Your First Visit

During your first appointment to IVF Plano, we will discuss your previous attempts to conceive and identify any potential issues related to infertility so both partners should plan to attend. At this time, Dr Douglas will compile a comprehensive medical history of both partners, including information about the woman’s menstrual cycle, infections, surgeries, past pregnancies and other basic health conditions, as well as the male partner’s health conditions and past ability to father a child.

Because lifestyle factors such as smoking and drug use, weight loss or gain and previous sexually transmitted diseases can impact fertility, we will also ask questions about these issues. From this information, Dr Douglas can begin to look for any areas that might indicate a specific fertility problem.

Fertility Evaluation

• Getting Pregnant

Once the initial consultation has taken place, Dr Douglas will establish a plan for a diagnostic evaluation and clearly outline the best course of action for treatment. All couples who come to IVF Plano leave the first visit with a clear outline of the testing and treatment plan needed to conceive a child.

Evaluation of the Female Partner

Physical exam
Many patients who visit IVF Plano have already had multiple physical exams and have extensive notes in their medical history from their Ob-Gyn or primary care provider. We will only repeat the exam if medically necessary or if the notes are unclear. If Dr. Douglas needs to perform a basic exam, the analysis may involve:

Cervical Mucus Tests
With a cervical mucus test, we may include a post-coital test (PCT) and a bacterial screening to check for the presence of low grade infections. Post-coital tests evaluate sperm after it is exposed to cervical mucus in the uterus, and they can be performed midcycle, around the time of ovulation, to identify female factor infertility due to hostile cervical mucus or poor sperm motility. If sperm is absent or not motile during the post-coital test, these findings may indicate poor or hostile cervical mucus quality. Post-coital testing can also determine other cervical factors of infertility.
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Blood Work

Depending on your individual situation, we may recommend various blood tests for either the female or the male partner, such as checking the following levels:

17-hydroxyprogesterone (17-OHP) (Click to Read Definition)

We want to make sure that 17-hydroxyprogesterone (17-OHP) levels are in the normal range because occasionally the adrenal gland makes excessive amounts of androgens. An over-secretion of androgen can cause elevated 17-OHP levels which can in turn interfere with ovulation. This is called congenital adrenal hyperplasia. Once this condition is found it can be corrected with medication to help patients ovulate normally.

Anti-Cardiolipin Antibody (ACL) (Click to Read Definition)

Cardiolipin helps regulate blood clotting in our bodies. With infertility patients, specifically those dealing with recurrent miscarriage, the clotting factors aren’t working properly and may actually cause clots in the wrong places. With particularly abnormal levels, Dr. Douglas may prescribe a medication, like aspirin, heparin, Lovenox or prednisone, to decrease the chances that you will form clots that may interfere with a normal pregnancy.

Estradiol (E2) (Click to Read Definition)

Estradiol, the primary type of estrogen produced by your ovaries, plays an important role in achieving a successful pregnancy. When the follicles grow and develop, the cells surrounding the eggs produce and secrete estradiol, which causes various effects throughout the cycle, including thickening of the uterine lining and triggering of the spontaneous LH surge that leads to ovulation. We often run this blood test in women over age 35 with a Day 3 FSH test to evaluate the ovarian reserve.

Follicle Stimulating Hormone (Click to Read Definition)

Also called the day 3 FSH, follicle stimulating hormone is produced in the pituitary gland of women. The FSH stimulates the growth of follicles (eggs) within the ovary. Usually, FSH levels are checked on day 2, 3, or 4 of the patient’s menstrual cycle, and this level helps determine the patient’s ovarian reserve. Dr. Douglas often checks FSH levels in patients 35 years of age and over, as well as in other patients who exhibit signs of ovulatory dysfunction or ovarian failure.

Insulin Resistance Testing/PCOS Testing (Click to Read Definition)

Designed to regulate the uptake of glucose into the body's cells, elevated insulin may suggest an increased likelihood of polycystic ovarian syndrome (PCOS), a medical condition that can impact your ability to conceive. Oral medications such as Metformin can increase your body’s capability to process glucose and help control PCOS.

Lupus Anticoagulant (Click to Read Definition)

Like any anticardiolipin antibody, lupus anticoagulant, has to do with the blood clotting process. A positive test for lupus anticoagulant can lead to a higher risk of forming blood clots in the small blood vessels of the placenta. These small clots cause complications like miscarriages. Dr. Douglas usually recommends this test for patients with a history of recurrent miscarriage. If your levels are abnormal, just as with anticardiolipin antibody, Dr Douglas may choose to prescribe a medication to decrease the chances of forming clots. Oral medicines, such as aspirin or prednisone, or injectable, like heparin or Lovenox, can increase the odds of conception.

Progesterone (P4) (Click to Read Definition)

Secreted from the follicle that ovulated, progesterone supports both implantation and maintenance of pregnancy. Rising levels of progesterone help prepare the lining of the uterus for implantation of the fertilized egg. Testing the progesterone level can let Dr Douglas know if ovulation has occurred and how well your body would maintain a pregnancy. At IVF Plano, we will monitor progesterone during a normal cycle, but will also check levels in women who have a history of recurrent miscarriage or spotting in early pregnancy.

Prolactin (Click to Read Definition)

Produced by the pituitary gland, the hormone prolactin promotes lactation, the production of milk. Too much prolactin production, a condition called hyperprolactinemia, can prevent normal ovulation. Hyperprolactinemia may present with symptoms such as irregular cycles or a milky breast discharge. Dr. Douglas typically treats elevated prolactin levels with an oral medication that will correct the hormonal imbalance.

Testosterone (T) (Click to Read Definition)

Although testosterone is thought to be a male hormone, small amounts are present in women and aid in ovarian function, bone strength, and sex drive. If your levels become too high, you may have trouble conceiving. One of the most common problems seen in our office is Polycystic Ovarian Syndrome (PCOS). When a woman has PCOS their ovaries makes too much testosterone and this elevated level of testosterone causes abnormal ovulation or anovulation. Patients with PCOS may also notice dark hairs in places they don’t want them and excessive acne. Weight gain and insulin resistance are also associated with increased testosterone in the body.

Thyroxin (T4) and thyroid stimulating hormone (TSH) (Click to Read Definition)

Your body needs thyroid stimulating hormone (TSH) and thyroxin (T4) to cause oocyte growth and then ovulation. High TSH levels typically show that thyroid hormones are not being produced (hypothyroidism), and low TSH may suggest hyperthyroidism. Both hypo- and hyperthyroidism can interfere with normal ovulation. Patients who report irregular menstrual cycle will need a TSH blood test. Also during pregnancy, normal thyroid function is also important for the development of the brain of the baby.

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Testing for Structural Problems with Ultrasounds

Transvaginal Ultrasound
Because various conditions in the uterus and ovaries may contribute to female factor infertility, Dr. Douglas may suggest a transvaginal ultrasound, a painless procedure often included as part of a routine fertility workup. Using a probe, Dr. Douglas can visualize the uterine cavity and search for signs of polyps, fibroids, or other uterine abnormalities. On the day of LH surge, we utilize ultrasounds to measure the thickness of the endometrium, monitor follicle development, and assess the condition of the uterus and ovaries. For example, a thin endometrial lining may indicate a hormonal problem. With a transvaginal ultrasound, we can often detect fibroid tumors, abnormalities of the uterine shape, ovarian cysts, and in some cases, endometriosis.

Transvaginal Ultrasound

Sonohysterogram
A sonohysterogram, or a saline infusion sonogram, is an ultrasound of the uterine cavity performed after injecting a sterile saline solution vaginally through the cervix directly into the uterus. Dr. Douglas generally recommends this procedure for female patients who are having trouble conceiving. During a sonohysterogram, the saline expands the uterine walls so that Dr. Douglas can more easily identify abnormalities.
With advances in techniques and diagnostic machines, sonohysterograms offer a good first look inside the uterus. Once the uterine walls are visible, Dr Douglas can use the ultrasound probe to look at structures in the uterus. To get the best view of the uterine walls, Dr. Douglas will time the sonohysterogram at a specific point in a patient’s cycle so that the uterine lining is as thin as possible.
With a sonohysterogram, Dr. Douglas can often diagnosis problems relating to:

Abnormal vaginal bleeding due to polyps and fibroids
Recurrent miscarriages
Uterine abnormalities such as a uterine septum or bicornuate uterus

Patients usually tolerate saline sonohysterogram better than hysterosalpingograms (HSGs), and this scan is not a surgical procedure like a hysteroscopy. Some saline leakage and light spotting may occur afterward. Mild over-the-counter pain relievers such as Advil or Tylenol will alleviate any discomfort.
Read more about Saline Infusion Sonohysterography - an ASRM Guide

Hysterosalpingogram (HSG)
During a hysterosalpingogram (HSG), an x-ray procedure, a doctor injects a liquid, dye-like solution injected through the cervix so that he can view the inside shape of the uterus and fallopian tubes. The HSG is done with the patient awake and requires no IV sedation. It is done as an out patient procedure and the patient is able to leave immediately. An HSG can cause moderate cramping and mild discomfort, but over-the-counter pain relievers such as ibuprofen or acetaminophen will relieve any soreness. At IVF Plano, some patients are treated with an oral antibiotic, doxycycline prior to the procedure if there is a history or a previous pelvic infection.
The results from an HSG study, can tell Dr. Douglas whether the tubes are open or damaged, and whether the uterine cavity appears normal. Sometimes, an HSG may provide a small increase in fertility because the dye solution potentially “flushes out” the system and allows for better movement of the egg through the tubes. However, this temporary correction only appears to impact fertility for two to three menstrual cycles after the HSG.
Read more about Hysterosalpingogram (HSG) - an ASRM Guide

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Diagnostic Surgical Procedures

Because the physical condition of your reproductive organs, impacts your fertility, Dr. Douglas will want a thorough assessment the fallopian tubes, the uterus, and the ovaries. Any abnormalities, such as a uterine septum, fibroids, or endometriosis, may require minor surgical procedures, completed either via laparoscopy or hysteroscopy. IVF Plano provides diagnostic surgical procedures such as:

Diagnostic laparoscopy
Considered an outpatient procedure, a diagnostic laparoscopy is preformed under general anesthesia. Dr Douglas will insert a laparoscope, a thin, lighted telescope-like instrument, into the abdominal cavity through an incision in the navel. This tiny camera allows Dr Douglas to see the overall condition of the pelvic structures.

While inside the pelvic cavity, Dr Douglas can look for problems with the uterus, ovaries, and fallopian tubes, as well as for the presence of scarring or endometriosis. At this time, the doctor may inject a solution into the uterus and up thru the tubes to ensure that the tubes are open or patent.

Often, we can use a Diagnostic laparoscopy to confirm the findings of a hysterosalpingogram (HSG). During the laparoscopic examination, Dr. Douglas will correct minor and may also address larger problems such as fibroids, cysts and extensive pelvic adhesions. If the fallopian tubes appear to be beyond repair, Dr. Douglas may advise more extensive surgery to remove the damaged tubes (see treatments: tubal surgery)

Hysteroscopy
To visually inspect the uterine cavity and detect uterine abnormalities, Dr. Douglas performs a hysteroscopy, a surgical procedure in which a telescope is placed vaginally through the cervix directly into the uterus. If a uterine abnormality is suspected after a hysterosalpingogram (HSG), Dr Douglas may opt for this procedure.

A hysteroscopy is usually performed in the early half of a woman's cycle so that the endometrial layer does not obscure the view of the uterine walls. Usually, patients recover from a hysteroscopy within 12 to 24 hours, with mild cramping and bleeding. We recommend over-the-counter pain relievers such as Tylenol or Advil for any pain or discomfort.

Laparotomy
A laparotomy is often used to remove multiple fibroid tumors within the uterus or to treat severe endometriosis or adhesions that cannot be safely treated by laparoscopy. With a laparotomy, Dr. Douglas creates an abdominal incision, typically made along the ‘bikini-line'. Dr Douglas will make the incision as small as possible and uses stitches are close the incision to allow for minimal scarring. Most patients will require a short hospital stay to recover and can return to work in about two to four weeks .

Evaluation Results and Treatment
Once Dr. Douglas has completed a full assessment, he will usually schedule a meeting with you and your partner to review the results and discuss treatment (to tab) recommendations. At this time, Dr. Douglas will outline the treatment plan and its success rates, explain the risks of any recommended treatment, and work with you and your partner to determine the best course of action. Deciding which fertility treatment to pursue depends on many factors, including your age, the underlying cause of infertility, how long you have been trying to conceive, the cost and success of treatment chosen, and insurance coverage. Once you and your partner select a specific therapy, you will receive a treatment plan and calendar with instructions on how to begin the process and when to schedule your next appointment.

Should you have questions about costs or insurance, our business office will be happy to discuss an estimate of charges and your insurance benefits, so don’t hesitate to contact us.

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Evaluation of the Male Partner

Semen Analysis
If problems conceiving relate to male factor infertility, the Presbyterian of Plano ARTS Program offers semen analysis, which studies the quality and quantity of sperm of the male. This test will look at sperm volume, morphology, motility, and concentration, as well as for the presence of antisperm antibodies. Nearly half of all infertile couples experience some degree of male factor infertility, so semen analysis testing plays a critical role in the diagnostic process.

If the semen analysis indicates an issue, we may refer the male partner to a Urologist for a full physical workup, which can rule out structural problems such as varicoceles and blocked vas deferens.

Genetic Testing

When any possible family history of genetic illness exists, Dr. Douglas often encourages parental genetic testing. The blood work screens for many inheritable diseases and most commonly will help patients identify the genes for cystic fibrosis, sickle-cell, and tay sachs disease. When a couple has an increased risk for genetic diseases that may be passed down, we may refer these patients to genetic counseling though one of our partner service providers.

Testing for Ovulation Disorders
Ovarian dysfunction is the most common type of infertility in women. By testing the ovarian reserve, a woman's remaining egg supply, Dr Douglas can develop an accurate idea of fertility treatment success. Dr. Douglas will gather this information with a day 3 FSH and estradiol testing, a transvaginal ultrasound examination of ovarian volume, and antral follicle count. Anti-Mullerian hormone may also be tested.

Hormones, such as follicle stimulating hormone (FSH), luteinizing hormone (LH), progesterone, and estrogen, impact female fertility. Because healthy follicles produce estrogen and low amounts of FSH, high amounts of FSH, LH, or estrogen point to diminished ovarian reserve.

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