Contraception, Infertility

Contraception, Infertility
OBgyn Week Contraception, Infertility

Contraception Prevention of pregnancy
Requires prevention of fertilization and/or implantation Many different methods in these general categories: prevent ovulation (hormonal methods) prevent sperm from meeting ovum (barrier methods, female and male sterilization, spermicide, calendar) prevent implantation (IUD, hormonal methods) These are basic concepts, but often an avoided subject. Understand these concepts well and be able to discuss them intelligently w patients.

Preg and Contracep stats
In 2002, about 50% of the 6.4 million pregnancies in the US were unintended About 18% of these pregnancies ended in elected abortion (1.4 million) About 65% of these pregnancies ended in live birth (4.14 million) Any sexually active fertile woman can become pregnant

CONTRACEPTION Contraceptive use in US women - 2002
Oral contraceptives 19% Sterilization Female – 17% Male – 6% Male condom 11% Progestin injection 3.3% Withdrawal 2.5% IUD 1.3%% Periodic abstinence 0.9%% Implant, Lunelle, or Patch 0.8%% Diaphragm 0.2%% Not using contraception – 38%

Contraceptive Methods
How to choose? The best option will be: Medically appropriate Used every time A method patient is happy with

TYPES OF CONTRACEPTION CURRENTLY AVAILABLE
Periodic abstinence Spermicides Barrier techniques Diaphragm Cervical cap Male condom Female condom

TYPES OF CONTRACEPTION CURRENTLY AVAILABLE
Hormonal contraceptives – oral, patch, ring Long acting hormonal contraceptive Injectable Implants Intrauterine devices Sterilization Tubal ligation Vasectomy Emergency contraception

Contraceptive Effectiveness and Cost Issues
Effectiveness rates are usually reported in the following ways Typical use effectiveness (TER) Perfect use effectiveness (PER) Failure rates The most effective techniques provide the greatest total cost savings Top 5 total savings – Copper-T IUD, vasectomy, implant, injectable, OCPs Cheapest – barrier methods – condoms, diaphragm, cervical cap, sponge, spermicides

Contraceptive Methods - Periodic Abstinence
Avoidance of sexual intercourse during fertile window Must avoid intercourse on all calculated fertile days Four techniques commonly utilized Calendar rhythm method Temperature method Cervical mucus method Symptothermal method Sperm live for 2-3 days or so, while ovum live for 1 day. Kinda of amazing anyone is ever born at all. Periodic abstinence technique is really limiting because there are so many “non safe” days.

CALENDAR RHYTHM METHOD
Woman records length of cycle over several months Establishes fertile period by subtracting 18 days from shortest cycle, and 11 days from longest cycle Couple avoids coitus during this fertile period Cannot be used by women with irregular menses Perfect use effectiveness rate 91% Typical use effectiveness rate 75%

Note that only about ½ of the month is considered low risk
Note that only about ½ of the month is considered low risk. What a bummer. Estrogen thickens cervical mucus and acts as a superhighway for sperm. Being aware of its presence can help with avoiding preggers.

TEMPERATURE AND CERVICAL MUCUS METHODS
Rely on measurement of either BBT or change in cervical mucus to identify ovulation Coitus is avoided from onset of menses until third day of elevated temperature in temp method Coitus is avoided during menses, then every other day until ovulatory mucus is detected, then daily until 4 days after ovulatory mucus is gone Requires highly motivated couples and training in techniques PER 97% TER 75% Basal temperature has to be taken right at wakening or will get a poor reading. The place you take temp doesn’t matter as much as taking it at the same place every time and at the same time gives better results.

SYMPTOTHERMAL METHOD Relies on several indices to identify fertile period Calendar calculations and cervical mucus to establish onset of fertile period Cervical mucus or BBT to estimate end of fertile period Coitus avoided during fertile period Requires significant training and motivated couples PER 98% TER 75% There are some test kits for ovulation prediction that can be acquired. There’s even a digital ovulation predictor for about $250.

PERIODIC ABSTINENCE Overall, typical use effectiveness rate is 75%
Major objection of users is need to avoid intercourse for many days each month Combined with barrier methods during fertile periods may increase effectiveness rates and decrease discontinuation rates

PERIODIC ABSTINENCE Home ovulation predictor kits that test urine for hormone metabolites are now becoming available Test must be done 12 days each month Can reduce the number of days of abstinence required to a maximum of 7

BARRIER METHODS Diaphragm Circular spring with latex rubber coating
Covers the cervix, preventing sperm from entering os Must be fit by HCP Woman must demonstrate ability to insert and remove correctly during fitting Spermicide should be used with diaphragm Diaphragm left in place 8 hours after intercourse Remove device within 24 hours of insertion UTI’s higher in users vs non-users PER 94% - TER 84% Gotta use spermicide with these bad boys – put ‘em in 6 hours prior or so, then for 8 hours after to kill off those sperm. If it doesn’t fit correctly the sperm will swim around it, the little bastards. Lots of women are allergic to spermicides, so it may not be that desireable to a lot of women. Note: diaphragms are a lot bigger than I expected them to be. Hmmm.

BARRIER METHODS Cervical cap – FemCap, Lea’s Shield
Cup shaped plastic or rubber cap Fits around the cervix Must be fitted by HCP Woman must demonstrate ability to insert and remove during fitting Can only be used by those with normal PAP Repeat PAP 3 months after starting use of cap Can remain in place for up to 48 hours Spermicide recommended No increase in UTI’s PER parous 74% nullip 91% TER parous 68% nullip 84% Lots smaller than diaphragms – just go around the cervix. Harder to properly place for many women, which is a bummer because if you don’t get them in the right place you could get preggers.

BARRIER METHODS Male condom
Latex or animal intestine sheaths that cover penis Captures semen to prevent deposition into vagina Must be applied tightly Tip should extend half an inch beyond end of penis Care must be taken to prevent spillage after ejaculation Most effective method to prevent STD transmission (latex) PER 98% TER 85% Should not be kept in wallet or hot car, or used beyond expiration date (increased risk of breakage)!!

BARRIER METHODS Female condom Polyurethane vaginal pouches
Soft, loose-fitting with two rings, one internal, one external Prevents deposition of semen in vagina Less likely to rupture than condom PER 95% TER 79% Noise and distraction are major obstacles

BARRIER METHODS Sponge Made of urethane foam Contains spermicide
Moistened with H2O, inserted into vagina PER 91% TER 84% Advantages Can put in hours ahead of time Can leave in for up to 30 hours Disadvantages May be irritating or messy Watch out for spermicide allergies.

BARRIER METHODS Barrier methods are most effective contraceptive method to reduce transmission of STD’s Contraceptive effectiveness increased with concurrent use of spermicide

SPERMICIDE Made up of spermicidal chemical, either nonoxynol-9 or octoxynol combined with a base of cream, jelly, foam, foaming tablet, film, or suppository No evidence of teratogenicity in several studies Toxic to lactobacillus Increased colonization with E. coli seen, may result in bacteriuria after intercourse PER 82% TER 71%

ORAL CONTRACEPTIVES 1960 marked initial year of use in US
Quickly became the most widely used method of reversible contraception Mechanism Synthetic progesterone (progestin) inhibits ovulation and thickens cervical mucus Synthetic estrogen maintains endometrium, prevents abnormal bleeding, and inhibits follicular development

OC’s Three major types Monophasic combination (fixed dose)
Estrogen/progestin in same doses X 3 weeks Estrogen/progestin in same dose for 84 days Most widely used and most effective Biphasic or multiphasic combination Estrogen/progestin in varying doses X 3 weeks Lower total Est dose for possible lower SEs Progestin only Progestin same dose every day all month Must be taken every day, at same time (within 3 hrs) Monophasic 21 days ; orthoscyclen, orthosnovum, yasmin, ovral Mono-phasic 84 days – Seasonale – 4 periods per year Bi-phasic; Mircette, necon 10/11 Tri-phaisc; estrostep, triphasil Progesterone only Nor-QD norethindrone

OC’s All made from synthetic estrogens and/or progestins
Ethinyl estradiol (EE) most common estrogen First generation OCP’s contain > 50ug estrogen Due to SE’s, these are no longer marketed in US Second generation OCP’s contain ug estrogen and older progestins Third generation OCP’s contain newer progestins – desogestrel, norgestimate, gestodene, drospirenone, norethindrone Early OCPs high Est content coupled with high smoking rates --> led to more incidents of stroke, heart attack, pulmonary emboli

OC’s Failure of combination OC’s occurs primarily when pill free interval is extended Most important pill to take is the first one of each cycle PER combined 99.9% PER progestin only 99.5% Overall TER 97%

OC’s Progestin only OC – AKA “mini-pill” Estrogen effects not seen
Thromboembolism Nausea Breast tenderness HTN No effect on lactation Disadvantages Abnormal bleeding Amenorrhea Slightly less effective than COC’s POSSIBLE CANDIDATES MIGHT BE LACTATING WOMEN, OR WOMEN AT HIGH RISK OF CLOTS. ALSO, THOSE WHO CANNOT TOLERATE ANY ESTROGEN Cigarette smoking drastically increases the risk of blood clots.

SIDE EFFECTS OF OC’s SE’s from estrogen component Nausea
Breast tenderness Headache Fluid retention Decreased B-complex vitamins, vitamin C, and increased vit A Melasma Breakthrough bleeding Possibly mood changes/depression Thrombosis Increases in some coagulation factors and angiotensinogen HTN Neoplastic effects Small increase in current and recent users- -probable small promoting effect with breast cancer Cervical cancer – may be cocarcinogen Protective effect on endometrial and ovarian cancer

SIDE EFFECTS OF OC’s SE’s from progestin components Weight gain Acne
Mood changes Amenorrhea Increased insulin, decreased glucose tolerance Increased LDL, decreased TC, HDL, TG’s Headache Breast tenderness

CONTRAINDICATIONS TO OC’s
Absolute contraindications Hx vascular disease Hx SLE, DM with nephropathy or retinopathy Cigarette smoking > 35 yrs of age Uncontrolled HTN Breast or endometrial CA Pregnancy Functional heart disease Active liver disease Cigarette smoking = increase risk of blood clots in a big way.

CONTRAINDICATIONS TO OC’s
Relative contraindications Heavy cigarette smoking under 35 years of age Migraine headaches Undiagnosed amenorrhea Prolactin secreting macroadenoma Prior to prescribing, screen for diabetes, lipids, liver disease if patient has personal or family history

OCs Protect against: May increase risk for:
Ovarian cancer Uterine cancer Follicular ovarian cysts PID from STI (thickened cervical mucus) May increase risk for: Breast cancer Heart disease Deplete levels of (need supplementation: Folic acid B 12 B6 (pyridoxine) B2 (riboflavin) Vitamin C Zinc

FOLLOW-UP Monitor for side effects Follow-up in 3 months
Hx, BP If patient on medications, check for interactions If no SE’s and BP OK, see patient annually St. John’s Wort, Rifampin, barbiturates, sulfonamides, cyclophosphamide, anti-epilepsy drugs reduces effectiveness of OC’s

The Patch Ortho Evra Synthetic Estrogen and progestin
Patch changed weekly X 3 weeks PER >99% TER 92% Simple, convenient Same contraindications, disadvantages and possible SE’s as OC’s

The Ring NuvaRing Synthetic estrogen and progestin on plastic ring
Ethylene vinyl acetate Inserted into vagina, left X 3 weeks PER >99% TER 92% Simple, convenient Same contraindications, disadvantages and possible SEs as OCs

POTENTIAL BENEFITS OF HORMONAL CONTRACEPTIVES
Reduced endometrial and ovarian cancer Reduced menorrhagia, intermenstrual, and irregular menses Reduced benign breast disease Reduced PMS and dysmenorrhea Reduced PID Reduced bone loss

LONG ACTING CONTRACEPTIVE STEROIDS
Injectable Two types Monthly (Lunelle), q 3 months (Depo-Provera) PER 97.7% TER 97.7% Adverse effects Amenorrhea or irregular menses Weight gain Headache Mood changes Increased LDL, decreased HDL Potential benefits Decreased endometrial cancer

LONG ACTING CONTRACEPTIVE STEROIDS
Subdermal implants Levonorgestrel in a silastic capsule, implanted under the dermis PER 97.7% TER 97.7% NORPLANT NO LONGER AVAILABLE, BUT SOME WOMEN STILL HAVE THEM IN THEIR SKIN Implanon approved by FDA July 2006 Adverse effects Irregular bleeding Infection or local irritation Headache Weight gain Acne Mastalgia Mood changes

INTRAUTERINE DEVICES Devices implanted into uterus
Creates inflammatory reaction and acts as spermicide, may also prevent implantation Two primary types ParaGard (Copper T-380A) PER 99.4% TER 99.2% Good for 12 years Mirena (Levonorgestrel) PER 99.9% TER 99.9% Good for 5 years

See those wires? Gotta make sure they’re even or the IUD isn’t in the right place. 99% effective though otherwise.

Size of Mirena

IUD’s Advantages Disadvantages Highly effective and cost-effective
Convenient, no compliance or perfect use issues Long lasting, easily reversible Minimally invasive Safe during lactation Disadvantages Must be inserted and removed by health care provider Does not protect against STDs Another disadvantage: kinda pricey….like more than $100.

IUD’s Adverse effects Menorrhagia or intermenstrual bleeding
Usually diminishes with time Expulsion of device - occasional Perforation of uterus - rare Complications related to pregnancy - rare Infection - rare Does not protest against STD’s Less well-tolerated in women who have never been pregnant

IUD’s Contraindications Pregnancy Acute or hx PID
Postpartum endometritis Known or suspected uterine or cervical malignancy Genital bleeding of unknown origin IUD previously inserted and still in place Vaginitis, cervicitis, STD, TB (current) Allergy to copper or Wilson’s dz (ParaGard) Liver disease (Mirena) Slide has changed

STERILIZATION Most common method of non-hormonal contraception used by couples in US Female No-Incision Method (Essure) – metallic coils placed into fallopian tubes via vagina, cx, uterus Tubal ligation – Tubes ligated via mini-laparotomy or laparotomy PER 99.6% TER 99.6% Slight surgical risk with ligation Coils can be expelled or perforate rarely semi non-surgical – go in through vagina/cervix/uterus Reversal procedure 75% successful Risk of ectopic pregnancy expensive

There will be adhesions, scarring in the tube, so greater risk of ectopic pregnancy when reversed.

STERILIZATION Male – vasectomy
Require local anesthesia and office setting Excision of portion of vas deferens PER 99.9% TER 99.9% Sperm still present for up to 3 weeks Slight surgical risk, no reduction in sexual performance Reversal procedure 50% successful, expensive

EMERGENCY CONTRACEPTION
Emergency contraception pills Combined E/P Preven Regular OCP’s (certain brands only) Reduces risk of pregnancy 75% Progestin only Plan B Reduces risk of pregnancy 89% Take first dose within 72 hours, second dose 12 hours later Stops ovulation, fertilization, or implantation May cause nausea and vomiting Don’t use if pregnant Depending on brand of OC’s, pt. Should take 2-5 of the active pills each dose, for two doses, 12 hours apart

Plan B - current dosage recommendations is both pills at same time.
Emergency contraception pill – not an abortion pill – prevents implantation. Spot bleeding, nausea, cramping. Fertilization doesn’t happen the day of intercourse – takes a bit, then fertilization, then implantation. Takes about a week total. The earlier you take it the better it works.

Emergency IUD insertion ParaGard (Copper T 380A) Inserted within 5 days Can be left in for up to 12 years, or removed after next menses Not recommended for women at HR of STD, including rape victims Reduces risk of pregnancy 99.9% IUD’s can be used w/in 5 days of unprotected sex.

Where to get EC Available OTC to those >18 yo EC hotline NOT-2-LATE Planned Parenthood PLAN God bless Planned Parenthood. May they live forever.

INDUCED ABORTION One of the most common gynecologic procedures performed in the US and many other countries 90% performed in the first trimester Two primary methods Vacuum aspiration methods Manual vacuum aspiration Dilation and suction curetttage (D&C) Medication methods Mifepristone (RU 486) or methotrexate followed by misoprostol

INDUCED ABORTION Vacuum aspiration abortion Medication abortion
Procedures take about 10 minutes May have cramps and clots for 10 days May bleed for up to 2 weeks >99% effective Medication abortion Entire process may take from 1-2 weeks May bleed for up to 4 weeks May have cramps, N&V, diarrhea 90-97% effective

INDUCED ABORTION Safety issues
Risk of death from abortion: 0.7 per 100,000 abortions Risk of death from pregnancy: 7-8 per 100,000 live births Performed in outpatient clinics, general anesthesia not required

INDUCED ABORTION Risks Allergic reactions Infection
Incomplete abortion Bleeding Injured organ – vacuum aspiration only

Key Concepts Major categories of contraception are:
Periodic abstinence Barrier methods Oral contraceptives Long acting contraceptive steroids IUD’s Emergency contraception Sterilization Which are most effective? What are some pros/cons of each? Which help prevent STD transmission?

Infertility Defined as the reduced capacity to conceive as compared with the mean capacity of the general population Inability of couples of reproductive age to establish a pregnancy by having unprotected sexual intercourse within a certain period of time (usu. 1 year) Primary: woman has never been pregnant Secondary: infertility after one or more pregnancies

Infertility Fecundability (monthly conception rate) in normal, fertile females is about 20% Half of the couples who try to conceive do so within the first 3 months Three fourths will conceive within 6 months 90% will conceive within 1 year Two categories of infertility: Hypofertile – couples have low fecundability Woman with mild endometriosis Male with low sperm count (oligospermia) Sterile – couples who are never able to conceive without therapy Woman with complete occlusion of Fallopian tubes

Infertility and Age Fertility decreases with age
Failure to conceive within 1 year steadily increases from ages 25-44 About 1 in 7 couples are infertile if the woman is years 1 in 5 if woman is between years old 1 in 4 if woman is between 40-44 Monthly ovulation decreases greatly after age 45

Causes of Infertility 10-15% annovulation
10-15% abnormal sperm-mucus penetration 30-40% abnormalities in the male repro tract Oligozoospermia, high semen viscosity, low motility of sperm, low semen volume 30-40% pelvic factors Tubal occlusion Endometriosis adhesions Idiopathic or unexplained infertility Tend to be hypofertile and eventually able to conceive without treatment

Anovulation Anovulation may be due to:
Physiologic (pregnancy, postpartum, menopause) Extreme exercise Low body fat Too much stimulation of breasts may elevate prolactin Psychogenic Acute physical or emotional stress Traveling, lifestyle changes Chronic stress Anorexia nervosa (amenorrhea a likely early symptom)

Anovulation May be due to hormone imbalance
Decreased progesterone production (or problem with progesterone receptors) Estrogen deficiency Hyperprolactinemia (endocrine tumors, breast feeding, hypothyroidism) Insufficient function of hypothalamus/ pituitary Ovarian insufficiency (cysts, tumors, insulin resistance, autoimmune)

Annovulation/ Hormone Imbalance
Systemic diseases: Hypothyroidism (elevated TSH associated with elevated prolactin) Adrenal abnormalities (Cushings, Addisons: heavy irregular menses; adrenal insufficiency/ burnout) Diabetes, Anemia Malnutrition

Infertility General Counseling
Timing Best chance for conception the day prior to ovulation Sperm has ability to fertilize 5-7 days Ova viable for only about 24 hrs. Daily intercourse for 3 consecutive days midcycle

Stop smoking Lowers sperm count, higher proportion of malformed sperm Worse response to fertility treatment Lengthens time to conceive Women who smoke are twice as likely to be infertile

Avoid coffee Coffee drinking during pregnancy is associated w >2x inc risk of miscarriage Risk of not conceiving for 12 months is: 55% higher for women drinking 1 cup/ day 100% higher for cups/day 176% higher for 3 or more cups/ day

Avoid alcohol Alcohol consumption by the woman 1 week prior to IVF treatment reduces success nearly 3 times Alcohol consumption by the man the month before IVF reduces success rate 2.5 times; 8 times if the week prior Alcohol consumption by either partner the week prior to conception associated with increased risk of miscarriage

Avoid marijuana Males: decreases sperm count Lowers testosterone Males: avoid increase in pelvic temperature: Hot tubs, laptop on lap for extended periods Sperm motility may be decreased by keeping cell phone in front pocket Avoid pesticide and chemical exposure Manage stress well Many emotional and other relationship issues often come up or are exacerbated if couple is having difficulty conceiving

Avoid douches Avoid use of saliva or petroleum-based lubricants Even some water-based lubricants may interfere with sperm motility and integrity FemGlide, Replens, and Astroglide (laboratory study) KY had lowest negative effect on sperm

Infertility and Body Weight
Small amounts of weight loss (5-10%) may dramatically improve ovulation and pregnancy rates in overweight women (BMI> 25) Sperm counts lower in both over- (21%) and underweight (28%) men

Diagnostic Evaluation:
Documentation of ovulation Regular menstrual cycles Serum progesterone level in midluteal phase (should be above 10ng/ml to indicate adequate luteal function) BBT Semen analysis: volume, viscosity, sperm density, sperm morphology, sperm motility Male partner should abstain from ejaculation 2-3 days prior to specimen collection Analysis should be performed as soon as possible after the liquefaction of semen Liquefaction should occur after about 1 hour, testing should be done within minutes of this

(Semen Analysis) Volume: >2.0ml Concentration: >20 million/ml
Total Cells: >40 million Motility: ~50% Normal Forms: >14% White & red blood cell counts If abnormally high, antibiotics may be recommended Semen Viscosity Coagulated sperm should liquefy within an hour Sperm Agglutination Sperm that "clump together” - indicates autoimmune response or presence of infection

Infertility Workup CBC, UA, cervical cytology (PAP)
If over 35 years old, serum FSH, estradiol on day 2, 3, or 4 of cycle If FSH >24 mlU/ml, ova unable to be artificially fertilized CA-125 serum levels Serum prolactin Pelvic ultrasound Thyroid panel - esp if cycles irregular Antibodies to Chlamydia High correlation between Ab titer and tubal adhesions/ obstruction

Infertility - other possible factors
Women may have an occult (asymptomatic) infection of upper genital tract Women may produce antibodies to sperm that may immobilize them or cause them to agglutinate These antibodies have been found in both fertile and infertile women Not a established cause of infertility

Infertility Workup Hysterosalpingogram if tubal adhesions/ blockage suspected Performed during the week following menses Involves a steady beam of X-rays to visualize uterus and Fallopian tubes while a contrast media is applied through cervical os Diagnostic laparoscopy if suspect endometriosis Usually performed after several rounds of ovarian hyperstimulation and intrauterine insemination

Infertility Prognosis
Better in cases due to: Anovulation Uterine adhesions Lower in cases due to: Sperm abnormalities Tubal disease

Infertility Management
Annovulation Agents to induce ovulation Clomiphene citrate/ Clomid (synthetic estrogen), hMG, FSH, GnRH Bromocriptine if due to hyperprolactinemia Corticosteroids if due to excess adrenal androgens Intrauterine adhesions Hysteroscopic lysis Good prognosis if no other contributing factors

Infertility Mgmt Leiomyoma Infection causing cervicitis
May physically distort the endocervix and interfere with normal sperm transport or if submucous could interfere with implantation Myomectomy justified in cases where they are of moderate size and position and no other factor that contributes to infertility Infection causing cervicitis High levels of WBC kill off sperm as they enter os Cervical mucus may be to acidic for sperm Appropriate antibiotic or antimicrobial agent

Infertility Mgmt Tubal problems Management of tubal problems:
Scarring from PID is leading cause of female infertility Scarring may also be from prior surgery (e.g. ectopic pregnancy) or congenital tube defects Management of tubal problems: Selective salpingography and tubal cannulation Done in cases of proximal tubal obstruction Purpose is to “open” tubes– achieve tubal patency Surgical tubal reconstruction Prognosis depends on amount of damage to tubes If damage extensive, greater chances of conceiving with IVF than with tubal reconstructive surgery

Infertility Mgmt Endometriosis: up to 40% of infertile women have endometriosis Blood from endometrial tissue irritates tubes, producing scarring, adhesions, or cysts May cause hypertrophy of uterine lining, interfering with implantation Mild cases: 65% of women can conceive without treatment (if no other contrib factor) Moderate to severe cases: only 0-25% can conceive

Infertility Mgmt Endometriosis
Surgical treatment in absence of tubal adhesions or endometrioma (mild endometriosis) does not result in improved fertility rates Medical treatment of mild endometriosis has not been shown to improve fertility rates (vs. no treatment) Surgical treatment of moderate (over 1cm size endometrioma) endometriosis slightly improves fertility rates Surgical treatment of severe endometriosis improves fertility rates Nearly all of the women treated for severe endometriosis who conceive do so within the first 15 months after surgery

Infertility Mgmt Unexplained infertility
Controlled ovarian hyperstimulation (usu. via Clomid) Intrauterine insemination (IUI) Initial treatment consists of 4-6 cycles Pregnancy rates with this method decrease dramatically after age 40

IVF In Vitro Fertilization
Ovarian hyperstimulation to harvest as many ova as possible Success rate proportional to number of implanted embryos Ova are retrieved via follicle aspiration Oocytes cultured and incubated in a rigidly controlled, sterile environment A few hours post retrieval, sperm separated from semen are added to culture medium

IVF continued 18 hours later oocytes are observed to determine if fertilization has occurred Those that have been fertilized are cultured for hours Embryos are placed via catheter through cervical canal Rate of pregnancy following IVF is directly related to number of implanted embryos After six failed cycles of IVF, chances of pregnancy very low

Infertility Unexplained infertility
May be due to environmental pollutants or exposure to other toxic chemicals Heavy metal burden (lead, mercury, cadmium, etc.) Chelation therapy The couple must REFRAIN from actively trying to conceive during ANY form of chelation / cleanse Endocrine disruptors: exogenous estrogens, pesticides, chemical solvents Electromagnetic radiation Chelation must also include mineral replenishment sessions, and must have proper elimination throughout txt (bowel movements, kidney function)

Infertility Other Helpful Modalities
Energy work Counseling Spinal manipulations Mayan uterine/abdominal massage …

Contraception, Infertility

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