During the second half of your menstrual cycle, the hormone progesterone kicks in to help prepare the lining of your uterus for a fertilized egg. If the egg isn't fertilized and doesn't implant, it disintegrates, progesterone levels fall, and about 12 to 16 days later, the egg -- along with blood and tissues from the lining of the uterus -- is shed from the body. That process is menstruation. It usually lasts 3 to 7 days.
IVF using no drugs for ovarian hyperstimulation was the method for the conception of Louise Brown. This method can be successfully used when women want to avoid taking ovarian stimulating drugs with its associated side-effects. HFEA has estimated the live birth rate to be approximately 1.3% per IVF cycle using no hyperstimulation drugs for women aged between 40–42.[63]

Infertility is a medical condition, and a fertility specialist can help with thorough, focused examinations directed at discovering the underlying cause. For every couple that begins an evaluation, about 35% discover that there is an issue with the man which is contributing to the couple’s infertility. 50% is related to female factor while 5% is due to rare causes. The remaining 10% (1 in 5 couples) is due to unexplained infertility despite completing a full infertility work-up.(2)
Intercourse must take place frequently, particularly before and around the time of ovulation, and the couple must have been trying to conceive for at least one year (6 months if the woman is over 35 years old). Using these criteria, about 10-20% of all infertile couples have unexplained infertility. However, the percentage of couples classified as having unexplained infertility will depend upon the thoroughness of testing and the sophistication of medical technology. 
In some cases, laboratory mix-ups (misidentified gametes, transfer of wrong embryos) have occurred, leading to legal action against the IVF provider and complex paternity suits. An example is the case of a woman in California who received the embryo of another couple and was notified of this mistake after the birth of her son.[94] This has led to many authorities and individual clinics implementing procedures to minimise the risk of such mix-ups. The HFEA, for example, requires clinics to use a double witnessing system, the identity of specimens is checked by two people at each point at which specimens are transferred. Alternatively, technological solutions are gaining favour, to reduce the manpower cost of manual double witnessing, and to further reduce risks with uniquely numbered RFID tags which can be identified by readers connected to a computer. The computer tracks specimens throughout the process and alerts the embryologist if non-matching specimens are identified. Although the use of RFID tracking has expanded in the US,[95] it is still not widely adopted.[96]
For any woman or couple facing infertility, the task of deciding on your next steps can feel very daunting. Of course, there’s no substitute for the advice of a fertility specialist, but a general idea of what to expect can help give you confidence. You might be wondering what is the difference between In Vitro Fertilization (IVF) and  IUI, or artificial insemination?
If a physician believes infertility is a concern, a number of tests will be administered. For women, these may include ovulation testing, ovarian reserve testing, hormone testing, and hysterosalpingography (X-rays of the fallopian tubes) or other imaging tests. Assessing male infertility involves semen analysis, which examines the number of sperm, as well as their motility and morphology (shape). Other tests for men may include hormonal and genetic testing, testicular biopsy, and additional imaging.

Statistically, the biggest decline in live births happens between the ages of 40 and 42+. In other words, a woman who has just turned 40 has a much higher chance of conceiving and delivering a baby than a woman who has just turned 42. Of course, these numbers and trends concern women using their own eggs. With donor eggs, consider the age of the woman at the time the eggs were harvested and use that age.
In the United States, women seeking to be an embryo recipient undergo infectious disease screening required by the U.S. Food and Drug Administration (FDA), and reproductive tests to determine the best placement location and cycle timing before the actual Embryo Transfer occurs. The amount of screening the embryo has already undergone is largely dependent on the genetic parents' own IVF clinic and process. The embryo recipient may elect to have her own embryologist conduct further testing.
The cost of an IUI is almost certainly less on a per cycle basis, but because IVF has much higher success rates and IUI is a poor option for some, the higher per cycle cost of IVF can actually be more affordable in the long run – in terms of the cost to bring home a baby.  Because most successful IUIs happen in the first three or four-cycle, it eventually becomes very expensive to bring home a baby with an IUI.
Treatment with Clomid tablets plus IUI improves fertility rates. For unexplained infertility, studies have shown that for women under 35, monthly success rates for Clomid plus insemination are about 10% per cycle. This pregnancy rate holds up for about 3 tries and the success rate is considerably lower after that. More about success rates with IUIs is on the insemination page and on the Clomid for unexplained infertility page. The insemination component boosts fertility more than the Clomid does - but success rates are higher when both are used together.
When the ovarian follicles have reached a certain degree of development, induction of final oocyte maturation is performed, generally by an injection of human chorionic gonadotropin (hCG). Commonly, this is known as the "trigger shot."[67] hCG acts as an analogue of luteinising hormone, and ovulation would occur between 38 and 40 hours after a single HCG injection,[68] but the egg retrieval is performed at a time usually between 34 and 36 hours after hCG injection, that is, just prior to when the follicles would rupture. This avails for scheduling the egg retrieval procedure at a time where the eggs are fully mature. HCG injection confers a risk of ovarian hyperstimulation syndrome. Using a GnRH agonist instead of hCG eliminates most of the risk of ovarian hyperstimulation syndrome, but with a reduced delivery rate if the embryos are transferred fresh.[69] For this reason, many centers will freeze all oocytes or embryos following agonist trigger.
^ Hozyasz, K (March 2001). "Coeliac disease and problems associated with reproduction". Ginekol Pol. 72 (3): 173–9. PMID 11398587. Coeliac men may have reversible infertility, and as in women, if gastrointestinal symptoms are mild or absent the diagnosis may be missed. It is important to make diagnosis because the giving of gluten free diet may result in conception and favourable outcome of pregnancy.
3-6 months of treatment with Clomid pills (clomiphene citrate) might improve fertility by as much as 2 times as compared to no treatment. This is a very low level infertility treatment. Infertility specialists do not usually recommend Clomid treatment( without insemination) for unexplained infertility for women over the age of about 35. Most fertility specialists do not use it (without IUI) on any couples with unexplained infertility. If a woman is already having regular periods and ovulating one egg every month, giving Clomid, which will probably stimulate the ovaries to release 2 or 3 eggs per month (instead of one) is not really fixing anything that is broken - and is not likely to be successful.
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With egg donation and IVF, women who are past their reproductive years, have infertile male partners, have idiopathic female-fertility issues, or have reached menopause can still become pregnant. Adriana Iliescu held the record as the oldest woman to give birth using IVF and a donor egg, when she gave birth in 2004 at the age of 66, a record passed in 2006. After the IVF treatment some couples are able to get pregnant without any fertility treatments.[3] In 2018 it was estimated that eight million children had been born worldwide using IVF and other assisted reproduction techniques.[4]
Undergo minor surgery to retrieve eggs. Following a round of injections, your doctor will determine the best date to retrieve eggs from the follicles of your ovaries. If you choose to use donor eggs, the retrieval process will occur with the donor, or the frozen eggs may be collected and used. A partner’s sperm or donor sperm will also be collected.

An IUI procedure is the process of directly injecting sperm into the top of the uterus. This increases the odds of conception by reducing the distance the sperm must travel to meet the egg. That said, when most people talk about IUIs, they’re referring to the steps leading up to and after the actual procedure. An IUI treatment can be summarized into a few steps:
This information is designed as an educational aid to patients and sets forth current information and opinions related to women’s health. It is not intended as a statement of the standard of care, nor does it comprise all proper treatments or methods of care. It is not a substitute for a treating clinician’s independent professional judgment. Read ACOG’s complete disclaimer.
DNA damage reduces fertility in male sperm, as caused by oxidative DNA damage,[31] smoking,[28] other xenobiotic DNA damaging agents (such as drugs or chemotherapy)[32] or other DNA damaging agents including reactive oxygen species, fever or high testicular temperature.[33] The damaged DNA related to infertility manifests itself by the increased susceptibility to denaturation inducible by heat or acid [34] or by the presence of double-strand breaks that can be detected by the TUNEL assay.[35]
• Women having irregular periods. Regular periods indicate that you are ovulating regularly. Eggs are produced through ovulation two weeks prior to the next period. Ovulation of the egg is essential for pregnancy, and any irregularity in this process leads to an inability to conceive. If you have irregular periods then it is better to get evaluated from a reproductive endocrinologist.
Advanced technologies add to your IVF bill but may also make a huge difference to your success rate. Pre-implantation genetic screening (PGS) can improve implantation rate by selectively transferring genetically normal embryos. For couples with male factor infertility, Intracytoplasmic sperm injection (ICSI) can help deliver a sperm directly into the egg. Nevertheless, ICSI only improves success rate in couples with severe male infertility.

Gonadotropins are another drug used to trigger ovulation. Gonadotropins are used if other drugs are not successful or if many eggs are needed for infertility treatments. Gonadotropins are given in a series of shots early in the menstrual cycle. Blood tests and ultrasound exams are used to track the development of the follicles. When test results show that the follicles have reached a certain size, another drug may be given to signal a follicle to release its matured egg.
Give in to the grief. While you probably feel incredibly disappointed and sad about your infertility problems, you may feel guilty giving in to those emotions. Parents facing secondary infertility often feel they don’t have the “right” to feel sad about their struggles because they should be grateful for the child they already have. But if you want more children and are having trouble getting pregnant again, you are just as entitled as anyone else to feel depressed or angry. The last thing you need when you’re coping with secondary infertility is to let guilt weigh you down even more.
Male infertility may be caused by trouble with sperm delivery due to structural difficulties like testicle blockage or damage to the reproductive organs, sexual function concerns such as premature ejaculation, or genetic conditions including cystic fibrosis. Another root of male infertility may be abnormal sperm function or production, often due to genetic defects or health problems including diabetes or certain sexually transmitted diseases. Other risk factors include overexposure to certain environmental factors, such as alcohol, cigarette or marijuana smoke, chemicals, and pesticides, as well as frequent exposure to high temperatures (hot tubs and saunas). Specific cancers and their treatments can also be harmful to male fertility.
Though there are some risk with older women pregnancies, there are some benefits associated with caesareans. A study has shown that births over 40 have a lower rate of birth trauma due to increased delivery by caesarean. Though caesarean is seen to benefit mothers over 40, there are still many risk factors to consider. Caesarean section may be a risk in the same way that gestational diabetes is.
Assess your preconception prep. Have you been on top of the preconception game or are you just too busy for baby-planning activities like charting and timing baby-making sex (or any sex for that matter)? Given that you have a little one underfoot, it's understandable if you're more exhausted than ever. It’s not easy for wannabe second-time parents to devote as much time and energy to TTC as they likely did on the first go-around, but it would be helpful to take a step back (and a hard look) at what's going on. Are your cycles still regular, or have there been any changes that might be hurting your chances for conception success? Have you been able to pinpoint ovulation with accuracy, or are you just having sex whenever (which would make conception less likely)? Getting back on track with tracking your fertility signs may be enough to put you back in the game.
The industry has been accused of making unscientific claims, and distorting facts relating to infertility, in particular through widely exaggerated claims about how common infertility is in society, in an attempt to get as many couples as possible and as soon as possible to try treatments (rather than trying to conceive naturally for a longer time). This risks removing infertility from its social context and reducing the experience to a simple biological malfunction, which not only can be treated through bio-medical procedures, but should be treated by them.[104][105] Indeed, there are serious concerns about the overuse of treatments, for instance Dr Sami David, a fertility specialist, has expressed disappointment over the current state of the industry, and said many procedures are unnecessary; he said: "It's being the first choice of treatment rather than the last choice. When it was first opening up in late 1970s, early 80s, it was meant to be the last resort. Now it's a first resort. I think that it can harm women in the long run."[106] IVF thus raises ethical issues concerning the abuse of bio-medical facts to 'sell' corrective procedures and treatments for conditions that deviate from a constructed ideal of the 'healthy' or 'normal' body i.e., fertile females and males with reproductive systems capable of co-producing offspring.
Undergoing fertility treatment requires precise scheduling of frequent tests and procedures—a tricky proposition when you're a parent. "I've had to go to the doctor early in the morning three times a week for testing," says Bozinovich. "Who can you find to babysit at 7 a.m. on a weekday?" (The answer: a grandparent or, when all else fails, a nurse at the doctor's office.) Your instinct might be to keep your treatment a secret, but it can make your life easier to enlist a friend or relative to help with child care. Also, choose a doctor's office you're comfortable with. You'll be spending a lot of time there; a compassionate staff can make treatment easier.
IVF is complicated and, while we wish we could say that it's possible to absorb all the details during the 5 - 30 minute visits with your doctor, that's really not the case. This comprehensive guide to IVF boils down every major issue you'll encounter -- a high level overview of the IVF process, a deeper dive into the IVF process, IVF success rates and how they differ depending on diagnosis and age, the medication protocols that can be used during IVF, the choice of inseminating eggs either using ICSI fertilization or conventional insemination, the pros and cons of growing embryos to Day 3 cleavage stage or Day 5 blastocyst stage, the decisions around genetic screening of embryos, deciding which embryo to transfer, deciding how many embryos to transfer at once, the ways the IVF laboratory can impact your odds of success and the things you need to know up front to avoid going to the wrong lab for you, the risks of IVF, and the costs of IVF. We're always sure to provide details about how data might be different depending on different unique types of patients -- because in the world of fertility, it's really not one-size-fits-all. We truly believe this guide is the foundation every fertility patient should start with when they're navigating the world of treatments.
A woman normally produces one egg during each menstrual cycle. However, IVF requires multiple eggs. Using multiple eggs increases the chances of developing a viable embryo. You’ll receive fertility drugs to increase the number of eggs your body produces. During this time, your doctor will perform regular blood tests and ultrasounds to monitor the production of eggs and to let your doctor know when to retrieve them.

In the United States, women seeking to be an embryo recipient undergo infectious disease screening required by the U.S. Food and Drug Administration (FDA), and reproductive tests to determine the best placement location and cycle timing before the actual Embryo Transfer occurs. The amount of screening the embryo has already undergone is largely dependent on the genetic parents' own IVF clinic and process. The embryo recipient may elect to have her own embryologist conduct further testing.
Assess your preconception prep. Have you been on top of the preconception game or are you just too busy for baby-planning activities like charting and timing baby-making sex (or any sex for that matter)? Given that you have a little one underfoot, it's understandable if you're more exhausted than ever. It’s not easy for wannabe second-time parents to devote as much time and energy to TTC as they likely did on the first go-around, but it would be helpful to take a step back (and a hard look) at what's going on. Are your cycles still regular, or have there been any changes that might be hurting your chances for conception success? Have you been able to pinpoint ovulation with accuracy, or are you just having sex whenever (which would make conception less likely)? Getting back on track with tracking your fertility signs may be enough to put you back in the game.

Secondary infertility is the inability to conceive a child or carry a pregnancy to full term after previously giving birth. To classify as secondary infertility, the previous birth must have occurred without help from fertility medications or treatments, like in vitro fertilization. Secondary infertility typically is diagnosed after trying unsuccessfully to conceive for six months to a year. A related condition is recurrent pregnancy loss where patients and couples are able to conceive but are unable to carry to term.

We also care about not only your physical well being, but also your emotional health. In fact, these issues as important enough to us that one of our core team members is a psychologist. Julianne Zweifel is an expert in addressing the mental aspects of secondary (and primary) infertility and she can promote emotional well being in a way that few others have the training or experience to do. If you should feel you do not wish to talk a specialist, but are struggling emotionally, please at least let other team members know-the more we hear from you, the easier it is for us to help.  
There are multiple treatment options including using oral or injectable medications, intrauterine insemination (IUI), assisted reproductive technology using in vitro fertilization (IVF), or a combo of these solutions to help. A 2010 study called the FASTT trial indicated that in vitro fertilization might be the quickest and best route to pregnancy for couples with unexplained infertility.(4)
In 2006, Canadian clinics reported an average pregnancy rate of 35%.[11] A French study estimated that 66% of patients starting IVF treatment finally succeed in having a child (40% during the IVF treatment at the centre and 26% after IVF discontinuation). Achievement of having a child after IVF discontinuation was mainly due to adoption (46%) or spontaneous pregnancy (42%).[14]
4. Significant Hair Growth (or Hair Loss): Polycystic ovarian syndrome causes small cysts to form on the outside of the ovaries, and it also causes the body to produce an excess of male hormones. If you notice hair growing in unusual places like your face, arms, chest or back, this could be a warning sign. On the flip side, hair loss or thinning could be a sign of other infertility related conditions like thyroid issues, anemia or autoimmune disorders.
There is a risk of multiples, which includes twins, triplets, or more. Multiple pregnancies can be risky for both the babies and the mother. It's important to discuss with your doctor how many embryos to transfer, as transferring more than necessary will increase your risk of conceiving twins or more. When embryos have been tested with PGT, typically only a single embryo is transferred.
As a result, most patients need to undergo multiple cycles, and as we pointed out in a another lesson, no cycle is as likely to succeed as the first one. Below is data out of the UK published in the Journal of The American Medical Association that illustrates that after a few cycles most younger patients succeed with IVF but that is not necessarily true for older patients.
^ Chavez-Badiola, Alejandro; Flores-Saiffe Farias, Adolfo; Mendizabal-Ruiz, Gerardo; Garcia-Sanchez, Rodolfo; Drakeley, Andrew J.; Garcia-Sandoval, Juan Paulo (10 March 2020). "Predicting pregnancy test results after embryo transfer by image feature extraction and analysis using machine learning". Scientific Reports. 10 (1): 4394. Bibcode:2020NatSR..10.4394C. doi:10.1038/s41598-020-61357-9. PMC 7064494. PMID 32157183.
The sperm and the egg are incubated together at a ratio of about 75,000:1 in a culture media in order for the actual fertilisation to take place. A review in 2013 came to the result that a duration of this co-incubation of about 1 to 4 hours results in significantly higher pregnancy rates than 16 to 24 hours.[70] In most cases, the egg will be fertilised during co-incubation and will show two pronuclei. In certain situations, such as low sperm count or motility, a single sperm may be injected directly into the egg using intracytoplasmic sperm injection (ICSI). The fertilised egg is passed to a special growth medium and left for about 48 hours until the egg consists of six to eight cells.
The stress of secondary infertility on an individual's life and relationships can be significant. It can be hard to find support from family and friends, especially when a woman or couple already has/have children. Sentiments such as, "you should be grateful for what you have," or, "just keep trying," almost never serve as useful advice or support. Couples and single parents can even experience resentment from other couples with infertility who are unable to even have their first child.
Intracytoplasmic sperm injection (ICSI): This procedure involves direct injection of a single sperm of the male partner into the eggs of the female for fertilization. Just like IVF procedure, in ICSI, the sperm and egg are collected from both the partners. The only difference is the fertilization process as in IVF the sperms and egg are mixed naturally, and in ICSI the sperms are injected into the egg using a needle.
IUI is a procedure during which processed and concentrated motile sperm are inserted directly into a woman’s uterus. This procedure is timed according to a woman’s ovulation, and may be performed one to two times in the days immediately following the detection of ovulation. After ovulation a woman’s egg is picked up by the fallopian tube and waits there for the sperm. Since the IUI procedure deposits higher concentrations of good quality sperm close to where the egg is waiting, the chances that the egg and sperm will find one another are increased.
If a man and woman 35 or younger have had unprotected sex for at least 12 months (or six months if older than 35) without getting pregnant, they should suspect secondary infertility. This especially applies to women older than 30 who have experienced pelvic inflammatory disease, painful periods, irregular menstrual cycles or miscarriages, and to men with low sperm counts.
Only 30 percent of patients who receive 100 mg of Clomiphene a day will produce more than three follicles. Patients that produce less than than three follicles have about half the chance of getting pregnant than those that produce greater than three follicles. Patients that receive fertility medications but do not do an insemination have only half the success rates compared to those who do.
Hashimoto's thyroiditis or chronic lymphocytic thyroiditis, is an autoimmune disorder causing inflammation of the thyroid gland. Hashimoto's thyroiditis is a type of hypothyroidism, and is the most common cause of hypothyroidism in the US. Symptoms of Hashimoto's thyroiditis may include dry skin, fatigue, weight gain, feeling cold, excessive sleepiness, dry skin, dry coarse hair, difficulty swallowing, a lump in the front of the throat, muscle cramps, mood changes, vague aches and pains, problems concentrating, leg swelling, constipation, and depression. There is no cure for Hashimoto’s thyroiditis. Diet changes, natural supplements, vitamins, or other natural products will not treat Hashimoto’s thyroiditis. Treatment for the autoimmune disorder is with thyroid hormone replacement therapy, which will be necessary for the rest of the person’s life.

Step on the scale. Have you put on some extra pounds since your last baby was on board? Or maybe you’ve lost a lot of weight (because after all, who has time to eat when you’re running after a little one)? Your weight can impact your fertility, so getting as close as possible to a healthy BMI can also help get you closer to that second pregnancy you’re hoping for.
There is a risk of multiples, which includes twins, triplets, or more. Multiple pregnancies can be risky for both the babies and the mother. It's important to discuss with your doctor how many embryos to transfer, as transferring more than necessary will increase your risk of conceiving twins or more. When embryos have been tested with PGT, typically only a single embryo is transferred.
We also care about not only your physical well being, but also your emotional health. In fact, these issues as important enough to us that one of our core team members is a psychologist. Julianne Zweifel is an expert in addressing the mental aspects of secondary (and primary) infertility and she can promote emotional well being in a way that few others have the training or experience to do. If you should feel you do not wish to talk a specialist, but are struggling emotionally, please at least let other team members know-the more we hear from you, the easier it is for us to help.  
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