Preface. The infertility epidemic
The importance of understanding your biological clock
Misleading diagnoses of the cause of your infertility
The simple unexplainable effect of age
The male factor and varicocele myth
IVF and ICSI bypass everything that can go wrong no matter what the so-called diagnosis is
Change in thinking since the early 1980s
Progress in male infertility
Even men who don't make sperm can have children
Can you save your eggs for later?
How can I be sure my baby will be normal?
Achieving pregnancy without the new technology
1. Getting pregnant naturally
A brief review of female anatomy
How do the egg and the sperm reach the fallopian tube?
Ejaculation into the vagina
Formation of the follicle
Production of progesterone
A review of the hormones that control ovulation and the menstrual cycle
How a primitive region of the brain called the hypothalamus controls the menstrual cycle
Clinical importance of GnRH release from the brain for IVF
How do hormones genetically prepared the egg for fertilization?
Reduction division (meiosis) of the egg's chromosomes
Development of the egg during growth of the follicle
Resumption of meiosis after the LH surge
Penetration of the egg by a sperm
Completion of meiosis and union of the male and female genes
Early development of the fertilized egg
2. Why are humans so infertile?
Humans don't know when to have sex
Why is sex in the human so reproductively inefficient?
Reproductive inadequacy of the human male
Is the environment causing the human sperm count to go down?
Monogamy and lack of sperm competition
Our worldwide infertility epidemic
Human destiny and infertility
3. Beating your biological clock : antral follicle counts
Age-related decline in a woman's fertility
Most infertile women were once fertile
Where are you on your biological clock?
Age-related decline in fertility is due to loss of your egg supply
Evidence that it is your ovary, not you
What IVF pregnancy rates tell us about how the ovary ages
You can freeze your eggs (and even your ovary) for later
Tests for ovarian reserve
Day three FSH and estradiol
Day three inhibin B level
How does the biological clock work?
Antral follicles and your ovarian reserve
Emergence of the dominant single follicle during a normal ovulatory monthly cycle
Antral follicle count studies
Antral follicle count and number of eggs left in your ovary
Antral follicle count and your age
Antral follicle count and your remaining years of fertility
Is there anything that can preserve the declining follicle pool in your ovaries?
Aggressive ovarian surgery can hurt your biological clock
Antral follicle count and older women
What if I already had a child but want more?
Antral follicle count and counseling older infertile patients
How is a woman's endowment of eggs determined at birth?
4. Are we infertile? : simpler treatments
How long does it normally take to get pregnant and how do we know when to look for help?
Probability of conception per month in fertile couples
After what period of time does not getting pregnant mean we're infertile?
Proper timing of intercourse
Clomid (clomiphene citrate)
Drug treatment for endometriosis
Surgery for endometriosis, watch out!
Surgery for blocked tubes and pelvic scarring
5. Figuring out what's wrong : tests on the female
Irregular periods and oily skin
Basal body temperatures (BBT)
Effect of the brain on the hormonal cycle
Ploycystic ovarian syndrome (PCOS)
X-ray of uterus and tubes (hysterosalpingogram)
6. Emotions and infertility (evidenced based)
Popular myths about emotions and infertility
Does infertility cause emotional tension, or does emotional tension cause infertility?
Anxiety caused by trying to time your intercourse
Anxiety causing you to hurry into worthless and potentially damaging treatment
The effect of emotions on IVF success
The effect of emotional calm on your body
IVF embryo transfer and emotions
How to avoid difficult embryo transfers
Function of the testicles
Sperm production, the assembly line
What can be done to stimulate greater sperm production? : nothing!
How sperm reach the ejaculate
What happens to sperm in the epididymis?
The shape (morphology) of the sperm
How many sperm are really necessary for a man to be fertile?
The hamster test and other wastes of time and money
Whose fault is it, the husband's or the wife's?
The tragedy of not treating the whole couple
8. Sperm washing, intrauterine insemination (IUI), and ovarian stimulation
Several methods of sperm washing
Intrauterine insemination (IUI) of washed sperm
Ovarian stimulation with gonadotropins
Lupron (or GnRH agonist) to prevent premature LH surge
How are HMG and FSH (gonadotropins) made?
Monitoring HMG or FSH treatment and timing when to give HCG
Indications and directions for using HMG
Using birth control pills for timing the cycle
Comparison of the different stimulation protocols and drugs
Recombinant FSH versus menopausal gonadotropins
Step-up and step-down protocols
GnRH antagonist protocols
Ovarian stimulation for timed intercourse or IUI versus ovarian stimulation for IVF
Hyperstimulation syndrome
No increased risk of ovarian cancer
Multiple births and selective reduction
Subsequent pregnancies without treatment
9. IVF (in vitro fertilization)
Improvement in IVF pregnancy rates
Ovarian stimulation protocols and egg retrieval
Egg and embryo culturing techniques
Intracytoplasmic sperm injection (ICSI)
Improving IVF results when there is tubal disease
Rationale for doing IVF sooner in all cases of infertility.
10. Step-by-step details of your IVF cycle
Culture techniques for egg and sperm
Culture dishes and test tubes designed to keep pH constant when out of incubator
Egg handling after retrieval from ovary
Culturing the sperm and eggs, and embryo transfer
Embryo quality and embryo selection
How many embryos to transferred?
11. ICSI, the long-sought solution to male infertility
How the ICSI technique was invented
The type of patients who need ICSI
Are all types of male infertility equally treatable with ICSI?
The role of the egg in normal fertilization
Pitfalls of sperm injection
Avoiding damage to the egg nucleus and spindle
The membrane is invaginated by the injection pipette but not broken
Problem of the sperm swimming around inside the egg substance
Step-by-step details of the ICSI procedure
Step 1 : preparation of the eggs
Step 2 : preparation of the sperm
Step 3 : setting up the injection dish
Step 4 : the pipettes used for injection
Step 5 : picking up the sperm, breaking the tail, and injecting it into the egg
Step 6 : checking for fertilization and cleavage
ICSI for male infertility versus trying to increase the sperm count
Nonobstructive azoospermia
Should ICSI be used for all IVF cycles?
12. Will my baby by normal?
IVF statistics and your biological clock
Fears about IVF offspring not related to age
First published studies on risk to offspring from IVF or ICSI
Risks associated with multiple pregnancy
Incidence of birth defects in ICSI and IVF offspring
Compared to spontaneously conceived children : the Brussels study
Understanding genes and chromosomes
An abnormal number of chromosomes causes Down syndrome and miscarriage
How your aging eggs develop chromosome errors
Is it the egg or the sperm that is at fault?
Chromosomal errors (aneuploidy) versus single-gene defects
Chromosomal translocations and infertility
Sex-chromosomal aneuploidies
Severely infertile males and sex-chromosomal aneuploidy
Chromosomal abnormalities in infertile men and women, and in their ICSI and IVF children
Transmission of infertility to IVF and ICSI offspring
Inheritance of male infertility
The X and the Y chromosome and male infertility
Inheritance of female infertility.
13. How to make sure your baby is normal : preimplantation genetic diagnosis (PGD)
Preimplantation embryo biopsy with genetic diagnosis
Is there a risk from embryo biopsy?
Fluorescent in situ hybridization (FISH) and polymerase chain reaction (PCR) to analyze the embryo
PGD for chromosome defects
How defective meiosis causes Down syndrome and miscarriage
Chromosome errors and the biological clock
Embryo quality and chromosome abnormalities
Preventing specific genetic diseases
PGD to prevent Down syndrome : FISH
PGD for preventing autosomal-recessive gene disease : cystic fibrosis
PGD for preventing muscular dystrophy : x-linked versus autosomal-dominant disease
PGD for preventing Marfan's syndrome
Genetic prevention of early onset Alzheimer's
Predisposition toward cancer and Rh disease
PGD for human leukocyte antigen (HLA) tissue typing : having a baby who can save the life of her dying sister
DNA fingerprinting, single nucleotide polymorphisms (SNPs), linked markers, and PGD
14. Understanding and preventing miscarriage
Chromosome errors cause most miscarriages
Screening embryos for chromosomal errors
Aneuploidy versus chaotic mosaicism
Preventing miscarriage caused by chromosomal translocations
Miscarriages not caused by chromosome errors
Thrombophilia and folic acid
15. Reversing vasectomy, sperm blockage, and tubal ligation
Vasectomy reversal and microsurgery
Why do men want to reverse their vasectomy?
The "simple" microsurgical operation to reconnect the vas deferens
How does vasectomy affect the ducts of the testicle?
Length of time since vasectomy
With modern vasectomies, blowouts occur much sooner
How is the epididymal blockage bypassed?
Recovery of fertility after vasectomy reversal
ICSI with retrieved sperm
Obstruction to sperm outflow in patients who have not had a vasectomy
Microsurgical vasoepididymostomy
Congenital absence of the vas deferens
TESE-ICSI versus microsurgical vasoepididymostomy
Reversal of tubal ligation
Comparison of tubal sterilization in the female to vasectomy in the male
Methods of blocking the tubes
Reversal of tubal sterilization
How the type of sterilization affects the technique for reversal
What factors affect successful sterilization reversal?
How difficult is tubal reversal surgery for the patient?
Frozen sperm and sperm banks
Insemination with donor sperm or ICSI with donor sperm
17. Egg donation and gestational surrogacy
Surrogate uterus (your mother can have your kids for you)
Egg donation (you can get pregnant after menopause)
18. The controversy over IVF, cloning, and stem cells
Use of stem cells to cure human disease.
