations concerning important issues in Reproductive Medicine and the transcription of each presentation is also provided for your review.

Providing narrations on a wide range of topics is the ultimate goal. You can check back regularly to see which topics are completed and which topics are pending.

Please select from the Narrated Presentations below:

Polycystic Ovarian Syndrome

Ovulation Disorders

Successful human reproduction normally requires the maturation and release (ovulation) of an egg from the ovary.

The process that results in ovulation is complex, very delicate (easily disrupted), and involves many different components. If you learn this material, then many of the reasons for irregular menstrual cycle intervals and poor egg quality will become clear. You can also focus specifically on problems that your physician has addressed with you.

In this ovulation tutorial, Dr. Eric Daiter presents a great deal of information about ovulation.

Click image to visit the Ovulation Tutorial site
for additional information.

The ovarian reproductive lifecycle ranges from puberty to menopause and generally spans a 30-40 year time interval. Dr. Daiter presents the events that occur at puberty to allow for the release of a mature egg at ovulation and the events that can affect the overall duration of the ovarian reproductive lifecycle.

The normal events that occur within the female body to allow for regular ovulation involve the brain (central nervous system and hypothalamus), the pituitary gland, and the ovary. Dr. Daiter reviews the physiology and clinical importance of the development of a monthly pool of recruitable follicles (ovarian cysts containing eggs), the role of FSH in follicular development, the development of a dominant follicle, the role of the midcycle LH surge to trigger ovulation, the changes that allow a follicle to become a corpus luteum cyst to produce progesterone following ovulation, the window of uterine receptivity during which an embryo can implant into the uterine cavity, and menses when pregnancy does not occur.

There are different techniques to detect ovulation, each with their own reliability, sensitivity and specificity. Dr. Daiter examines the significance of a history of regular menstrual intervals with premenstrual symptomatology, basal body temperature records, cervical mucus characteristics, ovulation predictor kits and monitors, blood work for luteal phase progesterone concentration, serial ultrasound examinations, and experimental methods.

There are many known causes for ovulation dysfunctions, each with their own specific treatments. Dr. Daiter categorizes and presents these causes, including ovarian disorders (role of the woman's age, ovarian surgery, pelvic radiation or chemotherapy, premature ovarian failure, cigarette smoking, pelvic infections, compromised blood supply, endometriosis and medications), pituitary gland disorders (role of thyroid disease, excessive prolactin, pituitary tumors resulting in Cushing's syndrome or acromegaly, pituitary damage, the empty sella syndrome and medications), and hypothalamic and central nervous system disorders (polycystic ovarian syndrome, functional hypothalamic amenorrhea, structural lesions, stress, strenuous exercise, sudden weight loss or anorexia nervosa, illicit drug use and medications).

A thorough clinical evaluation for ovulation disorders should include certain components. Dr. Daiter discusses his own approach to the clinical evaluation, including a detailed menstrual history, a detailed medical history, the physical exam and the initial laboratory evaluation.

There are various treatment alternatives each with their own risks and benefits. Dr. Daiter discusses treatments for thyroid disease, prolactin disorders, the appropriate use of fertility medications, and when to consider donor eggs.

Slide 2
In order to understand ovulation disorders, you will need to know what normally occurs during ovulation.

Normal ovulation generally causes regular monthly menstrual intervals with a consistent amount of flow and premenstrual symptoms.

Disorders of ovulation can involve the central nervous system, the hypothalamus, the pituitary gland or the ovary.

Slide 3
The normal female reproductive lifespan starts at puberty, when the first mature fertilization capable egg is released from an ovary, and it ends at menopause, when this process of ovulation stops because there are no maturation capable eggs left in the ovaries.

At puberty, there are thought to be roughly 300,000 to 400,000 eggs in the ovaries and at menopause very few or no eggs remain. A normal reproductive lifespan is about 30-40 years long, with 12 monthly cycles per year, so there are only about 300 - 400 ovulations in a normal reproductive lifespan. Therefore, during a normal human reproductive lifespan, 300-400 thousands eggs are used during 300-400 ovulations, or eggs are used at a rate of about 1,000 eggs per ovulation. This is a tremendously inefficient system.

Many biological systems are inefficient including the human male reproductive system. The need to release several million sperm during intercourse just for one sperm to find and fertilize the egg is evidence of inefficiency in the male system.

Slide 4
A complex and highly regulated series of events must occur to result in regular monthly ovulation and regular menstrual cycle intervals. These events involve the Central Nervous System, the hypothalamus, the pituitary gland, and the ovary.

The preoptic area and the arcuate nucleus of the hypothalamus respond to neurotransmitter signals in the brain and various local hormones to release the hormone, gonadotropin releasing hormone or GnRH at very specific frequencies and amplitudes. This GnRH hormone is transported to the blood vessels in an area called the median eminence and these vessels then carry the GnRH to anterior lobe of the pituitary gland.

The anterior lobe of the pituitary gland has specific receptors for the GnRH hormone that allow it to capture and respond to GnRH by releasing the gonadotropin hormones: follicle stimulating hormone or FSH and luteinizing hormone or LH into the general circulation or bloodstream. FSH and LH secretion is also tightly regulated and has normal pulse frequencies and pulse amplitudes.

FSH and LH in the blood can reach the ovary where they can find and bind to their own specific hormone receptors. These receptors are concentrated around ovarian cysts that contain an egg, called a follicle. The follicle matures from an immature follicle to a fully mature follicle predominantly under the influence of the hormone FSH (follicle stimulating hormone). The developing follicle actively produces hormones, predominantly estrogen before ovulation. The estrogen produced by the developing follicle prior to ovulation stimulates the cells that line the uterine cavity, the endometrial cells, to grow or multiply in number and this lining becomes thicker.

Once a fully mature egg has developed, the follicle is thought to send a signal to the pituitary gland in the form of high concentrations of estrogen hormone that ovulation should occur. In response, the pituitary gland releases LH in high concentrations to provide the hormonal trigger (or signal) to ovulate, which is called the LH surge. It takes about 36 hours after the onset of the LH surge for the egg to complete its final maturation steps and for the ovary to release the mature egg into the pelvis.

After ovulation, the ovarian cyst that contained the egg remains hormonally active yet it converts its hormone production from predominantly estrogen to predominantly progesterone and it is now called a corpus luteum cyst. The progesterone produced after ovulation modifies the cells that line the uterine cavity, the endometrial cells, to allow for embryo implantation and the development of a normal pregnancy. If a pregnancy does not occur within 14 days of ovulation, then the corpus luteum no longer produces progesterone and the lining is shed as the menstrual flow.

Normally, this entire process repeats itself at monthly intervals throughout the reproductive lifespan.

Slide 5
The central nervous system uses a huge number of neurotransmitters to accomplish its tasks. Normal neurotransmitter function can be disrupted by almost any mild altering drug or medication. Chronic opioid use, whether in the form of illicit drugs, like heroin, or in the form of medications, like narcotic pain medication, can easily disrupt the reproductive axis and ovulation.

Slide 6
There are several hypothalamic causes for ovulation dysfunction. Polycystic ovarian syndrome (PCOS) involves a vicious cycle of problems can be considered to originate in the hypothalamus, the pituitary gland or the ovary. This syndrome involves irregular menstrual intervals, elevated androgen (male hormone) concentrations that may result in excess male pattern hair growth or acne, and/or polycystic ovaries as seen on ultrasound examination. This is another presentation that specifically deals with the complex and important situation of PCOS that is available through The NJ Center for Fertility and Reproductive Medicine website.

Functional hypothalamic amenorrhea is a diagnosis of exclusion, meaning that the menstrual disorder has no identifiable cause. It is most often thought that neurotransmitter regulation of the hypothalamus results in an irregular GnRH pulsatility or amplitude, and that this abnormality in GnRH secretion then results in an ovulation disorder.

Structural lesions of the hypothalamus can limit the ability of GnRH from the hypothalamus to reach the pituitary gland. These structural lesions can include tumors (the most common tumor in this region is a called a craniopharyngioma) or granulomas (due to either tuberculosis or sarcoidosis). If blood work suggests a low estrogen and also a low FSH and LH concentration, then looking for a lesion using radiologic tests is considered prudent.

Stress, strenuous exercise, sudden weight loss, and malnutrition can all interfere with ovulation. It is possible that almost any significant physical or emotional stress will alter the brain's neurotransmitter levels to disrupt GnRH secretion, increase the brain's levels of natural opioids called endorphins to reduce GnRH secretion, or modify the adrenal gland's releasing hormones like CRF and ACTH to interfere with ovulation.

Medications that affect the hypothalamic release of GnRH include any medicine that alters mood or mental status, such as anti anxiety or anti depression medication.

Slide 7
Both hypothyroidism and hyperthyroidism can result in an ovulation disorder. The mechanism for these dysfunctions is not clearly understood, but most experts believe that there is an increase in circulating estrogen concentration due to reduced metabolism of estrogen in the liver. The elevated circulating estrogen concentrations can then interfere with follicle growth. Additionally, hypothyroidism causes an increase in hypothalamic TRH (which primarily releases thyroid stimulating hormone or TSH from the pituitary gland). The TRH can cause a release of the hormone prolactin and elevated prolactin concentrations can cause an ovulation dysfunction.

The way in which elevated prolactin causes a problem with ovulation is not clearly understood. Elevated prolactin concentrations result in elevated dopamine concentrations (since dopamine inhibits prolactin release) and increased dopamine is known to reduce GnRH release from the hypothalamus.

The pituitary tumor that is not related to elevated prolactin that is most likely to result in an ovulation disorder is an ACTH producing tumor, which results in excess cortisol secretion from the adrenal glands, called Cushing's syndrome. A Cushingoid appearance involves a moon facies (round face), truncal obesity (excess weight especially around the waist rather than the hips), excess fat tissue under the back of the neck between the shoulder blades (sometimes referred to by our internal medicine colleagues as a buffalo hump), muscle weakness, purple linear discoloration of the skin, easy bruising, low fracture threshold, insulin resistance or diabetes, and high blood pressure.

Blood clots or bleeding around the pituitary gland can result in permanent destruction or damage. Rarely, a severe postpartum hemorrhage can result in low blood pressure and damage to the pituitary gland, called Sheehan's syndrome. Whenever there is damage to the pituitary gland itself it is important to evaluate the other pituitary hormones to rule out such life threatening problems like adrenal insufficiency.

To understand the empty sella syndrome you must know a little about the anatomy of the pituitary gland. The pituitary gland is surrounded by a bony structure called the sella turcica and there is a diaphragm of tissue over the top of this bony container. The empty sella syndrome occurs when this diaphragm herniates into the sella turcica and cerebrospinal fluid fills most of the sella turcica while flattening the pituitary gland along its sides. This condition results in reduced pituitary FSH and LH, which then lead to an ovulation dysfunction.

Medications that affect the pituitary gland include any medication with estrogenic (estrogen like) or progestagenic (progesterone like) substances, such as oral contraceptive pills or progesterone supplements.

Slide 8
There are multiple ovarian causes for an ovulation dysfunction.

The reproductive lifespan for a given woman normally spans several decades. As a woman ages, she uses her eggs and there are fewer and fewer eggs remaining in the ovaries. It is commonly thought that a woman may use her best eggs earlier in the reproductive lifespan, which if true may account for the finding of reduced fertility and increased miscarriage rates as a woman ages.

Infertility doctors are fond of blood work that assesses ovarian reserve, or the number of eggs remaining in the ovaries, such as cycle day 3 FSH and estradiol concentrations or the clomiphene citrate challenge test. Despite the reduced reproductive potential with aging, it should be noted that I have had many patients who have successfully conceived and delivered normal babies well into their 40s.

Ovarian surgery may destroy many normal eggs adjacent to abnormal ovarian tissue that is removed. The removal of an entire ovary or a significant part of an ovary can immediately reduce the ovarian reserve.

Pelvic radiation or chemotherapy can result in months or years of anovulation. The classes of chemotherapy agents most strongly associated with long-term ovarian dysfunction are the alkylating agents. If the ovary begins to produce mature eggs and ovulate even several years after chemotherapy and radiation therapy, then the eggs that are produced are generally thought to be of normal quality.

Premature ovarian failure occurs when there is ovarian failure (menopause) prior to the age of 40 years old. Premature ovarian failure may be caused by an abnormality in one of the X chromosomes or there may be an immune disorder that doesn't allow the ovary to respond to FSH. There are occasions in which an immunological disorder goes into spontaneous remission (resolves temporarily on its own), menstrual cycles occur because ovulation can occur when the ovary can respond to FSH, and a woman can become pregnant.

There are over 13 articles in the literature that show that cigarette smoking can reduce a woman's reproductive lifespan up to 1-2 years. Cigarette smoking also increases the miscarriage rate by up to 2 fold and increases the ectopic pregnancy rate by up to 4 fold.

Pelvic infections, especially those that result in pelvic abscesses, can destroy a lot of eggs in the ovaries. These infections should be treated aggressively and as early as possible.

Decreased blood supply to the ovary can occur when an ovary twists or torsion occurs. Also when there is surgery in the vicinity of the ovary it is possible that the blood supply to the ovary is compromised. Whenever there is reduced blood supply to the ovary eggs can be damaged.

Endometriosis is a common abnormality of the female pelvis and it can reduce the ovary's response to stimulation with FSH.

Medications that affect the ovary's ability to ovulate include nonsteroidal anti-inflammatory agents, like ibuprofen, since these medications reduce prostaglandins that may be necessary for the ovary to release a mature egg.

Slide 9
Whenever I consult with a woman who has an ovulation disorder, I take time to obtain a thorough history including both a menstrual history and a medical history. The information that can be obtained during a careful history is invaluable and can often guide further evaluation.

The single most common reason for a reproductive age woman to be late for a menstrual flow is pregnancy so I always suggest a pregnancy test whenever there is an absence of flow for greater than a month.

A basal concentration of FSH, LH and estradiol is informative since these tests can determine ovarian reserve (at least roughly), they illustrate whether there is an increase in LH to FSH concentration (suggestive of PCOS), and they are all often low when dealing with stress (emotional, weight loss, extreme exercise).

TSH is my preferred screening test for thyroid disease. If the TSH is abnormally high it is repeated with thyroid hormone tests and anti-thyroid antibody levels. Prolactin concentration is also routinely tested, with follow-up as needed.

The progesterone challenge test determines whether there has been growth or thickening of the uterine lining since this lining should shed (there should be a menstrual flow) after administration of progesterone. A pregnancy test should always be done prior to this test.

Blood androgen concentrations, like free testosterone, androstenedione and DHEAS should be considered when there is a PCOS like appearance. I also screen for insulin resistance if there is a suggestion of PCOS.

If there is any significant suggestion of Cushing's syndrome, I screen with a 24 hour "urine free cortisol" level or an overnight 1mg Dexamethasone suppression test.

Radiologic tests may be advised based on the history and blood work results.

Slide 10
Treatment is strongly goal oriented.

When the ultimate goal is fertility, then ovulation induction may be the immediate goal. If a woman has 12 ovulatory cycles per year then she is at a fertility advantage compared to a woman with only 3 ovulatory cycles per year. 12 opportunities to conceive per year are more likely to result in success compared to 3 opportunities per year.

Ovulation induction may be attempted in any woman with an ovulation disorder as long as there are some eggs remaining in the ovaries that might respond.

Specific abnormalities found during the initial evaluation should be corrected whenever possible. On several occasions in my own practice, a thyroid abnormality or a prolactin abnormality is corrected and pregnancy quickly follows.

When a woman is overweight, weight reduction of only 5% can be very significant in terms of inducing ovulation.

Clomiphene citrate is the normal entry-level medication for ovulation induction. It has few complications and it is often well tolerated. There are some women who are intolerant to the side effects of clomiphene so other induction techniques should be used. About 85% of women with an ovulation disorder will respond to clomiphene citrate with either regular menses or significantly more regular menstrual intervals.

If clomiphene citrate is ineffective or the woman is intolerant to the side effects, then menotropins can be considered. These medications contain FSH as the active ingredient and are generally very effective. There are risks involved with menotropin controlled ovarian hyperstimulation, such as multiple pregnancies and ovarian hyperstimulation syndrome, and these medications need to be administered by a qualified fertility physician.

The first donor egg success was in 1983 and since this time many women with very few or no maturation capable eggs have looked to donor egg IVF for assistance. A qualified fertility physician should advice you of the appropriateness of this option if you are considering it.

Slide 11
The uterine cavity or inside of the womb is lined by a delicate and dynamic tissue called endometrium. This endometrium grows in response to estrogen to become thicker and it is organized in response to progesterone to allow for implantation and the development of a normal pregnancy.

Estrogen stimulation occurs primarily prior to ovulation and progesterone increases after ovulation. When pregnancy does not occur, the entire lining that developed for that ovulation cycle would then be shed as the menstrual flow. When there is a problem with regular ovulation and when menstrual flows occur infrequently, there can be an overgrowth of endometrium due to persistent estrogen without any progesterone (since ovulation does not occur). This can lead to a benign abnormality known as endometrial hyperplasia, or overgrowth of the uterine lining. This chronic exposure to unopposed estrogen (without progesterone) can also lead to atypical endometrial hyperplasia or endometrial carcinoma (cancer).

To minimize the increased exposure to risk of endometrial hyperplasia and carcinoma a progesterone or progesterone like medication should be administered regularly. Oral contraceptive pills (or patch) are a common and effective way of providing protection since all of the pills are predominantly progestagenic. The oral contraceptives also reduce ovarian androgen production by reducing excess LH so they may help with excess hair growth or acne. Note that the progestagen contained in the pills can also have some androgenic side effects. There are several pills with low androgenic side effects some of which, but by no means all, are listed here. Ortho tri cyclen is FDA approved for treatment of acne and is thought to have few androgenic side effects. Yasmin contains a progestagen with antimineralocorticoid and antiandrogenic actions similar to the popular medication for excess male pattern hair growth, Spironolactone. Demulen 1/50 may be used if there is persistent break through bleeding on a low dose estrogen pill and additional estrogen is desireable.

If a woman is not a candidate for the pill or is intolerant to the side effects of the pill, then intermittent use of progesterone can be useful. A common regimen is provera 10mg x 7-10 days every 1-2 months. Many gynecologists are more comfortable with just giving provera 10mg x 10 days every month on calandar days 1-10 (January 1-10, February 1-10, etc). If a woman is also intolerant to the side effects of provera then natural progesterone like prometrium usually has less side effects.

The use of metformin for endometrial protection is unproven at this time (2006)

Slide 12
The ultimate goal in the treatment of ovulation disorders is to use modern medical knowledge to help women and couples enjoy a happy and healthy family.

It was a pleasure to be able to present this information to you and I hope you have found it useful. If you are interested in being notified of other similar presentations, you can check the website for The NJ Center for Fertility and Reproductive Medicine (with links on the lower right hand corner of each slide) since a full list of narrated presentations is listed there.

Pelvic factor infertility refers to any structural (anatomic) abnormality that limits or prevents the mature sperm and mature egg from meeting and developing into a normal pregnancy.

In this pelvic factor tutorial, the mechanical events that must occur for normal human reproduction are reviewed and discussed by Dr. Eric Daiter.

Click image to visit the Pelvic Factor Tutorial site
for additional information.

The normal events that allow fertilization (of the mature sperm and mature egg) and implantation (of the subsequent pre-implantation embryo) are active areas of medical research. Dr. Daiter reviews pelvic factor abnormalities that can reduce the chances for successful pregnancy, including mechanical barriers that limit the release of a mature egg (from the ovary and its subsequent entry into the fallopian tube) or the release of a mature sperm (from the testis and their subsequent entry into the female reproductive tract), cervical mucus abnormalities that reduce viability of sperm, and anatomic abnormalities of the pelvis (such as endometriosis or pelvic adhesions) or uterus that limit normal fertilization and implantation.

Dr. Daiter discusses the available diagnostic tests to detect a pelvic factor problem, including the sensitivity and specificity of the screening semen analysis, sterile speculum exam, postcoital test, hysterosalpingogram, sonohysterogram, endometrial biopsy and pelvic evaluation (laparoscopy and hysteroscopy).

There are a number of different locations where pelvic abnormalities may reduce fertility, each with their own treatment alternatives. Dr. Daiter describes the anatomic problems involving the male outflow tract, the vaginal vault, the cervix, the uterus, the fallopian tubes, pelvic endometriosis, and pelvic adhesions.

The clinical evaluation for pelvic factor infertility that Dr. Daiter employs in his practice at The New Jersey Center for Fertility and Reproductive Medicine is presented. The questions asked to obtain a thorough history and a description of the procedures involved with the postcoital test, hysterosalpingogram, sonohysterogram, and pelvic evaluation (laparoscopy and hysteroscopy) are provided.

The treatment options for pelvic factor abnormalities are based primarily on the type of problem identified. Dr. Daiter reviews these treatments, including intrauterine inseminations, controlled ovarian hyperstimulation, surgery, and In Vitro Fertilization (IVF).

Slide 2
It is believed that as many as 10% of all reproductive age women (or as many as 1 in 10 reproductive age women) suffer from PCOS. PCOS is clinically characterized by irregular or absent menstrual intervals, signs of elevated male hormones such as excessive male pattern hair growth or acne and oily skin, and many small to mid sized cysts containing eggs within the ovaries that have been arrested in their maturation (or development).

Slide 3
The National Institutes of Health (the NIH) held a conference in 1990 where medical experts discussed, debated and eventually proposed a set of minimal criteria to be used for the diagnosis of PCOS. According to the consensus, the diagnosis of PCOS requires that the woman have (1) irregular or absent menstrual intervals, (2) evidence of elevated male hormones (hyperandrogenemia), and (3) no other identifiable cause for the menstrual irregularity and elevated male hormones.

Slide 4
The NIH panel of experts identified menstrual irregularity due to an ovulation dysfunction as either (1) fewer than 9 menstrual cycles per year, or (2) an absence of menstrual cycles for 3 or more consecutive months (3 months in a row). Other identifiable causes for ovulation disorders should be excluded, such as hormonal imbalances that result in ovulation dysfunctions, trauma, medications or stress. A detailed review of the potential causes for ovulation disorders is presented in another presentation that is also available through the NJ Center for Fertility and Reproductive Medicine website (linked at the lower right hand corner of each slide in this presentation)

Slide 5
The NIH panel of experts also identified evidence of elevated male androgenic hormones as either (1) clinical signs such as excessive male pattern hair growth (hirsutism) or acne and oily skin, or (2) abnormal bloodwork for androgenic hormones such as testosterone, androstenedione, or dihydroepiandosterone sulfate or DHEAS. Other causes of elevated male hormones need to be excluded including congenital adrenal hyperplasia or CAH, Cushing's syndrome, androgen producing tumors, and androgenic medications.

Slide 6
Experts from the European Society of Human Reproduction and Embryology and the American Society of Reproductive Medicine convened as a consensus workshop group in Rotterdam (within the Netherlands) in 2003 to further explore the definition of PCOS. The diagnostic criteria that were proposed as a result of this conference were a revision of the 1990 NIH criteria and they included a broader range of women. The 2003 Rotterdam criteria require any 2 of 3 conditions to define PCOS. The three conditions include the two criteria identified at the NIH conference in 1990 and also a third condition: polycystic ovaries on ultrasound examination.

Slide 7
The Rotterdam group specified that in order to identify polycystic ovaries on ultrasound examination there must be either (1) more than 12 follicles in each ovary that measure 2-9 mm in diameter, or (2) the calculated total ovarian volume must be over 10 cubic centimeters or mL.

Slide 8
The clinical evaluation of a woman who may have PCOS includes a complete medical history and a thorough menstrual history. Initial laboratory tests for a woman with irregular or absent menses includes a pregnancy test, basal hormone concentrations assessing ovarian reserve (including FSH, LH and estradiol concentrations on the 2nd to 4th day of the cycle), thyroid stimulating hormone or TSH and prolactin hormone concentrations. Further tests are directed according to the history, physical examination and initial bloodwork.

The classic history obtained from women with PCOS includes an early age of onset for menstrual irregularity (around puberty) or immediately following a rapid increase in weight, slowly progressive appearance of thick dark hair in a male pattern distribution (such as under the belly button, on the face, on the back), inflammatory acne that is unusually aggressive and difficult to treat, android rather than gynecoid obesity (that is, excess weight around the waist rather than around the hips), and dark velvety irregular raised patches of skin (called acanthosis nigricans) especially in moist locations (such as the back of the neck, the armpit, or under the breasts)

For women who may have PCOS, additional androgenic bloodwork may be obtained (including total or free testosterone, androstenedione, and DHEAS) along with an ultrasound looking for polycystic ovaries. Once a woman is defined with PCOS, additional testing for insulin resistance is often suggested.

Slide 9
The treatment of PCOS is directly related to the desired goal. Fertility, protection of the endometrium from endometrial hyperplasia and carcinoma, treatment of excessive male pattern hair growth or acne, and overall protection of health if the metabolic syndrome or syndrome X coexists are all common and reasonable treatment goals.

When the ultimate goal is fertility then ovulation induction to produce a mature fertilization capable egg is the immediate goal. Simply put, women with 12 ovulation cycles per year have more eggs that may result in a pregnancy per year than women with fewer cycles per year.

For overweight women with PCOS ovulation induction has been shown to be significantly more successful following a 5-10% weight loss. If a PCOS patient also has insulin resistance then insulin-sensitizing medications such as glucophage are sometimes suggested since ovulation induction may be significantly easier.

The entry-level ovulation inducing medication for PCOS is clomiphene citrate. This medication induces ovulation in 60-85% of PCOS patients, is generally less expensive than injectable medication, has few complications (the twinning rate is about 8-10% and ovarian cysts are relatively uncommon), and the side effects are often mild. When clomiphene citrate is ineffective or the woman is intolerant to the side effects, then injectable medications like menotropins are considered.

Injectable menotropins medications contain FSH as the primary active ingredient, are relatively expensive, usually result in the maturation of multiple eggs simultaneously which then increases the incidence of complications (such as multiple pregnancies including higher order multiples like triplets and ovarian hyperstimulation syndrome), and require frequent monitoring with bloodwork and ultrasounds by a qualified fertility physician. However, these medications are usually highly effective in PCOS patients.

Surgery designed to remove or destroy part of the outer ovary has been used over the years with mixed success. At present, most fertility specialists believe that the scar tissue resulting from this type of surgery is often very damaging.

Slide 10
A hormonally active and dynamic tissue called endometrium lines the cavity of the uterus. Estrogen stimulates the endometrium to grow thicker and progesterone stabilizes the lining to allow for embryo implantation and development of a normal pregnancy. With PCOS, there are irregular menstrual intervals with fewer than the normal number of menstrual flows per year. In these situations, the estrogen hormone that is active prior to ovulation stimulates a greater than normal amount of endometrial growth and in fact the endometrium may become overgrown (a condition called endometrial hyperplasia) and may deteriorate into a malignancy (called endometrial carcinoma or endometrial cancer).

In order to limit exposure to the risk of endometrial overgrowth or cancer a progesterone or progesterone like medication should be administered regularly to those women with less than 1 cycle every other month.

Oral contraceptive pills are a common and effective way of providing protection since all contraceptive pills are predominantly progestagenic. The oral contraceptives also reduce ovarian androgen production by reducing excess LH so they may help with excess male pattern hair growth or acne. Note that the progestagen contained in the pills can also have some androgenic side effects. There are several pills with low androgenic side effects some of which, but by no means all, are listed here. Ortho tri cyclen is FDA approved for treatment of acne and is thought to have few androgenic side effects. Yasmin contains a progestagen with antimineralocorticoid and antiandrogenic actions similar to the popular medication for excess male pattern hair growth, Spironolactone. Demulen 1/50 may be used if there is persistent break through bleeding on a low dose estrogen pill and additional estrogen is desireable.

If a woman is not a candidate for the pill or is intolerant to the side effects of the pill, then intermittent use of progesterone can be useful. A common regimen is provera 10mg x 7-10 days every 1-2 months. Many gynecologists are more comfortable with just giving provera 10mg x 10 days every month on calandar days 1-10 (January 1-10, February 1-10, etc). If a woman is also intolerant to the side effects of provera then natural progesterone like prometrium usually has fewer side effects.

Slide 11
The physical signs of elevated androgens disturb many women with PCOS. These include acne and oily skin, excessive male pattern hair growth or male pattern balding, obesity with a distribution that is mainly around the waist rather than the hips, or dark velvet-like discolorations of the skin in small patches. Excess male pattern hair growth may be a minor cosmetic issue for some women and an emotionally challenging problem with significant psychological impact for others.

The treatments that are designed to reduce the effect of androgen hormones should not be used during pregnancy since a male fetus may not develop normally when the androgenic hormones are blocked.

Oral contraceptive pills are often effective and are considered a first line therapy when PCOS presents with signs of hyperandrogenemia since the hormones in the pill will reduce LH concentrations and this will in turn reduce ovarian androgen production and there is some reduction in adrenal androgen secretion. Corticosteroid medications may reduce the adrenal gland's production of androgenic hormones (such as DHEAS) but chronic steroid use has some potentially serious risks such as weight gain, osteoporosis, impaired glucose tolerance and adrenal suppression so it is not currently recommended for this purpose at this time.

Any treatment for excessive hair growth takes 3 to 6 months to see an effect since the half life of a particular hair in a follicle is about 6 months. When oral contraceptives alone are not effective then the addition of a second medication may be suggested. Spironolactone inhibits the binding of testosterone and its derivatives to their receptors (for example in hair follicles) and this then reduces the action of excess androgenic hormones. Spironolactone is considered one of the safest medications for the treatment of hyperandrogenemia and is often recommended in addition to oral contraceptive pills. Flutamide inhibits the binding of testosterone to its receptors but it is very expensive, it is not FDA approved for treatment of excess hair growth, and it can be toxic to the liver and result in very serious complications. Therefore, Flutamide is not recommended for this purpose. Finasteride inhibits the conversion of testosterone to its more potent bioactive derivatives but is not as effective as Spironolactone and also has some potentially very serious complications, so it is also not recommended for this purpose at this time. Cyproterone acetate is a progestin with antiandrogen activity and it has been shown to be effective in combination with oral contraceptive pills in European and Canadian studies, but this medication is not available in the USA at this time (2006).

Slide 12
PCOS is associated with obesity (especially android obesity with most excess weight around the waist rather than hips) and insulin resistance, both of which are risk factors for type 2 diabetes.

A syndrome known as the "metabolic syndrome" or "syndrome X" has been defined by the World Health Organization as elevated insulin or elevated glucose concentrations in the blood along with at least two of the following conditions: (1) abdominal obesity, (2) abnormal lipid concentrations with either elevated cholesterol or elevated triglycerides, and (3) high blood pressure. This syndrome is recognized by many other prominent health organizations including the American Heart Association and the International Diabetes Federation. There is a significant risk for subsequent development of Diabetes, Heart Disease, fatty liver disease, chronic kidney disease and sleep disordered breathing including sleep apnea.

Whenever there is a suspicion of metabolic syndrome I suggest an internal medicine consultation and aggressive management to reduce future morbidity and mortality.

Slide 13
The ultimate goal in the treatment of polycystic ovarian syndrome or PCOS is to employ modern medical knowledge and treatments to help women and couples enjoy a happy and healthy family.

It was a pleasure to be able to present this information to you and I thank you for your attention. If you are interested in similar presentations, you can check the website for the NJ Center for Fertility and Reproductive Medicine regularly since new topics will be posted as they become available.

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In Vitro Fertilization (IVF) is used liberally by more "contemporary" infertility programs as kind of a "panacea" (universal treatment), presumably since it can bypass many pelvic and severe male factor obstacles and it has a relatively high success rate (per attempted cycle). The downside is that IVF doesn't repair or fix the underlying problem and it is generally expensive.

Pelvic evaluation and repair using highly specialized surgical techniques and skills has been the more "traditional" approach, presumably since the identification of pelvic abnormalities and their restoration (when possible) may significantly enhance a couple's overall reproductive potential (so that IVF or other fertility procedures are no longer necessary). Surgical repair is generally covered by medical insurance so cost is usually contained. The downside is that surgical complications, while uncommon, are possible and if the repair does not restore natural fertility then other procedures such as IVF may still be required.

In this procedures tutorial, the risks, benefits and alternatives of various common infertility procedures are reviewed and discussed by Dr. Eric Daiter.

Click image to visit the Procedures Tutorial site
for additional information.

Intrauterine insemination (IUI) is a procedure that involves the placement of washed sperm at the top of the uterine cavity, near where they could normally fertilize an egg within the fallopian tube. Dr. Daiter reviews the general indications for intrauterine insemination (iui), the specific risks associated with the iui procedure, and the techniques available to wash and prepare sperm for insemination.

Infertility physicians commonly use ultrasound examination of the female pelvis to assess reproductive pathology as well as the development of eggs within the ovarian follicles since it is inexpensive, noninvasive and has very low risk. Dr. Daiter discusses the basic principles of ultrasonography, the techniques used during an ultrasound exam to identify relevant structures, and the safety of the procedure.

Controlled ovarian hyperstimulation involves the use of injectable fertility medications containing FSH (follicle stimulating hormone) to stimulate the development of multiple mature eggs. The primary benefit is the release of a greater number of fertilization capable eggs (targets) for the sperm. Dr. Eric Daiter discusses the indications for controlled ovarian hyperstimulation ("medicated cycles"), the types of medications that are available for use during a stimulated cycle, the appropriate protocols and office procedures that should be expected during a medicated cycle, and the inherent risks involved with the medications and procedures. Risks discussed include multiple pregnancies, when selective termination is medically appropriate, ovarian hyperstimulation syndrome, premature LH surge (trigger to ovulate), ovarian torsion, sub-optimal response to medications, and ovarian cancer.

Surgery is a valuable medical tool that can be used to restore natural reproductive potential and it may allow many couples to achieve spontaneous pregnancies. Dr. Eric Daiter presents and reviews a great deal of information of interest, including the types of incisions that may be needed, the importance of noninvasive preoperative testing and establishing a preoperative diagnosis, the "microsurgical techniques" that are used to minimize postoperative scar formation and optimize functional (reproductive) outcome, the importance of the operating room team and available equipment, what normally occurs in the operating room during pelvic evaluation, and the complications that are possible during operative laparoscopy and operative hysteroscopy.

In Vitro Fertilization (IVF) has become a very popular procedure and success rates are increasing rapidly as major developments occur in fields such as embryology. Dr. Daiter discusses many of the major issues involved with In Vitro Fertilization, including indications for IVF, patient selection criteria for IVF, patient preparation for IVF, and some of the cost considerations. Additionally, there is a presentation of the medication protocols used during IVF, egg retrieval techniques employed for IVF, and when to consider Gamete Intra-Fallopian Transfer (GIFT). There is further discussion of embryology laboratory issues such as hatching of pre-implantation embryos for IVF, in vitro maturation of eggs (currently only experimentally available), Intra-Cytoplasmic Sperm Injection or ICSI and some of the genetic concerns with this procedure, and embryo co-culture systems and their utility during IVF embryo development. Dr. Daiter reviews information about embryo implantation, including the window of uterine receptivity for embryo implantation, immunological concerns associated with embryo implantation, and when to consider gestational surrogacy.

Infertility, or the inability to reproduce, affects roughly 15% of reproductive age couples. This means that on average 1 in every 6 couples have significant problems with childbearing.

A thorough clinical evaluation of infertility is appropriate if a couple has not achieved a pregnancy within one year of unprotected intercourse or whenever there is a heightened suspicion of a fertility problem. An infertility evaluation is prudent prior to a year of trying if the woman is older than 35 or 40 years old, the husband has had a vasectomy, the woman has had a tubal ligation, or the woman has irregular or absent menstrual flows.

Selecting someone to help with an infertility problem can be difficult and confusing. Important qualities to look for when choosing a physician include expertise in the rapidly changing and complex field of Reproductive Endocrinology and Infertility as well as a willingness to listen to and respect your specific needs. When these qualities are present, it becomes possible to develop a management plan that best serves you as the patient.

Getting pregnant and having babies should not be an impersonal experience that drains the bulk of your resources. You can benefit in many ways when you find an infertility specialist who gets to know you well and customizes a treatment plan based on your individual desires and budget. You should always feel like a valuable partner in the process rather than like a number. If you are unhappy at one office, then you really should consider trying another office. Ultimately, couples who are comfortable seem to get pregnant much more easily than couples with similar medical issues who have additional significant stress.

The American Board of Obstetricians and Gynecologists is willing to "certify" candidates in Reproductive Endocrinology and Infertility (REI) only after completion of an approved training fellowship in REI (typically 2-3 years of highly specialized training) and prior board certification in Obstetrics and Gynecology. The American Board defines a Reproductive Endocrinologist as "a specialist in Obstetrics and Gynecology who is capable of managing complex problems relating to Reproductive Endocrinology and Infertility, and whose current professional activity involves the practice of Reproductive Endocrinology in a setting wherein essential diagnostic and therapeutic resources are available and being used appropriately." A list of American Board Certified REIs is available on the website for the Society for Reproductive Endocrinology and Infertility (http://www.socrei.org).

For more information on the type of care that you could expect from The NJ Center for Fertility and Reproductive Medicine and Dr. Eric Daiter, click here.

It is to your benefit to find an infertility office that offers the full range of infertility treatments and is willing to customize your management plan to best fit your own goals, desires, budget, insurance coverage, and schedule.

When a couple visits The NJ Center for Fertility and Reproductive Medicine for an infertility consultation, Dr. Eric Daiter reviews their history in detail. Information is collected on

1. ovulation, including
   

   the menstrual cycle (regularity, duration, premenstrual symptoms) previous pregnancies and outcomes
   
   previous techniques used to detect ovulation (basal body temperature charting, ovulation kits, luteal phase bloodwork, ultrasounds, endometrial biopsies)
   
   prior hormone evaluations (assessment of the ovarian reserve, thyroid function tests, prolactin concentrations)

2. sperm, including
   

   semen analyses (type of laboratory used, criteria for assessing the shape of the sperm, assessment of motility and/or forward progression)
   
   previous pregnancies (in any relationship)
   
   prior sperm function testing, urologic examination, hormone evaluation

3. the pelvic factor, including
   

   history of pelvic pain with menses, intercourse or ovulation
   
   history of abdominal surgery, pelvic infections, or IUD use
   
   review of hysterosalpingogram report and films (if available)
   
   postcoital test results
   
   previous surgical treatment of gynecologic abnormalities

Initial testing of an infertile couple with no prior evaluation is to determine the occurrence of regular ovulation (usually a history of regular menses with premenstrual symptoms and biphasic basal temperature charting is adequate), the appearance of the sperm on semen analysis (Dr. Eric Daiter will often perform his own semen analysis if there is uncertainty with regard to prior semen testing), and the presence (or absence) of a pelvic factor using the less complex tests that are available (the postcoital test will determine if there is a sperm mucus interaction problem, the hysterosalpingogram can evaluate the shape of the uterine cavity and patency of the fallopian tubes). These tests can be completed within one menstrual cycle and may determine the cause of the fertility problem in 75-80% of infertile couples.

Treating an ovulation dysfunction should be directed at correcting any identified hormonal cause (thyroid abnormality or excess circulating prolactin concentration). If no hormonal cause for an ovulation dysfunction is identified, use of fertility medications is often appropriate. Usually, a course of clomiphene citrate is initially attempted and if unsuccessful (at accomplishing ovulation) then controlled ovarian hyperstimulation (use of FSH containing medication to enhance the number of mature eggs per cycle) with intrauterine insemination (COH/IUI) is often recommended.

Treatment for an identified male factor varies with severity, IUI (or COH/IUI) is often effective for mild to moderate abnormalities and assisted fertilization (In Vitro Fertilization with IntraCytoplasmic Sperm Injection) results in good fertilization rates even when there is a severe abnormality.

Cervical mucus incompatibility (with sperm) is effectively bypassed with IUI. Proximal (fallopian) tubal occlusion can often be opened (treated) using selective catheterization under flouroscopy. Distal (fallopian) tubal occlusion or anatomic abnormalities identified within the uterine cavity (such as fibroids or endometrial polyps) often require surgical repair.

In the event that all of the initial testing is normal, or the couple has had a reasonable course of treatment for an identified problem without successfully achieving a pregnancy, Dr. Eric Daiter may suggest a pelvic evaluation (laparoscopy and hysteroscopy). These surgical procedures can be performed on an outpatient basis and may determine the majority (up to 75%) of the remaining fertility problems. Dr. Daiter attempts to repair any identified abnormality as it is found (endometriosis, pelvic adhesions and/or subtle problems within the uterine cavity) so that the woman does not need multiple surgical procedures. After surgical treatment of an identified pelvic factor, Dr. Daiter typically suggests 3-4 cycles of trying (timed intercourse) before moving to more aggressive management.

About 5-10% of infertile couples have no identified abnormality ("unexplained infertility") after this testing has been completed. Also, some couples do not become pregnant after all identified abnormalities have been appropriately treated. The two treatment options that have been shown to be useful for these couples are (1) controlled ovarian hyperstimulation (use of FSH containing medication to enhance the number of mature eggs per cycle) with intrauterine insemination (COH/IUI), and (2) In Vitro Fertilization (IVF). Generally, if 3-4 cycles of COH/IUI are unsuccessful then IVF is suggested.

For testimonials from patients and physicians who have worked with Dr. Eric Daiter at The NJ Center for Fertility and Reproductive Medicine, click here.