The Ovarian Assessment Report (OAR)™ provides the most accurate available assessment of a woman’s ovulatory egg supply using a single blood sample.
- More accurately identify patients likely to respond poorly to stimulation.
- Quantifiably outperform the predictive power of AMH or FSH testing alone.
- More accurately identify likely egg retrieval numbers in egg donor candidates.
By combining multiple hormones & age factors into one algorithm, the OAR increases the overall sensitivity of the test.
The OAR combines age with blood serum levels of various ovary related hormones such as AMH and FSH into a proprietary mathematical algorithm to provide the Egg Retrieval Score™ (ERS).
The ERS is calibrated to the most definitive measure of ovulatory egg supply:
the number of eggs retrieved through ovarian stimulation.
Combining multiple analytes into one algorithm safeguards against incorrect clinical interpretations that could occur due to errors in any single analyte.
The ERS ranges from 1 to 20 on an index derived from age & blood levels of menstrual cycle day 3 hormones, including AMH, inhibin B, FSH, & estradiol.
Also known as Saline Infused Sonogram (SIS) Hysterosonogram (HSN)
A hysterosonogram (HSN) is an ultrasound study of the uterine lining performed in the first half of the menstrual cycle. This particular test is used to determine if the cavity of the uterus is normal in appearance. It involves placing a small tubing (catheter) through the cervix into the uterus. Saline is then instilled in small amounts. Specifically, your physician is looking for the presence of abnormal tissue (ie: scarring, fibroids,polyps, etc.), which may impair or impede the implantation of a fertilized egg.
What happens during a Hysterosonogram
• You will need to call during regular business hours when your menstrual cycle begins. If this occurs on a weekend or holiday, call the next business day.
• You will be required to take an at home pregnancy test the morning of your procedure (even if you are on Birth Control Pills). Failure to do so may result in the cancellation of your procedure.
• Your message will be given to one of the nurses and an ultrasonographer. The ultrasonographer will enter you into their waiting list immediately. You will be notified as soon as possible when your appointment time is. Please be aware that it may take 2 menstrual cycles to get this procedure done as it needs to be coordinated between the ultrasound schedule and Dr. Miller’s schedule.
• The procedure is performed in the office setting.
• This test is usually performed between cycle day 6 and cycle 12. The doctor performs this test after your menstrual bleeding has subsided and prior to the time of ovulation.
• You will be asked to sign an informed consent which attests to your understanding of the procedure and gives the physician the permission to perform the test.
• There may be some cramping associated with the HSN. If this occurs, you will be offered oral medication to attempt to relax the uterine muscles.
• A speculum is inserted in the vagina.
• The cervical area is cleansed with long cotton swabs, using an antiseptic solution called Betadine (an iodine solution).
• A small plastic tubing is inserted through the cervical opening. A small amount of normal saline is injected through the catheter. A 3D ultrasound image will be obtained showing the outline of the saline filled endometrial cavity.
• The length of the procedure usually takes 10 minutes.
You may experience some slight cramping at the time of the HSN. There are times when you also may experience some slight spotting after the procedure.
However, if the cramping becomes severe, the bleeding heavy (as in a full menstrual flow), of you develop a fever, please call the office immediately. If it is after normal office hours, please call our answering service to have the physician paged immediately.
Depending on the treatment plan chosen by Dr. Miller, in addition to the HSN a FemVue is performed to evaluate Fallopian tube patency. The FemVue Saline-Air Device (FemVue) creates and delivers a consistent alternating pattern of saline and air as a continuous stream. Since air bubbles are highly visible under ultrasound, the saline and air pattern allows visualization of the fallopian tubes. The flow can be viewed traveling into the uterus and if patent, out through each fallopian tube.
A hysterosalpingogram or HSG is an x-ray procedure performed to determine whether the fallopian tubes are patent (open) and to see if the shape of the uterine cavity is normal. An HSG is an outpatient procedure that usually takes less than 30 minutes to perform. It is usually done after the menstral period has ended, but before ovulation, to prevent interference with an early pregnancy.
An HSG is done starting with the patient being positioned under a fluoroscope (a real-time x-ray imager) on a table. Dr. Miller then examines her uterus and places a speculum in her vagina. Her cervix is cleaned, and a device (cannula) is placed into the opening of the cervix. Dr. Miller then gently fills the uterus with a liquid containing iodine (contrast) through the cannula. The contrast then enters the tubes, outlines the length of the tubes, and spills out their ends if they are open. Also abnormalities within the uterine cavity may detected by Dr. Miller while observing the x-ray images. The HSG procedure is not designed to evaluate the ovaries or diagnose endometriosis. Frequently, side views of the uterus and tubes are obtained by having the woman change her position on the table. After the HSG, a woman can immediately resume normal activities.
Tubal factors make up 20-40% of the causes of infertility in women and can be due to previous pelvic inflammatory disease, previous infection from gonorrhea or chlamydia, previous tubal surgery, ruptured appendix, endometriosis and known or unknown infections following childbirth.
Autoimmune diseases are a category of reactive processes in which the body turns against aspects of itself. With autoimmune infertility, the body’s same defense mechanisms react to and reject an embryo that is trying to implant as if it is a foreign threat.
There are many different autoimmune implantation dysfunctions associated with a variety of antibodies. Those most commonly associated with reproductive failure are:
Antiphospholipid Antibodies (APA)
Antithyroid Antibodies (ATA)
Activated Natural Killer Cells (NKa)
Antiphospholipid Antibodies (APA)
Anticardiolipin (aCL) IgG and/or IgM
Thrombophilia panel was designed to include the most clinically significant acquired and inherited coagulation risk factors most commonly assessed by fertility specialists. The panel is used for determining coagulation abnormalities possibly related to recurring pregnancy loss, implantation failure, or venous thrombosis.
Chlamydia infection is the most common sexually transmitted disease, responsible for a record 1.1 million cases reported to the Centers for Disease Control and Prevention in 2007, and experts there estimate that twice that many cases go undetected. Left untreated, chlamydia can cause infertility or potentially fatal ectopic pregnancies. But many women aren’t even aware that they were exposed to it—possibly years ago—until they try to have a baby and can’t.
Mycoplasma is a less known bacterium that is associated with infertility and repeated pregnancy loss. It is generally sexually transmitted, can lay dormant in the cervix for long periods, and many times, is not associated with any symptoms. The thinking is that the mycoplasma bacteria may bind with sperm or even the early developing embryo causing a mycoplasma-sperm complex or mycoplasma-embryo complex that white cells will attack and destroy thus inhibiting pregnancy or increasing the risk of a miscarriage. . If the cultures for ureaplasma and mycoplasma are positive, both the patient and her sexual partner are treated with antibiotics. As these bacteria are may be present for many years without causing any symptoms, the finding of ureaplasma and mycoplasma on cervical cultures does not in any way indicate infidelity or sexual misconduct.
an Endometrial Biopsy (EMB) tests whether the uterine lining is preparing itself adequately for implantation of the embryo. The test is done several days before the onset of the menstrual cycle (usually cycle day 25-26). A small plastic instrument, called a Pipelle, is inserted through the cervix and into the uterine cavity where a very small piece of endometrial lining is removed by pulling back on the center piece of the Pipelle and creating a weak suction. The tissue is then sent to pathology to be evaluated for which day in the cycle the lining of the uterus is at. That is then compared to where the woman is chronologically in her cycle. The two have to be read within 1-2 days of each other, or the lining is out of phase, known as a luteal phase defect, which can prevent implantation from occurring or result in an early miscarriage. An abnormal Endometrial Biopsy (EMB) is treated with progesterone suppositories or intramuscular shots
This biopsy tests whether the uterine lining demonstrates presence or absence of ß3 integrin. ß3 integrin is a protein produced by the endometrium during the implantation window that has some evidence for a scientific basis for a role in implantation is the cell-to-cell adhesion molecule. This is determined through a special staining technique which is combined with histologic dating of the endometrium to provide a final result.
Thyroid Stimulating Hormone (TSH) is the most sensitive of all the thyroid testing and is elevated in patients with hypothyroidism and decreased in patients with hyperthyroidism. Even if you do not have any symptoms of either hypo or hyperthyroidism, it is still important to measure Thyroid Stimulating Hormone (TSH) because, more commonly in women than men, Thyroid Stimulating Hormone (TSH) can be elevated without any symptoms of hypothyroidism. This is known as compensated hypothyroidism, where the thyroid gland is beginning to fail and as a result, the brain is sending more signals, Thyroid Stimulating Hormone (TSH), to stimulate the thyroid gland to keep up its production of thyroxine or T4. If overlooked and not treated, compensated hypothyroidism can cause infertility. The treatment is usually simple and requires the addition of thyroid medication, usually Synthroid, in low doses and rechecking the Thyroid Stimulating Hormone (TSH) levels to make sure they are back into the normal range
Prolactin is a hormone secreted by the pituitary gland during pregnancy and lactation. If it is elevated in a non-pregnant state, it can affect steroidogenesis or the production of estrogen and progesterone, causing problems with ovulation, implantation of the embryo, development of the uterine lining and an increased risk of miscarriages. An elevated Prolactin (PRL) level in a non-pregnant woman is generally due to microscopic benign adenoma (tumor) on the pituitary gland that stimulates that area of the gland to produce an excess amount of prolactin. If the prolactin level is elevated high enough, a woman will not have periods and/or will have white milky breast discharge from one or both breasts, either spontaneously or with expression. Other symptoms of a high prolactin level are headaches, dizziness, lightheadedness, feeling faint, spots in front of your eyes and even decreased sex drive (which is commonly seen in men with elevated Prolactin (PRL) levels). On the other hand, Prolactin (PRL) can be mildly elevated but menstrual cycles can be regular and there is no breast discharge. These are the patients that should not be overlooked because mildly elevated Prolactin (PRL) levels can definitively affect fertility outcomes.
It has been shown that woman can lose their immunity to german measles and/or chicken pox, even if they were exposed as a child or received the vaccine in the past. If a woman’s immunity is lost, then that means she is susceptible, if exposed, to getting german measles and/or chicken pox. Both viruses can cause serious birth defects; and if exposed and infected, the strong recommendation is to terminate the pregnancy. With more and more parents electing not to vaccinate their young children with the MMR because of the “possible” increase risk of autism, more children are going to be exposed to and get german measles. It is generally a benign viral illness for the child, but it will put more pregnant woman at risk, especially those that have lost your immunity. If a woman tests negative for either rubella and/or varicella, meaning she has lost her immunity, the options are to be very careful and avoid children that could be infected; or, to take a vaccine. The down side of the vaccine is that you cannot attempt pregnancy for 3 months; the upside, is you do not have to worry about exposure.