Glossary

Dr. Singh and the staff at LifeStart Fertility Center has compiled a list of frequently used terms that you will see throughout your treatment and on this website. Please use the following list so you may better understand the procedures and treatments offered.

Aspiration - A method of obtaining eggs by utilizing a needle inserted through the vagina into the ovaries under ultrasound guidance.

Assisted Hatching (AH) - A small opening is made in the outer shell of the embryo to improve the chances of implantation.

Assisted Reproductive Technologies (ART) - Used to assist couples in overcoming infertility through the joining of the sperm and egg outside of the body and the transfer of resulting embryos. These procedures include: In Vitro Fertilization, Donor Oocyte IVF, Micromanipulation (ICSI and AH), Cryopreservation of embryos and sperm related procedures.

Controlled Ovarian Hyperstimulation - The use of medications to stimulate multiple follicular development in the ovaries. This stimulation is called “controlled” because the patient is carefully monitored with ultrasounds and hormonal blood testing.

Cryopreservation - A process that preserves embryos by freezing them for later thaw and implantation.

Egg Donation - For women who lack good quality eggs, have premature ovarian failure or don’t want to risk passing on a known genetic disease. The process takes eggs, usually from a younger woman, fertilizes them with the male’s sperm and places them into the patient’s uterus.

Follicle - The fluid-filled sac in the ovary that has nurtured the egg and from which the egg is released during ovulation or aspiration.

Follicle Stimulating Hormone (FSH) - A hormone produced and released from the pituitary that stimulates the ovary to ripen a follicle for ovulation. Elevated levels early in the cycle may indicate decreased quality and quantity of the eggs.

Gamete - A generic term referring to either the male sperm or the female oocyte (egg).

Gestational Surrogacy - This is an option for women with viable eggs, but who don’t have a normal uterus or can’t carry a baby for other medical reasons. A woman’s eggs are removed, fertilized with the male’s sperm and the embryos are implanted in a surrogate mother’s uterus.

Hysteroscopy: - A surgical procedure that involves using a special telescope inserted through the cervix to view the uterine cavity.

Infertility - The inability to conceive after one year of unprotected intercourse if less than 35 years of age or six months if older than 35 years of age.

Intracytoplasmic Sperm Injection (ICSI) - This is used when there is male-factor infertility and involves extracting a single sperm and injecting it into an egg while working under a microscope using specialized equipment.

In Vitro Fertilization and Embryo Transfers - In IVF, eggs are extracted from a woman and combined in a laboratory with sperm. Fertilization usually takes place in one day. The resulting embryos are kept in an incubator for three to five days, after which time they are checked for appropriate development, and then transferred into the woman's uterus.

Laparoscopy - A surgical procedure that involves the use of a small special telescope (laparoscope) to view abdominal and pelvic structures including the uterus, ovaries and fallopian tubes.

Microsurgical Epididymal Sperm Aspiration (MESA) - Used to obtain sperm when a man’s vas deferens is obstructed. This procedure is performed in an operating room. Sperm is extracted from the epididymis through an opening in the skin working under a microscope.

Oocyte - The egg produced in the ovaries.

Ovulation Induction - The stimulation of ovaries to produce eggs.

Preimplantation Genetic Diagnosis (PGD) - Technique used during In Vitro Fertilization procedures to evaluate the embryos for genetic or chromosomal abnormalities prior to their transfer into the uterus.

Reproductive Endocrinologist - An OB/GYN sub-specialist who has received advanced training (a fellowship) in the treatment of infertility, recurrent miscarriages, and hormonal disorders in women.

Testicular Sperm Extraction (TESE) - Used to obtain sperm from a testicle for ICSI in cases of azospermia.

Ultrasonography - A radiological procedure performed either transvaginally or abdominally that uses sound waves to assess uterine fibroids, ovarian cysts, pelvic masses, pelvic pain, and other gynecologic problems. It is also used to track the development of egg-bearing follicles during ovulation induction.

Zygote - The cell resulting after fertilization of the oocyte by the sperm.

Frequently Asked Questions

• What could be wrong?
• What happens in an ART (Assisted Reproductive Technology) cycle?
• Is there a psychological impact of IVF?
• What is ICSI?
• What is Assisted Hatching?
• What is Endometriosis?
• Is there a higher rate of multiple births while undergoing IVF?
• Are the chances of the child having birth defects increased?
• Are there any restrictions on physical or personal activities during an ART cycle?
• What happens if I become pregnant?
• If I am not pregnant, when can we try again?
• How do we decide how many embryos to transfer?
• Am I depleting my store of eggs by doing an ART cycle?
• What would you say is the number one most important thing a couple should do first in seeking out treatment??
• The second most important thing?
• What has the highest success rate for couples just starting out?
• How long should a couple stay on a regimen before it’s effectiveness rules it out? For example: Some doctors advise that if you haven’t gotten pregnant after 3 rounds of Clomid, you should move on. Is this timeframe the same for most of the procedures?
• Money and stress are important factors. Any tips on how to keep the stress level from getting so high, it adversely effects a couple’s health, and thus the ability to get pregnant?
• Is there ever a point where you would advise a couple to stop pursuing therapies?

What could be wrong?

Male and female factors can equally be the cause of infertility. Approximately 40% of the time the infertility is the result of a male factor and 40% of the time it is the result of a female factor. In 20% of cases, both male and female factors are involved.

It is imperative that you undergo a complete infertility evaluation before speculating on the causes and treatments. This information is not a substitute for a physician consultation or infertility evaluation. It just provides some insight into the common diagnoses.

The typical causes for female infertility and the rough percentages that they occur are graphed below. Please contact LifeStart Fertility Center for more information and to set up an appointment with Dr. Singh for an infertility evaluation.

What happens in an ART (Assisted Reproductive Technology) cycle?

A cycle begins with the administration of fertility drugs. This is called controlled ovarian hyperstimulation. The goal is to produce multiple follicles on the ovaries from which eggs are retrieved. The specific fertility drug protocol utilized varies and is individualized for each patient. Most of the medications used are for the female; however, the male is asked to comply with a regimen of antibiotic therapy to prevent and treat certain organisms in the semen that can lower fertility success rates.

Transvaginal ultrasound examinations and blood estradiol levels are used to monitor follicle growth and egg development. As the follicles in the ovaries grow, they produce increasing amounts of estradiol. The physician compares the estradiol level with the ultrasound results to determine if any medication adjustments are necessary. The physician also uses this information to determine the most optimal time to proceed with egg retrieval.

A baseline ultrasound and estradiol level is obtained prior to beginning any stimulation medications. A repeat ultrasound and estradiol level is usually obtained on stimulation day six. Eventually, ultrasound examinations and blood tests may be necessary on a daily basis. The ovarian stimulation is usually about 9 to 12 days.

Controlled ovarian hyperstimulation ends when the physician determines an appropriate number of eggs are likely to be mature (based on ultrasound and blood test results). All fertility-stimulating drugs are discontinued at this time. The patient administers an hCG (Pregnyl^TM or Profasi^TM) injection at a specific time as instructed by the physician. Oocyte (egg) aspiration is scheduled 36 hours following the hCG injection.

A small percentage of patients who begin taking fertility stimulation medications have their cycle cancelled before any procedure is done. The reasons for cycle cancellation can include an insufficient number of mature follicles, an inadequate blood level of estradiol, or an exaggerated response leading to a risk for hyperstimulation syndrome. If an ART cycle is cancelled, medications may be modified in subsequent attempts in order to try to improve the response.

Is there a psychological impact of IVF?

Those couples that do not conceive with basic fertility treatment modalities find themselves confronted with decisions concerning In Vitro Fertilization (IVF). Assisted Reproductive Technology may cause additional stress for couples that have already endured multiple disappointments. IVF can be difficult, both physically and emotionally. Studies have shown that couples that know what to expect are better able to endure these processes and use their own natural coping skills to their best advantage.

• For many couples this is the last step toward achieving a biological child.
• It is difficult to realistically confront the odds while remaining optimistic enough to endure a regimented treatment program.
• An IVF treatment cycle disrupts work, school and daily schedules.
• Physical distance from an IVF program may cause daily commuting, separation from the spouse if commuting is unrealistic, or additional expense and unfamiliar accommodations during treatment.
• A normal grief reaction is inevitable if pregnancy does not occur.
• Joy verses fear can occur when pregnancy occurs and the possibilities of miscarriage or tubal pregnancy remain a threat.

There are several strategies that can assist couples during this time:

1. Become informed about IVF.
2. Understanding the process of IVF and knowing what to expect will lessen your anxiety about the procedure.
3. Be realistic about your expectations. The chance of establishing a pregnancy is 20% to 60% each treatment cycle. Also, each cycle contributes valuable information that can be of assistance in subsequent cycles.
4. Set limitations.
5. Make decisions ahead of time. Discuss with your spouse your feelings about cryopreservation, donor semen, the number of cycles you will attempt, and who will be included in your confidence.
6. Provide for emotional support. Talk about your feelings.
7. Keep life simple. Plan activities that are relaxing and entertaining. If you are staying in a hotel, bring familiar items from home.
8. Counseling may be of assistance to some couples to help them cope with difficult emotions and stress.

What is ICSI?

ICSI or Intracytoplasmic Sperm Injection is an additional component of an IVF cycle usually used with male factor issues or when fertilization does not normally occur. The procedure, done in the IVF laboratory, takes one sperm and injects it into one egg. This is done with sophisticated magnification and handling equipment. This procedure obviously enhances fertilization rates. For more information about the ICSI procedure, please click here.

What is Assisted Hatching?

Assisted Hatching is a form of embryo micromanipulation that involves the creation of an opening in the outer covering, or zona pellucida, of the embryo. The procedure helps a normal, growing embryo hatch from the covering and implant in the uterus. This procedure may increase the implantation rate, especially in older women. For more information, please visit our Assisted Hatching section.

What is Endometriosis?

The formal definition of endometriosis is endometrium in an ectopic location that contains endometrial glands and stroma. In other words, it is uterine-like tissue that is growing outside the uterus causing pain and/or infertility. Its cause is unknown. There are many theories, but every answer has contradictions. It could be genetics. It could be retrograde menses, menstruation that goes backwards through the tubes into the abdomen. It could be congenital. It could be immunological.  It could be all of the above or none of the above. We simply don't know.

Endometriosis is common. The generally accepted percentage of women with Endometriosis is 5% to 15%. However, the true incidence is probably even higher. Many women have Endometriosis and don't have the symptoms (usually pain) or the pressing need to be diagnosed (usually infertility). Endometriosis can be classified as very mild to severe. There are likely many more women with very mild Endometriosis, which does not cause any symptoms.

The only way to diagnose Endometriosis with complete accuracy is to see it. The only way to see it is through surgery (laparoscopy). There are symptoms and tests that can give a physician clues, but Endometriosis is a very elusive disease. The adage "seeing is believing" is the safest and most effective route to pursue diagnosis and ultimately treatment. For more information on endometriosis, please click here.

Is There a Higher Rate of Multiple Births While Undergoing IVF?

There is a higher rate of multiple births for women treated with fertility drugs than in the general population. The actual rate depends on the type of drugs used and the chosen procedure. There are many strategies to minimize the risk of multiple births, but it is always a risk to some degree.

There are three basic types of therapy that increase the risk of multiple births. They are:

1. Ovulation induction with Clomiphene
2. Ovulation induction with gonadotropins
3. IVF procedures with fertility drugs

For more information on which procedure would best fit you, please contact us for a consultation.

Are the chances of the child having birth defects increased?

There is no reported correlation between babies conceived with medical intervention and birth defects. The risk is no greater than in the normal population. These are real and natural babies conceived with a little assistance.

Are there any restrictions on physical or personal activities during an ART cycle?

Yes, there are a number of them.

1. Smoking: Stop smoking before treatment begins. If you cannot stop "cold turkey," make an effort to stop at least two weeks before the egg aspiration.  Smoking can affect ovarian stimulations, egg and embryo quality, and the likelihood of conceiving.

   Numerous studies have demonstrated that smoking during pregnancy can lead to reduced birth weight and fetal compromise. There is some data to suggest smoking can also lower pregnancy rates. New medications are available that can help many people overcome the smoking habit. We strongly recommend that all women, especially those undergoing fertility therapy, cease smoking.

2. Drinking: Alcohol is a drug and, in general, should be avoided during infertility treatment and pregnancy. There is no reason to consume alcohol and it can introduce another "unknown" factor into treatment. If you drink socially, you may continue to do so during the controlled ovarian stimulation phase. Two to three alcoholic beverages per week is acceptable. Please do not drink alcoholic beverages from approximately 4 days before egg aspiration until the pregnancy test.
3. Medications: If you are taking any medication, prescribed or over the counter, please inform your physician. Some medication should not be taken before an operation, some may interfere with those prescribed during your cycle, and others may interfere with ovulation or pregnancy implantation.
4. Your physician will prescribe a multivitamin.
5. Inform your physician of any changes in your health even minor colds or infections. 
6. An ART cycle can be stressful physically and emotionally. Avoid becoming tired in the days before and after a procedure. Eating correctly, and getting proper rest are important.
7. An ART cycle can be an emotionally stressful time for you and your partner. You need to consider supportive relationships, for example; friends, clergy, family members, and psychologists.
8. Heavy exercise such as aerobics, jogging, weight lifting, roller blading, etc. will be prohibited during ovarian stimulation and until the pregnancy test.

What happens if I become pregnant?

If pregnant, you are asked to return to the office for repeat blood tests and ultrasounds to insure an ongoing successful pregnancy. After approximately 8 weeks, you are referred to an obstetrician for the remainder of the pregnancy.

If I am not pregnant, when can we try again?

Cycles can be done back to back but usually we ask the patient to wait one complete menstrual cycle before beginning another ART cycle. This gives us time to "regroup", evaluate what was learned from the prior cycle and determine the next steps.  Sometimes tests are required that can delay subsequent cycles

How do we decide how many embryos to transfer?

Dr. Singh will discuss this with you, but we usually follow the American Society for Reproductive Medicine Guidelines: under 35 years old - 2 embryos; 35-37 years old - 2 or 3 embryos; 38-40 years old - 3 or 4 embryos. The number may also vary depending on each individual clinical circumstance.

Am I depleting my store of eggs by doing an ART cycle?

A woman is born with a full complement of eggs. There are far more eggs than will ever be used during a normal lifetime and ART have no measurable "lowering" effect.

What would you say is the number one most important thing a couple should do first in seeking out treatment?

It is important for them not to wait for help longer than they need to. Women younger than 35 years of age should seek advice after one year of unprotected intercourse while women over age 35 should consult a doctor after 6 months of trying.

What is the second most important thing a couple should do?

They should consult a qualified physician as early as possible and consider seeing a Reproductive Endocrinologist.

What has the highest success rate for couples just starting out?

Success rates are variable depending upon multiple factors including female age and the cause of infertility. Overall, In-Vitro Fertilization (IVF) has the highest success rate amongst current available reproductive technologies.

How long should a couple stay on a regimen before it’s effectiveness rules it out? For example: Some doctors advise that if you haven’t gotten pregnant after 3 rounds of Clomid, you should move on. Is this timeframe the same for most of the procedures?

Once again, each patients case is unique and the # of “rounds” recommended depends on multiple factors including age and cause of infertility. In general, three to four cycles of any ovulation induction regimen done under proper monitoring are reported to have maximum effectiveness.

Money and stress are important factors. Any tips on how to keep the stress level from getting so high, it adversely effects a couple’s health, and thus the ability to get pregnant?

First, thoroughly understand your particular case and cause of infertility. Explore the possible treatment options and select the treatment plan only after a thorough review with a specialist. Make yourself aware that infertility treatments often tend to run a long course. Take advantage of infertility support groups and counselors/psychologists specializing in the area of infertility.

Is there ever a point where you would advise a couple to stop pursuing therapies?

This is a difficult question to answer, as each patient’s situation is unique. If the couple has gone through multiple failed ART (Assisted Reproductive Technology) cycles and if they are not open to egg, sperm or embryo donation as indicated, then adoption should be considered.

Male Infertility (Male Factor Infertility)

Traditionally, infertility has been thought to be strictly a female issue. In reality, however, infertility affects both men and women, and about half the cases of infertility are attributable to factors within the male. LifeStart Fertility Center serving greater Los Angeles, California recognizes this percentage and approaches infertility as a “couples disease.” All consultations at LifeStart Fertility Center include a detailed and thorough evaluation for both male and female infertility factors. We will take a brief look at male factor infertility below.

Causes of male factor infertility
A variety of conditions can lead to male infertility, including problems with sperm production, blockages in the reproductive tract, hormonal disorders, and problems within the testicle itself---all issues which affect sperm quality and quantity.

A man's health history and lifestyle can also affect his fertility. A past history of drug, alcohol or cigarette use, mumps after puberty, previous urologic surgery, prostate infections, a history of sexually transmitted diseases and current medications can all impact sperm production or delivery.

Diagnosis
The first step in determining what could be preventing conception is obtaining a thorough history from the male partner to evaluate for factors that are associated with male infertility. The next step is usually a semen analysis. For the semen analysis, a fresh semen sample is obtained and evaluated for various factors including sperm count, motility and morphology. Blood tests to measure hormone levels may also reveal pertinent information about testicular function and possible causes of infertility. A genetic assessment and diagnostic tests may also be taken that assess the ability of the man's sperm to penetrate and fertilize the egg.

Treatment
Treatment will depend on the cause of the man's infertility. Surgical therapy, treatment with medications, and assisted reproductive technologies (ART) are some of the treatment options available that can help nature along toward achieving pregnancy. Below are a few treatments that are offered at LifeStart Fertility Center.

Intrauterine Insemination (IUI) - IUI involves the placement of large numbers of motile sperm high inside the uterus during the most fertile time of the woman's cycle. It is performed in a physician's office without anesthesia. This procedure is useful when male factor infertility is an issue.

In Vitro Fertilization (IVF) - IVF involves placing the couple's sperm and egg together in a laboratory dish to fertilize in vitro, or outside the woman's body. The fertilized eggs are then placed back into the uterus. IVF is useful when a man's sperm is of reduced quantity or quality.

Intracytoplasmic Sperm Injection (ICSI) - This laboratory technique injects a single sperm into the cytoplasm of the woman's egg, bypassing the need for sperm to swim through the reproductive tract, locate the egg and penetrate it. This technique is useful for men with low amounts or weak sperm.

Microsurgical Epididymal Sperm Aspiration (MESA) - Used to obtain sperm when a man’s vas deferens is obstructed. This procedure is performed in an operating room. Sperm is extracted from the epididymis through an opening in the skin working under a microscope.

Testicular Sperm Extraction (TESE) - Used to obtain sperm from a testicle for ICSI in cases of azospermia.

Percutaneous Epidydimal Sperm Aspiration (PESA) - An aspiration technique that involves removing sperm from the epididymis.

For more information on male infertility and to set up an appointment please click here to contact us or call LifeStart Fertility Center at 818-889-4532.

Endometriosis

Endometriosis is a common yet poorly understood disease that can affect women of any socioeconomic class, age, or race. It is estimated that between 10 and 20 percent of American women of childbearing age have endometriosis. While some women with endometriosis may have severe pelvic pain, others who have the condition have no symptoms.

The name endometriosis comes from the word "endometrium," the tissue that lines the inside of a woman's uterus. If a woman is not pregnant this tissue builds up and is shed each month-it is discharged as menstrual flow at the end of each cycle. In endometriosis, tissue that looks and acts like endometrial tissue is found outside the uterus, usually inside the abdominal cavity.

Endometrial tissue residing outside the uterus responds to the menstrual cycle similar to the way normal endometrium in the uterus usually responds. At the end of every menstrual cycle, when hormones cause the uterus to shed its endometrial lining, endometrial tissue growing outside the uterus will break apart and bleed. However, unlike menstrual fluid from the uterus, which is discharged from the body during menstruation, blood from the misplaced tissue has no place to go. Tissues surrounding the area of endometriosis may become inflamed or swollen and the trapped blood may lead to the growth of cysts. The inflammation may produce scar tissue around the area of endometriosis.

Endometriosis is most often found in the ovaries, on the fallopian tubes and the ligaments supporting the uterus, in the internal area between the vagina and rectum, on the outer surface of the uterus, and on the lining of the pelvic cavity. Infrequently, endometrial growths are found on the intestines or in the rectum, on the bladder, vagina, cervix, and vulva (external genitals), or in abdominal surgery scars.

Having endometriosis does not increase a woman's risk for developing uterine cancer. Although some oncologists believe that women with endometriosis are at greater risk for ovarian cancer, the National Cancer Institute does not consider endometriosis to be a risk factor.

For more information on endometriosis and for a consultation, please contact Dr. Singh and LifeStart Fertility Center.

Premature Ovarian Failure

Premature Ovarian Failure (POF) or a premature menopause occurs when a woman’s periods stop before the age of 40. There is often some warning, just as there is at the time of the natural menopause (around the age of 50 for most women) with periods becoming irregular and more widely spaced. Sometimes, however, periods cease suddenly. The ovaries stop producing estrogen and so symptoms including hot flushes, mood changes and vaginal dryness occur. The ovaries also stop producing eggs and so conception is extremely unlikely. 

There is not always an explanation for a premature menopause. It sometimes is hereditary with women having their menopause at a similar age to their mother. Some women have abnormalities of the genes that control ovarian function, others make ‘auto antibodies’ which prevent the ovaries from working and a few women can be affected by viral infections of their ovaries. In most cases, the ovaries cannot start working again on their own.

Some women can have quite a long period during which the ovaries are slowing down rather than stopping and ovulation may occur from time to time. During this time the ovaries are resistant to the two hormones that come from the pituitary and which stimulate the ovaries to release eggs and estrogen. These pituitary hormones are FSH (follicle stimulating hormone) and LH (luteinizing hormone). The levels of FSH and LH in the blood at the time menopause are very high as they are trying to encourage the ovaries to work. Premature Ovarian Failure is therefore diagnosed by at least two blood tests that show elevated blood levels of FSH and LH. 

The ovaries will not respond to the body’s natural FSH and LH and in turn will not respond to FSH/LH injections. At this time, there are no treatments that will make resistant or menopausal ovaries work again. Woman with Premature Ovarian Failure should be given hormone replacement therapy (HRT), which will provide the right amounts of estrogen (together with progesterone, another ovarian hormone) and an artificial menstrual cycle. It is recommended that the hormone replacement therapy is taken at least until the age of 50. The oral contraceptive pill is an alternative to HRT. Oral contraception will not allow ovulation to occur. For women desiring to conceive options include donor egg and adoption. 

For more information on Premature Ovarian Failure, please click here to contact LifeStart Fertility serving greater Los Angeles or call us at 818-889-4532 for an appointment.