Frequently asked questions

Infertility is the inability to conceive after a year of regular, unprotected intercourse. Couples who have known barriers to fertility, such as endometriosis, polycystic ovarian syndrome (PCOS), male factor infertility, irregular cycles, etc., do not need to sit out the traditional "waiting period "for one year to seek expert care for infertility.

A reproductive endocrinologist or an infertility specialist, specializes in treating infertility, and is far more likely to have the experience necessary to identify and treat your problem than an OB/Gyn. It can be a tremendous waste of time, and money that you could put toward treatment with a specialist who can get to the root of your problem.

Ovulation occurs 36-40 hours after the HCG injection. Eggs will release in this timeframe if they have not been retrieved. This is adequate time for planning any form of treatment. Frequently, the ovulation is associated with mild discomfort felt in the lower abdomen and is confirmed by doing a serial ultrasound follicular monitoring by the doctor.

Normal, healthy sperm live approximately 48-72 hours. We do know that washed sperm can survive in the IVF incubator for up to 72 hours. That would be considered the upper practical limit.

Eggs are able to be fertilized for about 12-24 hours after ovulation. The older the woman, the shorter this time becomes.

Fertilization occurs within 24 hours after ovulation.

The earliest that a sensitive blood test can pick up any HCG at all is 5-7 days after ovulation. Your quantitative serum beta test can be reliable about 10-12 days after ovulation, if you have not taken a HCG booster. If you have taken a HCG booster, then you may have a reliable test at 14 days past ovulation. The serum beta HCG is the most reliable test. Your HCG level has to be above 50 units in the blood to get a positive result for urine pregnancy tests.

D1 is the first day you see a red flow, not just intermittent spotting. There is no universal rule for the cutoff time for that date. But most often D1 is considered the first day of full flow that begins before mid-afternoon.( some doctors believe in 8pm as the cutoff time and some will take it as the noon. However, this helps in giving some flexibility in starting treatment especially in women with irregular cycles.

If these bloods were drawn on day three of a cycle, the results would imply decreased ovarian reserve or eggs available. FSH is more of an indirect measurement of ovarian reserve. This is specially true if you are above 37 years of age, or you have had previous cycles which were not as expected in the ovarian stimulation.

Your doctor will also advise you for the same if she suspects any hormonal imbalance or PCOS or if you have irregular cycles.

Besides the number of sperm, the percentage with rapid forward-progressive motility and with normal morphology at the time of insemination are important to know. If this functional sperm count exceeds 1 million, chances for pregnancy with well-timed IUI are excellent.


A lead follicle should be at least 16-17 mm when the patient is on urinary gonadotropins for ovulation induction, it should beat least 18 mm on a recombinant FSH, and should be about 22 mm on Clomiphene citrate therapy. Other measurements such as E2 and progesterone should be used to indicate maturity.

Follicles grow 1 to 2 mm a day both while taking ovulatory stimulants and after the HCG shot.

1. What causes these cysts ?
   A corpus luteum, or functional cyst, is simply a leftover follicle that has outstayed its normal lifespan. Sometimes, they continue to produce progesterone and estrogen, which may delay the arrival of the next period.
2. Will they go away ?
   Functional cysts almost always go away with time. Birth Control Pills are sometimes prescribed for a month or two, to hasten their resolution. They never need any other intervention. If not, relieved by medication, they may not be functional cysts and need further evaluation.
3. How big do they need to be to reduce chances of pregnancy ?
   Research has shown that any cyst 10 mm or larger is associated with a lower chance of getting pregnant. Those that had a 10 mm cyst at the beginning of a cycle had half the pregnancy rate of those who had no cysts. It does not eliminate your chances of pregnancy, but it does sharply decrease them, through two mechanisms. First, physically, they can crowd out the development of new follicles. Also, if the cyst is secreting hormones at the wrong time of the cycle, it interferes with the chemical balance required for good quality ovulation and drastically reduces the chances of pregnancy.
   
   It is normal to have small cysts, which may be very small leftover follicles or follicles that are preparing for the next cycle. Anything under 10 mm shouldn't be cause for concern as long as your baseline hormone levels are in range.

The vast majority of Clomiphene pregnancies occur during the first 4-5 ovulatory cycles. If after the first 3 attempts at a reasonably high dosage, there is no response, you might consider moving on to Injectables earlier. The average number of cycles on Clomiphene before moving on is three to six.

The maximum dosage is 250 according to manufactures. It may be wise to move on if there is no response to 150 mg, as the risk of antiestrogenic side effects of Clomiphene increase sharply as the dosage goes up. Also, with the recent recommendation of the Royal college of Ob-gyn and the American college of Ob-gyn, Clomiphene use should be restricted to maximum of 12 months in your lifetime.

Once a patient has had 3-6 IUI cycles with injectables, they might consider moving to IVF as the chance of a successful IUI cycle is reduced.

In theory, days 3-7 of Clomiphene lead to more follicles and fewer side effects on the lining and the mucus. It seems to make a difference for some women and does not make any difference in others. What is important is that it should be used for a maximum of 6 cycles continuously and not more than 12 months in all.

Mixing injectables and Clomiphene is an attempt to get some of the stimulant, cervical mucous, and lining benefits of injectables without spending as much money as would be required by doing only injectables. This will be helpful in patients who do not respond with clomiphene and need more drugs for stimulation.

For most men, a 1-3 day break is ideal. That gives the "sample" an opportunity to regenerate. Too "old" of a sample raises the risk of poor motility, white cells, and other problems.

In most cases, doctors who do two IUIs do the first about 24 hours after the HCG shot and the second about 48 hours after the shot. Some studies have shown that doing one IUI about 36 hours after the HCG is equally effective. However, some recent research suggests that higher pregnancy rates may be achieved by doing two IUIs, one at 12 hours past the hCG shot and one at 34 hours. However, your doctor will decide depending on your current stimulation cycle.

There are several variations on the IVF protocol. This description is of a standard long "down regulation" protocol. When the patient is under 35 and has a history of good response to stimulation. In the long down regulation protocol, you start the cycle before your stimulation and retrieval cycle. On D3 of that cycle, your FSH level is measured. On D21, you do a progesterone test to see if you have ovulated. Starts the GnRH shots once a day. The dosage varies from doctor to doctor to some extent. Your period should arrive close to its due date. On D1 or 2, you are tested to ensure that medication has shut down your own hormone system. If you are adequately suppressed and an ovarian scan shows no cysts, you will usually start injectables on D2 or so. Your medication dosage depends on your diagnosis, age, and response history if you have taken injectables before. After three days of ovulatory stimulants, your follicles and Estradiol levels will be checked. E2 levels above 100. If needed, your medications will be adjusted. You will go in a few days later for a second round of blood work and an ultrasound follicle check.

After that, you might report to your clinic daily for blood work and ultrasounds. Once your follicles have reached an appropriate size and your E2 levels are good, you stop the stimulation and GnRH, and are given the hCG shot, in the presence of good blood flow. The eggs are retrieved using an ultrasound probe that has a needle at the end of it. They put the needle through the vaginal wall and aspirate the follicles. You will generally start progesterone immediately following the retrieval.

Sometimes, your doctor may change this protocol to a "short protocol", This decision is done during the planning of your cycle, and depends on the indication and other factors involved in individual case.

Many infertility specialists are using this as part of their protocol, especially for patients with histories of miscarriage and lining problems.

This decision will depend on your individual case history and the ovarian response to the stimulation drugs.

Most patients on progesterone during the luteal phase automatically. The underlying concept is that if you wait and find out if the progesterone is low, even at seven days past ovulation , it can be too late because the lining may not be receptive to implantation. Low progesterone can cause implantation failure, because its role is to vascularize and maintain the uterine lining, which is where implantation takes place. Some women require more progesterone support in the luteal phase than others and this depends on your baseline hormone levels. However, all patients undergoing an IVF cycle will be given progesterone in the luteal phase. This can be either as injectables, or tablets. There are four different common methods of progesterone supplementation: progesterone in oil shots, progesterone suppositories or vaginal capsules, vaginal gel, and oral progesterone. Discuss the best medication method and dosage with your doctor.

The idea of coasting is either to get a too-high level of Estradiol to drop a bit or to slow down development- generally eggs are of better quality if the patient has at least 7-8 days of stimulation. In addition, they may possibly want to slow down some of the lead follicles and get some of the smaller follicles to catch up a little, several studies have shown that coasting does not reduce success rates for a cycle, and it can also reduce the risk of ovarian hyperstimulation syndrome (OHSS).

No. there is no evidence that shows a statistically significant increase in the ovarian cancer risk. Many studies have shown that there is no direct relation with cancer, however, there is a limit on the use of Clomiphene for more than 12 months during the patients life-time and hence the doctor may stop Clomiphene and switch over to using injectable gonadotropins for ovarian stimulation.

If ther is a suspicion of any other pelvis pathology, the doctor will advise for a laparoscopy and hysteroscopy for it. Also, in patients where the response to treatment is not up to the expectations, the doctor will ask for it to rule out other causes of failed treatment cycles. Often, this may be combined as an operative procedure for correction of any associated pelvic pathology.

No, each cycle is independent. Your per-cycle chances do not increase.

The number of eggs retrieved is largely a function of age, responsiveness and the stimulation protocol, good monitoring, and a bit of luck.

If there are too many eggs, there may be a possibility of you developing ovarian hyperstimulation, and your doctor will counsel you for the same. Sometimes, the doctor may also advise cancellation of the current cycle, if the risk is very high.

If there are too few eggs, there maybe another stimulation, which may be needed and your doctor will advise the same. Or, she may ask for certain additional tests to find out the cause of this unexpected result to prevent its recurrence in the next cycle.

First, if you are concerned about the possibility of OHSS you should call your clinic as soon as reasonably possible. OHSS (Ovarian Hyperstimulation Syndrome) is when you have an unusually large number of mature follicles that release. When these follicles release, there is an unusually high concentration of estrogen-rich fluid in the peritoneal cavity, and the ovaries are generally enlarged far beyond their usual plum size. In milder cases, women experience bloating and some pain from the oversized ovaries.

The treatment then is just a matter of rest and staying well hydrated. In more severe cases, the estrogen in the peritoneal cavity causes fluid to leak out of the circulatory system into the peritoneal cavity. This can cause marked discomfort and bloating, and can cause difficulty breathing due to pressure on the diaphragm. In the most severe cases, the leaking of the fluid will lead to hypovelmic shock and organ damage because of a lack of perfusion. Generally you do not see severe OHSS until the Estradiol gets into the 5000+ range. As long as your doc keeps a close eye on your dosage and development, the chances of anything other than mild discomfort are minimal.

It does not mean you are pregnant. Nevertheless, it is a good indicator. If you have good progesterone levels, that means that a pregnancy that is trying to implant will have a better chance of finding a good receptive environment.

You are probably feeling the effects of the hormones you are taking. It's really too early to be feeling anything as a result of a pregnancy. Implantation normally takes place about 5-10 dpo, but even after that it takes a couple of days for the hCG to build up in the blood stream. The presence of these symptoms does not indicate pregnancy, and the absence of them does not indicate a failed cycle.

Yes, it is normal for menses to be light, heavy, or simply different, due to the hormone levels being different. Also, progesterone supplements can delay the onset of menses. Most women don't start their periods until the progesterone levels drops to somewhere between 2-4, which may take a few extra days.

There is not complete agreement on this. You might consider "too early" to be cycle day 10 and "too late" to be day 20. There are two problems with late ovulation. The first point is that you obviously you have fewer chances over a given time period. Second is the fact that late ovulation you may be releasing eggs that have not been matured properly. It is also possible that the other parts of the reproductive system are not in sync with the egg. That is not a say you cannot conceive if you ovulate late- it happens all the time. It is just that your chances are somewhat reduced.

Menstruation only requires development and shedding of the endometrium in response to alternating levels of estrogen then progesterone in the blood stream. These hormones can be produced by the ovary even when an egg does not mature or release.

You can get somewhat of an idea from the size of the egg and the estradiol level at midcycle. But other factors arise as you get further into your 30s. you really can't diagnose egg quality until you get the eggs out of the follicles, put them under the microscope, and see how they behave. There are some less invasive screenings for ovarian reserve/egg quality such as the Clomiphene challenge test, FSH, and Inhibin B, but they are also not as accurate as looking at the egg directly.

Many early pregnancy failures are due to genetic abnormalities, mainly "trisomies" where an extra chromosome is present in what should be a pair. The earlier the failure occurs after implantation, the more likely it is to be genetic. You can also have implantation problems that would cause chemical pregnancies such as hypercoagulation, failure to from the needed blood vessels, or autoimmune issues. It is important to remember that, chemical pregnancies are early miscarriages, not abnormal hormones as the name may imply.

Swimming and any other low impact exercise that doesn't over exert you are fine. It's best to avoid things like jogging and high impact aerobics. Avoid picking up anything too heavy during the waiting period (greater than 15 lbs.).

Just don't overdo it. Air travel is fine as long as the pressure is maintained, which it generally is in commercial aircraft.

The simplest protocol is Clomiphene 50-100mg 3-7 (or5-9) of the cycle. With the addition of vaginal ultrasound monitoring on the day of the LH surge or by day 14 if no LH surge, you may be given a HCG injection and IUI performed 36 hours later. Adjustments in the ovulation induction protocol can be made in subsequent cycles depending upon your response.

Even though women today are healthier and taking better care of themselves than ever before, improved health in later life does not offset the natural age related decline in the fertility. According to western data, the table below shows how infertility increases with age.

There's about a 50–50 chance that the man has a problem contributing to inability to conceive. He might:

• Produce too few sperms to fertilize an egg
• Make sperms that are not shaped properly or that do not move the way they should
• Have a blockage in his reproductive tract that keeps sperms from getting out.

The biggest risk after tubal surgery is the possible development of a tubal (ectopic) pregnancy. A tubal pregnancy is a serious health problem that is more likely to happen after tubal surgery or tubal disease. The fertilized egg does not travel to the uterus. Instead, it stays in the fallopian tube and begins to grow there. The tube is too small to hold a baby, and the tube will burst if the pregnancy continues. The mother may have internal bleeding or rarely could even die.

Infections, abdominal surgery, and other diseases, such as endometriosis, can cause scars to form between the end of the tube and the ovary. The tubes also can become damaged with adhesions or scar tissue inside the tube or can become completely blocked. You can get a tubal infection after your appendix ruptures or bursts. Surgery or endometriosis (lining of the uterus deposited in the lower part of the belly) can also damage your fallopian tubes.

The surgeon will try to cut the scars between your fallopian tube and ovary. If one or both tubes are completely blocked, your surgeon can attempt to open the tube. Surgery can be done in one of two ways (laparoscopy or laparotomy). Laparoscopy, or minimally invasive surgery, can be performed. During this procedure a very small camera attached to a thin telescope is inserted through a small incision (surgical opening) below your belly button. The surgery is performed during small tools, which can be inserted through other small incisions across your belly. A traditional open procedure, called a laparotomy, also may be used. In this procedure, the surgery is performed through a large incision made in your belly (abdomen).

Multifetal pregnancy reduction is usually done early in the pregnancy, within the first 12 weeks. At 12 weeks in the pregnancy, the fetus is enclosed in a fluid–filled pouch, called a gestational sac. The specialist will inject a needle filled with a liquid, frequently potassium chloride, into the gestational sac of the target fetus. The liquid will stop fetal heart motion.

Women who can get pregnant without fertility drugs or medical procedures usually have only one baby. Women who need fertility treatment are at higher risk to get pregnant with twins, and rarely with triplets or more. This is called multiple gestation.

• The health care cost for delivery and newborn care for twins is 4–times higher when compared to a singleton birth.
• Companies are not as willing to donate formulas, diapers, etc. to parents of multiples as in the past.
• The cost of caring for children with lifelong disabilities may be high. Some of your children may have a disability.
• The total cost of raising multiples is likely higher than the cost of raising the same number of singletons. Cribs, car seats, high chairs, and other items have to be bought all at once, which can be financially difficult.

1. Some multiples, especially newborns, may be hard to tell apart even if they are not identical. You will soon be able to tell them apart by their individual characteristics and personalities.
2. Parents may bond with multiples differently than with single–born children (singletons). During the first weeks, you may find yourself preferring one infant more than the others. Your "favorite" may vary from week to week as you get to know each one. Each infant will have different needs at different times, requiring differing amounts of attention.
3. It is physically harder to take care of multiples than singletons. This is especially true when they are infants and toddlers. They may make the parents feel tired and stressed a lot of the time. Make sure to take some time for yourself and your partner as a couple, even if only for a few minutes a day.
4. Older brothers and sisters may have a hard time getting used to the new babies. They will need you to pay attention to them too. Try to be sensitive to the needs of your older children. Involve them in the pregnancy by taking them with you to doctor visits.
5. Some parents and schools prefer that multiples be in separate classes. This may help promote individuality. This is true particularly if the children have different abilities. You can also work with your children’s teachers to provide the best environment for your children.
6. Parents of multiples may feel socially isolated. They may be tired, not have enough personal time, are too busy taking care of the children or are having money troubles. It is easy to become completely consumed in caring for multiples, but don’t abandon all of your hobbies and interests.
7. Multiples often attract attention. This may have positive or negative consequences depending on the personalities of the parents and children and the nature of the attention.
8. Help from family and friend is often short–term. Parents of multiples usually need additional help, even if one parent stays at home. Premature infants require smaller, more frequent feedings than full–term infants. It also requires a lot of time to feed them at night and change their diapers. You might need someone to help you at night until the babies have reasonable sleeping habits. If you can’t have someone in your home to help, work out a schedule so that each parent shares the work equally. Lack of sleep may cause fatigue and depression.

• In men: If sperm counts are consistently low, insemination, IVF, and ICSI may be effective measures for achieving pregnancy. Testicular biopsy may be a way to obtain sperm if sperm are not found in a semen analysis. If sperm cannot be obtained, pregnancy may be possible by using frozen donor sperm.
• In women: Many women will be able to conceive naturally or with fertility treatments. If significant damage has occurred to the ovaries or uterus, couples may wish to consider egg or embryo donation, a gestational carrier, or adoption to create a family.

• In men: Semen samples may be frozen at a sperm bank or fertility center before starting chemotherapy or radiation therapy. Sperm counts may be low or absent as a result of the underlying cancer. If sperm counts are low and/or the supply is limited from the frozen sample, the sperm can be used for in vitro fertilization (IVF) and intra cytoplasmic sperm injection (ICSI).
• In women: If time and circumstances allow, women may be treated with IVF. Embryos created by IVF are then frozen and may be stored for years. If radiation will be administered to the pelvis, the ovaries may be repositioned surgically out of the radiation ?eld. This will reduce the risk that radiation will damage the eggs.
  Lab Tests for infertility for women
  Luteinizing hormone (LH), follicle–stimulating hormone (FSH), prolactin, estradiol, progesterone and estrogen. The changes in pituitary or thyroid function can also affect the menstrual cycle and ovulation. TSH and/or T4 and steroids (testosterone and DHEA–S) are also informative.

When selecting an ART program, there are some important points that should be taken into consideration. These include the qualifications and experience of personnel, types of patients being treated, support services available, cost, convenience, live birth rates per ART cycle started and multiple pregnancy rates.

According to western studies, the chance for pregnancy in consecutive IVF cycles remains similar in up to four cycles. Many other factors should be considered when determining the appropriate endpoint in therapy, including financial and psychological reserves. Members of the IVF team can help couples decide when to stop treatment and discuss other options such as egg and/or sperm donation or adoption, if appropriate.

According to western figures, miscarriage may occur after ART, even after ultrasound identifies a pregnancy in the uterus. Miscarriage occurs after ultrasound in nearly 15% of women younger than age 35, in 25% at age 40, and in 35% at age 42 following ART procedures. In addition, there is approximately a 5% chance of ectopic pregnancy with ART.

Ovarian stimulation carries a risk of hyperstimulation, where the ovaries become swollen and painful. Fluid may accumulate in the abdominal cavity and chest, and the woman may feel bloated, nauseated, and experience vomiting or lack of appetite. According to western figures 30% of woman undergoing ovarian stimulation have a mild case of ovarian hyperstimulation syndrome (OHSS) that can be managed with over the–counter painkillers and a reduction in activity. Up to 2% of women develop severe OHSS characterized by excessive weight gain, fluid accumulation in the abdomen and chest, electrolyte abnormalities, over–concentration of the blood, and, in rare cases, the development of blood clots, kidney failure, or death. Women with severe OHSS require hospitalization until the symptoms improve. If pregnancy occurs, OHSS can worsen. initial reports suggested that women who use fertility drugs have an increased risk for ovarian cancer, numerous recent studies support the conclusion that fertility drugs are not linked to ovarian cancer.

The use of assisted hatching in all patients is not recommended. Assisted hatching should be reserved for patients who may have a harder time achieving pregnancy (poor diagnosis). This includes women who are 38 years old or older using their own eggs, patients with 2 or more failed IVF cycles, and those who had been noted to have poor embryo quality.

Assisted hatching is a procedure that is done in the laboratory three days after fertilization. During assisted hatching, the outer shell of the embryo is artificially weakened by making a small hole in the shell. This is done just before the embryo is put into the uterus.

In a normal cycle, the egg and sperm join together in the tube that connects the ovaries to the uterus (the fallopian tube) to form an embryo. The embryo travels through the tube and sticks (implants) to the lining of the uterus (womb). But, in order for the embryo to implant into the uterus, it has to "hatch" out of its outer shell (zona pellucida).

IVF is indicated for blocked tubes and failure of conventional infertility treatment. ICSI is indicated for poor sperm count or function or failure of fertilization in previous IVF.

With unexplained infertility, or when traditional treatments have failed, advanced infertility therapies such as superovulation with timed intrauterine insemination (SO/IUI) or in vitro fertilization (IVF) may be suggested. In an SO/IUI cycle, you receive fertility medications to initiate the growth of multiple eggs in your ovaries. When these eggs are ready to ovulate, your physician places your partner’s sperm directly into your uterus. IVF involves removing your eggs and fertilizing them with your partner’s sperm in the lab, and then transferring the resulting embryos to your uterus.

If you’re over 40, and have not succeeded with other therapies, or if you have premature ovarian failure, also known as early menopause, your treatment options are limited. One option is egg donation, which involves the use of eggs donated by another woman who is typically in her 20s or early 30s. If you are over 40, eggs from a younger woman are more likely to result in pregnancy and are less likely to end in miscarriage. Your chance of pregnancy is much higher in IVF cycles using donor eggs. The high success rate with egg donation confirms that egg quality is the primary barrier to pregnancy in older women.

In an egg donation cycle, the donor receives fertility medications to stimulate the production of multiple eggs in her ovaries. At the same time, you are given hormone therapy to prepare your uterus to receive the fertilized eggs (embryos). After the eggs are obtained from the donor, they are fertilized in the laboratory with your partner’s sperm. Several days after fertilization, the embryos are transferred to your uterus. Any embryos which are not transferred may be frozen (cryopreserved) for a future cycle.

According to western figures, couples diagnosed with endometriosis have success rates with assisted reproductive technology (ART) procedures such as in vitro fertilization and embryo transfer (IVF–ET) that are similar to those for couples with other causes of infertility. Success rates for ART procedures vary greatly depending on a woman’s age. Nationally, live birth rates for IVF–ET are approximately 30-35% for women under age 35, 25% from ages 35 to 37, 15–20% from ages 38 to 40, and about 10% between 41 and 42. IVF–ET is the most effective treatment for moderate or severe endometriosis, particularly if surgery fails to restore fertility.

• Metabolic and nutritional considerations: There is an increased need for maternal nutrition in multiple pregnancies. An expectant mother needs to gain more weight in a multiple pregnancy, especially if she begins the pregnancy underweight. With multiples, weight gain of approximately 45 pounds is optimal for normal weight women. The increase in fetal growth with appropriate nutrition and weight gain may greatly improve pregnancy outcome at a minimum of cost.
• Activity precautions: Women with multiple pregnancies are usually advised to avoid strenuous activity and employment at some time between 20 and 24 weeks. Bed rest improves uterine blood flow and may increase birth weight up to 20%. Intercourse is generally discouraged when bed rest is recommended.
• Monitoring a multiple pregnancy: Prenatal diagnosis by chorionic villus sampling can be done near the end of the first trimester to screen for Down syndrome and other genetic abnormalities Amniocentesis is performed between 16 to 20 weeks. Many physicians perform cervical examinations every week or two beginning early in pregnancy to determine if the cervix is thinning or opening prematurely. If an exam or ultrasound shows that the cervix is thinning or beginning to dilate prematurely, a cerclage, or suture placed in the cervix, may prevent or delay premature dilatation. Tocolytic agents are medications that may slow or stop premature labor. These medications are given in hospital "emergency" settings in an attempt to stop premature labor.
• Cesarean section: Vaginal delivery of twins may be safe in some circumstances. Many twins can be delivered vaginally if the presenting infant is in the head first position. Most triplets will be delivered by Cesarean section. Appropriate anesthesia and neonatal support are essential, whether delivery is performed vaginally or requires Cesarean section.

Your race, age, heredity, or history of prior pregnancy does not increase your chances of having identical twins, but does increase your chance of having non identical twins:

Race: Twins occur in approximately 1 of every 90 pregnancies in North America. The incidence is higher in Africa, with a rate of 1 in 20 births in Nigeria. Twins are less common in Asia. In Japan, for example, twins occur only once in every 155 births.

Heredity: The mother's family history may be more significant than the father's. Non-identical twin women give birth to twins at the rate of 1 set per 60 births. However, non-identical males father twins at a rate of 1 set per 125 births.

Maternal age and prior pregnancy history: The frequency of twins increases with maternal age and number of pregnancies. Women between 35 to 40 years of age with four or more children are three times more likely to have twins than a woman under 20 without children.

Maternal height and weight: Non-identical twins are more common in large and tall women than in small women. This may be related more to nutrition than to body size alone.

Fertility Drugs and Assisted Reproductive Technology: Multiple pregnancy is more common in women who utilize fertility medications to undergo ovulation induction or superovulation. Approximately 20% of pregnancies resulting from gonadotropins are multiples. While most of these pregnancies are twins, up to 5% are triplets or greater due to the release of more eggs than expected.

Embryo cryopreservation is the most common way of preserving your ability to get pregnant in the future. Before freezing the embryos, you undergo a procedure called in vitro fertilization (IVF). In IVF, you will be given hormones to stimulate the growth of your eggs. After that the eggs will be aspirated (removed by gentle suction). Embryos are then produced by joining the sperm and egg together in the laboratory. The embryos are then frozen. If you decide you want to have children after your cancer treatment is completed, one or two embryos can be placed in your uterus (womb) with or without the help of medications. Embryo cryopreservation offers the best chance of pregnancy. The odds of an embryo surviving the freezing and thawing process and implanting in your uterus are much higher than those noted with thawing and fertilizing an unfertilized egg or ovarian tissue.

• Diagnostic hysteroscopy: Hysteroscopy is sometimes used to diagnose a condition involving the uterine cavity. If your doctor performs this procedure in the office, he or she may give you ibuprofen and medication to numb your cervix. The doctor will then insert the hysteroscope through your vagina into the cervix. Because the hysteroscope is attached to a camera, both you and your doctor can watch the procedure on a television screen. After the procedure is performed, you can usually return to your normal activity.
• Operative hysteroscopy: Hysteroscopy can also be performed to remove tissue or growths that interfere with fertility. The hysteroscope that is usually used for operating is larger than the one used for diagnosing problems in the uterus, so you will need general, epidural or spinal anesthesia. After operative hysteroscopy, there is very little discomfort since there were no incisions made. If the cervix was stretched (dilated), your doctor may advise you to avoid swimming, taking a bath, or placing anything in the vagina for up to two weeks (this includes avoiding sexual intercourse). This will allow the dilated cervix to return to its normal size and will reduce the risk of infection.

There are many different ways for your doctor to look at your uterus. These include:

• Vaginal Ultrasound: A vaginal ultrasound utilizes a probe that is placed inside the vagina. The probe transmits sound waves that allow visualization of the organs in and around the pelvic cavity. The use of vaginal ultrasound helps the doctor see the wall and lining of your uterus.
• Sonohysterogram (Saline Infusion Ultrasound): When the inside cavity of the uterus needs to be evaluated, your doctor may want to perform a saline infusion ultrasound. During this procedure, a small amount of sterile solution is placed into your uterus for a better look at the cavity.
• Hysterosalpingogram: This procedure provides information about the fallopian tubes and uterine cavity. The doctor injects a special dye into your uterus and then performs an x–ray to visualize the path of the dye through the fallopian tubes. This test allows your doctor to determine if the fallopian tubes are open.
• Hysteroscopy: This procedure is performed with a small telescope attached to a camera (called a hysteroscope) that lets the doctor look inside your uterus. Because the doctor has a direct view of your uterus, this procedure may provide the most accurate information.

Sperm quality linked to dietary fat
Men who consumed large quantities of dietary fat had significantly lower sperm production and concentration than men who had lower fat intake, results of a clinical study showed. (Source: Medpage Today)