We strive to help our fertility patients achieve not only a pregnancy, but a healthy pregnancy and a healthy baby. We offer a full spectrum of fertility services at Madison Women's Health & Fertility. We offer preconception counseling, comprehensive diagnostic evaluations, and treatments that range from "low tech" options - such as natural cycle intrauterine insemination (IUI) and simple ovulation induction - to the most advanced assisted reproductive technologies including in vitro fertilization (IVF), intracytoplasmic injection (ICSI) for male factor infertility, donor sperm, donor eggs, preimplantation genetic diagnosis/screening (PGD, PGS) for genetic testing of embryos, embryo and oocyte cryopreservation, and gestational carrier. Most of our services are provided in our private office at 50 East 77th Street on Manhattan's Upper East Side. For IVF procedures Madison Women's Health & Fertility is affiliated with the NYU Fertility Center, providing our patients access to state-of-the-art embryology services while undergoing most of their treatment in the more personal and private setting of our office. All our physicians also perform surgical treatment of infertility at their respective hospitals.
Diagnostic evaluation: Our approach to the diagnostic evaluation of infertility and recurrent pregnancy loss is comprehensive yet personalized. We want you to understand the rationale for each test and how the results may affect your management. After we obtain your medical history and perform a complete physical examination we will recommend appropriate laboratory testing which may include hormonal testing, infectious disease screening, genetic screening, and evaluation of pelvic anatomy. Additional testing, such as screening for thrombophilias (the tendency of blood to clot) and factors that may interfere with implantation may be ordered when indicated. Testing of the male partner generally includes semen analysis as well as appropriate infectious and genetic screening. Many tests can be done at the time of your initial visit, while others may need to be done on a particular day of the menstrual cycle or while fasting.
Diagnostic testing for fertility may include: (Please click on the headings below to see details)
- Ovarian Reserve Testing
- Endocrine testing
- Transvavinal Sonogram
- Saline infusion sonohysterography (SIS)
- Hysterosalpingogram (HSG)
- Postcoital testing
- Semen Analysis
Fertility treatments may include:
- IUI (interuterine insemination
- Ovulation induction
- Donor sperm
- IVF (in vitro fertilization)
- ICSI (intracytoplasmic sperm injection)
- PGS (preimplantation genetic screening) and PGD (preimplantation genetic diagnosis)
- Reproductive surgery
- Oocyte (egg) donation
- Embryo cryopreservation (freezing)
- Oocyte cryopreservation (egg freezing)
- Gestation carrier
Ovarian reserve testing: Women become less fertile with advancing age, and women found to have decreased ovarian reserve have reduced fertility compared to woman the same age with normal ovarian reserve. Measurement of the hormones follicle stimulating hormone (FSH) and estradiol (E2) on cycle day 2 or 3 is the most widely used test of ovarian reserve. Repeat testing is usually informative for women who have demonstrated decreased ovarian reserve – elevated FSH and/or elevated E2 - on initial testing. We will review with you the results of any previous ovarian reserve testing and suggest additional testing, such as antral follicle count, when indicated. Importantly, results of ovarian reserve testing need to be interpreted in conjunction with information regarding your age, medical history, and prior fertility treatment. We have a great deal of experience treating women with decreased ovarian reserve, many of whom are still able to conceive with their own eggs.
Endocrine testing: Madison Women’s Health & Fertility’s endocrine laboratory performs daily hormonal assays, allowing your physician to determine if a hormonal imbalance is contributing to your fertility problem, and to closely monitor your hormonal response to treatment. Hormonal testing includes pregnancy testing and measurements of other hormones including estradiol, progesterone, LH, FSH, prolactin, and TSH. Our lab is certified compliant by CLIA (Centers for Medicare & Medicaid Services Clinical Laboratory Improvement Amendments).
Transvaginal sonogram: Images of the uterus and ovaries are obtained using the transvaginal ultrasound probe. If any anatomic abnormalities are visualized we will discuss with you whether they are likely to impair fertility, interfere with a healthy pregnancy, or pose a risk to your health. The timing of ovulation, whether natural or in response to fertility drugs, can also be determined using ultrasound along with hormonal monitoring. When indicated, sonograms may also be performed using an ultrasound probe placed on the abdomen, rather than in the vagina.
Saline infusion sonohysterography (SIS): SIS (also known as SHG) is a type of sonogram that may be recommended to further assess the endometrial (uterine) cavity. By gently injecting saline (salt water) into the endometrial cavity enhanced images are obtained that can clearly demonstrate abnormalities of the uterine cavity such as polyps or submucous fibroids.
Hysterosalpingogram (HSG): HSG is a dye contrast radiologic (X ray) study that demonstrates whether the fallopian tubes are open or occluded, while also providing images of the uterine cavity.
Postcoital testing: The post-coital test (PCT) may be used to assess the quality of the cervical mucus and how the sperm and cervical mucus interact. The PCT can also provide information that may suggest sexual dysfunction or poor semen quality. For some couples it may provide information that will help them to make decisions regarding IUI (intrauterine insemination). Although the PCT is no longer a routine part of the infertility evaluation it can provide valuable information regarding the adequacy of the sperm for couples who cannot yet obtain a complete semen analysis because of religious or cultural restrictions.
Semen analysis: Assessment of the ejaculate includes determination of the semen volume, sperm concentration, sperm motility, and sperm morphology (shape). When semen parameters are abnormal, urological consultation may be indicated to determine the cause and possible treatment options for male infertility. Medical or urological consultation may also be important to determine if the semen abnormality is related to a medical condition that could have other health consequences besides infertility. Based on the initial analysis we can determine if there are adequate numbers of sperm for IUI (intrauterine insemination) or IVF, or if ICSI may be necessary.
Hysteroscopy: Hysteroscopy involves placing the hysteroscope (a long slender optical instrument with a light source) vaginally, through the cervix and into the uterus, while the woman is under sedation. Hysteroscopy can be used for diagnostic purposes to allow your doctor to look directly inside the uterine cavity to visualize any abnormalities. In our practice, hysteroscopy is usually suggested as a therapeutic procedure when either saline infusion sonohysterography (SIS) or hysterosalpingogram (HSG) suggests an abnormality- such as an endometrial polyp or uterine fibroid - in the cavity. Our physicians perform hysteroscopic surgery in the operating rooms of their respective hospitals.
Laparoscopy:Laparoscopy is an ambulatory surgery procedure that involves placing a laparoscope (a long, slender optical instrument with a light source ) through a tiny incision into the abdominal cavity while the patient is under general anesthesia. Laparoscopy is now most commonly performed for therapeutic, rather than purely diagnostic purposes. When the hyserosalpingogram (HSG) suggests an abnormality with the fallopian tubes, laparoscopy can more accurately diagnose the nature of the problem and may provide an opportunity for treatment as well. Laparoscopy may also be indicated in women who suffer from pelvic pain or adnexal masses as well as infertility. If endometriosis or pelvic adhesions are found they can often be treated laparoscopically to reduce pain as well as improve fertility. Women found to have very severe endometriosis or scarring may be counseled to undergo IVF to become pregnant. When benign masses involving the ovary or fallopian tube need to be removed, the surgery can almost always be performed laparoscopically, avoiding a large abdominal scar and overnight hospitalization, reducing formation of adhesions or scar tissue, and providing for a speedier recovery compared with laparotomy. Our physicians perform laparoscopy in the operating rooms of their respective hospitals.
TREATMENTS OFFERED INCLUDE:
IUI (intrauterine insemination): IUI is an office based procedure in which washed sperm is gently placed into the uterine cavity. IUI can be used to treat mild male factor infertility as well as other causes of infertility such as unexplained infertility or infertility associated with advanced female age. IUI can be performed in a woman's natural cycle, but it is commonly performed along with treatment with fertility medications, resulting in higher pregnancy rates than with either IUI or fertility medications alone. IUI needs to be performed close to the time of ovulation. By monitoring a woman's menstrual cycle with ultrasound and hormonal testing the optimal time to trigger ovulation can be determined. The medication Ovidrel is given to trigger ovulation, and IUIs are generally performed on two consecutive days following the Ovidrel. With intercourse, sperm need to swim from the vagina through the cervix and finally through the endometrial cavity on their way to the fallopian tube where fertilization of the egg may occur. Compared to intercourse, IUI gives the sperm a "head start" and increases the concentration of motile sperm in the upper reproductive tract. The sperm wash separates the seminal fluid from the sperm (which is crucial for the IUI to be done safely) and concentrates the best moving sperm into a small volume that the uterus can readily accept. Women being inseminated with donor sperm can arrange for the sperm to be shipped from the sperm bank to our office. The IUI procedure is generally painless and feels similar to having a Pap smear. A twenty minute rest period in our office is recommended immediately after IUI is performed. Our three physicians provide coverage 7 days a week (except Christmas and New Year's) to allow optimal timing for IUI procedures.
Ovulation induction: Most women who do not ovulate regularly on their own can be effectively treated with fertility medications to help them become pregnant. Fertility medicationsare also widely prescribed, often in conjunction with IUI or IVF, to women who do ovulate naturally but who are experiencing infertility related to a variety of other causes. While many women respond well to oral medications such as Clomid (clomiphene citrate) or Glucophage (metformin), many others require treatment with injectable gonadotropins such as Follistim, Gonal F, or Menopur, or Luveris. Once you and your physician decide to proceed with ovulation induction treatment our nursing staff will teach you how to administer any injectable medications, most of which can be given with a very small needle. Treatment usually begins on day 2 of your menstrual cycle, and takes place over a period of about two weeks, during which you will visit our office for several, brief early morning office visits for ultrasound and hormonal monitoring. Based on your test results your physician will determine your daily medication dosage and the date of your next monitoring appointment. Later that day you will speak to one of our nurses by phone to review your instructions. When your physician determines that the time is right, you will be given instructions to take Ovidrel, the medication that will trigger ovulation. Either IUI or timed intercourse will be scheduled based on the timing of the Ovidrel. With careful monitoring by your physician, medications to induce ovulation can be taken safely and effectively. Our physicians have years of experience prescribing these medications and tailoring treatment to meet your individual needs.
Donor sperm: Our practice welcomes women seeking to be inseminated with donor sperm, whether because they are single, gay, or have an infertile male partner. We are licensed by the New York State Department of Health as an Approved Insemination Site, and women can choose a donor through any sperm bank licensed by the State of New York. Most sperm banks provide basic information online at no charge regarding all available donors, with more detailed information available for a fee. We will be happy to assist you in the donor selection process if requested. All donor sperm is frozen and quarantined for at least 6 months to allow for the donor to be re-screened for sexually transmitted diseases prior to release of the sperm. To maximize pregnancy rates with frozen thawed sperm, donor insemination is usually done as intrauterine insemination (IUI ), using prewashed or "IUI ready" sperm.
IVF (in vitro fertilization): Originally done for women with tubal infertility, IVF is now widely used to treat all types of infertility. The basic IVF procedure is as follows: First, fertility medications are administered in order to stimulate development of multiple eggs. Our nursing staff will teach you to administer the fertility medications, most of which can be injected with a small needle. Women planning to do an IVF cycle should anticipate a period of approximately two weeks during which they will visit our office for multiple, brief early morning office visits for ultrasound and hormonal monitoring. Based on your test results your physician will determine your daily medication dosage and the date of your next monitoring appointment. Later that day you will speak to one of our nurses by phone to review your instructions. When your physician determines that the time is right, you will be given instructions to take Ovidrel or HCG, the medication that will trigger the final maturation of the eggs. The egg retrieval is scheduled about 35 hours after the Ovidrel injection, so that mature eggs can be retrieved prior to ovulation. The egg retrieval is a needle aspiration procedure performed using transvaginal ultrasound guidance. Sedatation is given by an anesthesiologist during the egg retrieval procedure, which typically lasts about 15-20 minutes. Following the egg retrieval procedure the eggs are then inseminated in the embryology laboratory with sperm from the husband, partner or donor. Three to five days later the best embryo or embryos are selected for transfer to the uterus in a procedure that is gentle and typically painless. For patients who have more good quality embryos than can be transferred at one time the option of embryo freezing is offered.
IVF is often done after treatment with IUI has been unsuccessful, but in other cases IVF may be indicated sooner. We understand that while some of our patients prefer to pursue low tech options first, others may have reasons to proceed to more aggressive treatment such as IVF more quickly. Our physicians will discuss not only medical issues but also any cultural, religious and financial factors that may shape your attitude toward pursuing fertility treatment, so that together we can decide if and when IVF is indicated. IVF at Madison Women’s Health & Fertility is done in partnership with the NYU Fertility Center. Our IVF pregnancy rates can be found through SART as well as through the CDC annual ART success rates reports. During your IVF cycle you will undergo monitoring at Madison Women's Health & Fertility's private office. Decisions regarding how many embryos to transfer will be made jointly with your physician based on factors including your age, history, number and quality of embryos available, your attitude toward multiple pregnancy and whether there are embryos suitable for cryopreservation (freezing) following fresh transfer of the best embryos.
ICSI (intracytoplasmic sperm injection): In the ICSI procedure a single sperm is injected into each mature egg. ICSI allows couples with severe male factor infertility to achieve IVF pregnancy rates comparable to those for couples with other causes of infertility. ICSI may also be indicated in other selected cases such as with a history of prior poor fertilization, when PGS/PGD is being performed, or after egg freezing. Like all decisions regarding your fertility treatment, at Madison Women’s Health & Fertility the decision to use ICSI versus standard IVF insemination is a highly individualized one.
PGS (preimplantation genetic screening) and PGD (preimplantation genetic diagnosis): Genetic testing can be performed prior to implantation utilizing the DNA from a single cell. Embryos created through IVF can be biopsied in the embryology lab so that genetic testing can be performed prior to embryo transfer. PGS for aneuploidy (numerical chromosome abnormalities such as Trisomy 21 or Down’s Syndrome) can be performed using either 24 chromosome CGH (comparative genomic hybridization) technology (Reprogenetics) SNP Array technology (GSN) or more traditional FISH (fluorescence in situ hybridization). Aneuploidy screening can identify embryos with extra or missing chromosomes and may help improve ongoing pregnancy rates in women with recurrent pregnancy loss or previous IVF failures. PGD may be utilized to improve the chance of a healthy pregnancy for women or men who carry a known chromosomal translocation or for couples who both carry a single gene mutation for a disabling or lethal genetic disease.
Reproductive surgery: Our physicians’ expertise includes surgical treatment of gynecological disorders that may cause infertility including endometrial polyps, uterine septa, uterine fibroids/myomata, Asherman’s syndrome (intrauterine adhesions or scarring), ovarian cysts, endometriosis and pelvic adhesions. Recognizing that some women do get pregnant despite various gynecological disorders, our goals are first to determine when to it is appropriate to recommend surgery, and second to perform the surgery in a manner that maximizes your future fertility, utilizing surgical techniques designed to restore normal pelvic anatomy and preserve normal structures. Most surgeries are performed with minimally invasively techniques via hysteroscopyor laparoscopy, allowing for same day discharge and rapid return to normal activities. Laparotomy, or traditional open surgery, can usually be performed using a “bikini cut” incision, and is indicated in selected cases, such as myomectomy for removal of fibroids that are large, numerous, or deep withinthe wall of the uterus.
Oocyte (egg) donation: Women of advanced reproductive age and women who have undergone early menopause are able to achieve outstanding pregnancy rates with IVF using donor oocytes. Prospective anonymous egg donors undergo comprehensive medical, infectious, genetic, and psychological screening before being accepted into the program and matched with prospective donor egg recipients. Some women may wish to use a known donor (such as a younger sister) or a donor from an outside agency, but all donors must pass the same rigorous screening. Prospective recipients are extensively counseled and evaluated to maximize their chances not only of becoming pregnant but of experiencing a healthy pregnancy. The recipient’s cycle is hormonally synchronized with her donor’s cycle to allow transfer of embryos at the time of maximum endometrial receptivity for implantation to occur. Treatment consists of first the hormone estrogen, usually in the form of estradiol patches or pills, followed by the addition of the hormone progesterone in preparation for the day of embryo transfer. The initiation of progesterone treatment, usually via injection, is timed based on the date of the retrieval of the donated eggs, which are inseminated with sperm from the recipient’s husband, partner, or sperm donor. Recipients who still menstruate naturally are also treated with an additional medication (either Lupron or birth control pills) to ensure proper synchronization with the donor. Embryo transfer usually takes place five days after the donor's egg retrieval. The recipient continues the estradiol and progesterone treatment, which is essential to support early pregnancy, until the placenta takes over this function late in the first trimester.
Embryo cryopreservation (freezing): Many IVF cycles result in the production of more embryos than can safely be replaced at one time in the uterus. When this occurs, remaining healthy appearing embryos may be frozen for future use. Frozen embryo transfer (FET) cycles do not require an egg retrieval procedure and require substantially less medication and fewer visits than fresh IVF cycles.
Oocyte cryopreservation (egg freezing): Women who are not yet ready to become pregnant now have the option of freezing eggs for later use in an IVF cycle. Egg freezing is also an option to help preserve future fertility for women with recently diagnosed cancer requiring chemotherapy, which can induce premature menopause. Pregnancy rates in our program using frozen thawed eggs have been comparable to our current fresh IVF pregnancy rates for women in the same age group at time of egg retrieval. To date, women who were as old as 38 at the time of egg freezing have achieved a live birth using frozen thawed eggs through our program. In consultation with one of our three physicians we can help you decide if this is an option you would like to pursue. The basic procedure is just like a standard IVF cycle, except that instead of inseminating the eggs on the day of retrieval, mature eggs are immediately frozen for future use. Women planning to do an egg freeze cycle should anticipate a period of approximately two weeks during which they will be taking fertility medications and visiting our office for multiple, brief early morning office visits for ultrasound and hormonal monitoring, all leading up to the egg retrieval procedure and cryopreservation of the mature eggs. In advance of your cycle we will teach you to administer the fertility medications (the injections are all done using a very small needle). The treatments generally start during menstruation, and several weeks of birth control pills are commonly given just before the egg freezing cycle to enhance synchronization of the follicles and facilitate timing that is most convenient for you.
Gestational carrier: This treatment allows women who produce eggs but who, because of an abnormal or absent uterus, are unable to carry a pregnancy, to still have a baby using their own eggs. In gestational carrier IVF cycles the intended mother undergoes an IVF cycle leading up to egg retrieval and fertilization of the eggs with her husband's, partner's or donor sperm. Meanwhile, the woman who will be carrying the pregnancy (the gestational carrier) is treated with hormones to prepare her womb for embryo implantation. Any additional good quality embryos may be frozen for future use as in any IVF cycle. Laws vary from state to state and in many cases the genetic parents will need to legally adopt the baby from the gestational carrier..