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Reproductive ladder: treatment protocole that brings the best results in infertile couples The specific treatment for each couple is chosen once the infertility diagnosis is done. To choose the treatment or assisted reproduction technique, we use what is called the “Reproductive ladder”. The objective is to start with the first simplest treatment that offers real possibilities to succeed with a pregnancy. From this treatment, or step, we go up the ladder. This makes us choose the right treatment for each case avoiding treatments that are more complex or more expensive than what is needed. The reproductive ladder is divided in low and high complexity treatments. Each treatment is considered a step. a) Low complexity Sexual intercourse Programmed intercourse Intrauterine insemination (IUI, with couple or donor’s sample) b) High complexity In vitro fertilization (IVF) / Intracytoplasmatic sperm injection (ICSI) ICSI + Pre-implantation genetic diagnosis (PGD) Egg donation (Ovodonación) Egg donation + semen donation Embryo donation When do we suggest low complexity? When the values in the semen analysis are higher than the stablished standard by the WHO. When women are younger than 39 years old (depending the case). When the couple has been trying to have a baby for less than 2 to 3 years (depending the case). Permeable Fallopian tubes, with no myomas, polyps or endometriosis. When do we suggest high complexity? When the values in the semen analysis are lower than the stablished standard by the WHO. When the couple has been trying to have a baby for more than 2 to 3 years (depending the case). Women older than 39 years old. Bilateral tubal oclussion. Any other factor (uterus, endometrial, embryonary). Women’s age is a basic factor to consider for the selection of the complexity, as the egg reserve can diminish if the treatments take long. Click here for more information. It is well known that, the success rates of having a baby dimish from age 35. As well, from this age, the chromosomic abnormalities increase in the fetus. There are some stablished studies that assign a percentage of this risk according to the patients age (from 38). This is why, it is recommended to perform a pre-implantation genetic diagnosis (PGD) from this age, to know if the embryo is healthy so it can be transfered to the patient. Nowadays, this practice has increased the pregnancy rates, as placing a healthy embryo diminishes the possibility of an abortion. Show more For the cases of any familiar sickness, an embryo biopsy is indicated in order to place a healthy one inside the patient. Other consideration for the embryo biopsy is the sex selection. This is a delicate subject as it can be used in an indiscriminatory way. There is no legislation about this in Mexico so, in Centro FiVER no sex selection is done, unless it is mandatory due to healthy reasons. When the possibilities of success for a couple with their own eggs is very low, it is moment to go up the ladder. As well, if the male also has any sperm abnormality blocking the pregnancy, a semen donor should be considered. There are semen banks in the reproduction clinics as well as women donating eggs or donated embryos. The embryo donation is less expensive than the creation of a new embryo. Sexual intercourse 85% of couples succeed in a pregnancy within the first year of having regular sexual intercourse with no protection (every 2 to 3 days) and up to 9% will succeed in the first 2 years. These rates drop significantly when women are older than 35. The effect of age in men’s fertility is less clear. Timed intercourse This is the 2nd step in the reproductive ladder and the 1st to be done together with a reproduction specialist. It consists in the orientation of the couple to have sexual intercourse in the best moment of the woman’s cycle. It can be done with or without stimulation with medicines. Up to 6 cycles can be tried (depending the case). Click here to read more. Intrauterine insemination This is the 3rd step in the reproductive ladder. Must be done in assisted reproduction centers. It consists in placing the capacitated semen (best selected semen) directly inside the woman’s uterus. This way, the sperm and egg do what they are supposed to do naturally, fertilizing and resulting in an embryo that should stay there during 9 months. The successful rate is limited. Normally, the rate is 88% after 3 cycles. This is why, in assisted reproduction centers, no more than 4 cycles are recommended. It should be considered to go up the reproductive ladder if the specialist recommends it. Click here for more information. In vitro Fertilization (IVF) / Intracytoplasmatic sperm injection (ICSI) This is the 4th step in the reproductive ladder. Due to its complexity, must be done in a reproduction center. It consists in the obtention of the sperm and eggs to do a fertilization in the lab, transferring afterwards the embryo inside the uterus. The successful rate is 45-60% per cycle and it will vary depending on the couple and on the infertility causes. Click here for more information. ICSI + Pre-implantation genetic diagnosis (PGD) This is the 5th step in the reproductive ladder and it can only be done in reproduction centers. Once the embryo are created in the lab, a hole is done in the external wall of the embryo to extract a cell and analyse all its chromosomes. This way, a healthy embryo can be transfered to the patient. If no healthy embryo is obtained, no transfer is done. The success rate is 50-70%, with variations depending on the infertility causes and the percentage of health corresponding to the age. For example, at age 38, there is a 26% possibilities of a healthy embryo, if the healthy embryo is obtainted, then the rate of success is 50-70%. A 4-8% of error should be considered. Show more This should be done between day 3 and 5 of the life cycle of the

Most of infertility cases both in men and women can be diagnosed with infertility basic analysis A correct diagnosis can be obtained in more than 90% of infertility cases thanks to the infertility basic analysis. For this purpose, both members of the couple should be studied, getting their clinical history, having a complete physical assesment and performing the indicated infertility tests. As some of these studies should be done in specific days of the woman’s cycle, it is very important to have a proper coordination in order to perform all necessary analysis and tests in less than two months, avoiding any loss of precious time. Each couple and each infertility case is different, that is why the tests should be individualized. Some tests or analysis will be necessary for some people and won’t be necessary for other. Basic studies for the couple: Ovaries and ovulation studies: hormonal test and pelvic ultrasound Fallopian tubes study: hysterosalpingography, laparoscopy Male study: spermiogram Study of the uterus: transvaginal ultrasound, hyterosalpingography, hysteroscopy, laparoscopy Ovaries and ovulation studies The purpose of the infertility studies in women is to investigate how the ovaries are performing, to know their eggs reserve and to know if the ovulation is happening correctly. The study of the ovaric function is done as follows: Menstrual cycle evaluation: to know if the cycle is regular (each month) or not. Ovaries evaluation with transvaginal ultrasound: the folicules in the ovaries are counted (dark images that appear inside the ovaries where we find the eggs) Hormonal studies in blood: female hormone profile, anti mullerian hormone. According to the regularity of the menstrual cycles and the ultrasound valoration, it will be decided if it is necessary to have a hormonal study or, given the case, the determination of the anti mullerian hormone. In most of the cases, only a hormone profile will be necessary and it should be done in the second to the fourth day of the menstrual cycle. Show more The ultrasound study is very important, it should be transvaginal and it should be performed by an expert. By counting the follicles in each ovary, the egg reserve can be counted, as there is supposed to be one egg in each follicle. It is ‘supposed’ as some folicules must be empty of eggs. A number of less than 6 folilcles in the first days of the cycle in both ovaries can be considered as a low ovaric reserve. Age should also be considered, as 6 follicles is not the same at 41 than at 34. Besides the follicles number, the ultrasound also searches for any abnormality or cysts in the ovaries. Fallopian tubes study It is necessary to confirm that the Fallopian tubes are permeable (unblocked). This confirmation is done through an hysterosalpingography, which consists in the introduction of a contrast media through the cervix, previous to a pelvic radiography to assest how the uterus cavity is filled and how is the road through the tubes and to the exterior. As this study can be painfull, some indications must be considered. An hysterosalpingography is not always necessary, it will depend on the results of the semen study and the number of sperm. Male study To study the male, a spermiogram is performed. This study should be done in a special assisted reproduction center that has all the tecnology and experience necessary for it. The WHO parameters should be used in terms of motility, quantity and normal shape, besides, some other data as the presence of cells showing infection will be also considered. Show more It is important to point out that the production of sperm is done in 3 months renewing constantly during men’s life. This is why the quantity and motility of sperm can vary from one moment to the other, being in some occassions necessary to repeat the semen study. The most common case is when there are no sperm present in a study, this study should be repeated in 2 weeks or even until 3 months, so we can confirm there is no sperm present. For the cases where a severe alteration of sperm appears, is recommended to request for karyotype studies of the male, as well as sperm fragmentation study in some cases. When no sperm is present in the semen (azoospermia), other studies will be necessary such as hormonal determinations to discard any infection and to consider if a testicle biopsy is needed. Show more The testicle biopsy is the confirmation of sperm in a sample of testicular tissue. For the cases of obstructive azoospermia, no sperm appear in the semen but they appear in the testicle, making possible to perform an in vitro fertilization with intracytoplasmatic sperm injection (ICSI). Study of the uterus This study is done through a transvaginal ultrasound where we can detect data suggesting any abnormality. When there is any suspicion of abnormality, the following studies can be requested: Hysterosonography: introduction of a saline solution inside the uterus that will give abnormal images by ultrasound. This procedure can be done at the doctors office. Hysterosalpingography: cointroduction of a contrast media in the uterus doing then a radiography that will show the complete uterus and help detect any abnormal image. This procedure is done in specialized radiology centers. Hysteroscopy: introduction of a small camera inside the uterus to see the uterine cavity directly and detect any abnormality. Laparoscopy: introduction of a camera in the abdomen to confirm any uterine abnormality suspected in the previous tests. This procedure is performed in an operating room. It would be the last study to request as it an invasive test compared to the other tests than can be done without anesthesia.

Infertility causes There are several causes or factors that cause infertility. For a better study and understanding, they are grouped as follows: Ovarian factor Tubarian factor Male factor Endometrial factor Embryonary factor Ovaric factor: anovulation We call ovaric factor the fact of women not ovulating. The most frequent causes for this factor are: Polycystic Ovary Syndrome (PCOS): : this is probably the most frequent endocrinologic alteration among infertile women. These patients suffer from a hormonal disadjustment and overproduction of certain masculine hormones, such as androgens, producing lack of menstruation and ovulation.

Infertility personalized diagnosis: key to choose the treatment and reach the pregnancy. Infertility has its origins in lot of causes that can come from both men or women. It is necessary to perform studies to the couple in order to discard possible causes and get to the personalized diagnosis. Once the correct diagnosis is done, it is possible to choose the treatment with better results. Origin of infertility problems When studying couples with infertility problems, it is found that 40% of the problems come from men, 40% from women and 20% from a combination of both. That is why, it is key to go to the appointment together in order to have all the necessary studies. What is the natural course of ovulation, fertilization and embryo implantation? Before going deep into the infertility causes, it is convenient to know how the ovulation, fertilization and embryo implantation happen in a natural way. For a natural pregnancy it is necessary that: Ovulation happens At least one Fallopium tube is permeable so the sperm can meet the egg Enough number of motile sperm that reach and fertilize the egg Integrity of endometrium and womb to allow the implantation of the embryo Infertility causes There are several causes or factors that cause infertility. For a better study and understanding, they are grouped as follows: Ovarian factor Tubarian factor Male factor Uterine factor Embryonary factor Necessary studies for an infertility diagnosis The results of some studies allow us to discard some infertility causes. As some of these studies most be done according the woman’s menstrual cycle, it is important to be coordinated in order to finish them as soon as possible. If well programmed, the results can take less than 2 months after the first appointment. There are 4 basic infertility studies: Hormonal blood test: to study ovulation Hysterosalpingography: to study the Fallopian tubes Sperm study: to study the male factor Transvaginal ultrasound: to study the uterus, ovaries and cervix With these 4 studies, it is possible to discard 90% of infertility causes; therefore it is very important to perform them accordingly. Infertility personalized diagnosis As we can see, infertility causes are very diverse and affect couples and people in different ways, thus it is very important to have a personalized diagnosis. This is accomplished by performing the right studies to the couple. Once the personalized diagnosis is done, it is possible to, together with the patients, choose the treatment that will bring the best results.

Infertility: common and general suffering that is increasing Infertility is a very common suffering affecting millions of people. It is estimated that, 2 out of 10 couples in reproductive age, have the problem. This means that, in the world, there are from 50 to 80 million people with it. Infertility does not respect races, social status, religion or nationality. Mexico is no exception. It is estimated that infertility affects more than 1 million people in our country. Infertility has increased in recent times due to environmental factors such as: pollution, change in life style producing stress, and also the wish of waiting longer to have a family. In the past, couples were searching for a pregnancy when the woman was between 20 and 30 years old. Today, lot of women wish to finish their studies and then develop professionally, thinking about maternity after they are 35 years old. It is at this age precisely that women start the slowdown of their eggs reserve until the menopause. Thus, the probability of having a child after 35 years of age decreases. Show more Infertility is considered a sickness Human beings have the procreation and protection instincts very well developed. Lot of people with infertility problems are affected emotionally; causing problems in their health, social relations with their partner, family and even at work. That is why the WHO considers infertility as a sickness. Due to its impact and the number of people who suffers it, in some countries it is considered an important health problem. Infertility definition: when can we consider the existence of infertility? The WHO and many societies of reproduction specialists define infertility as: a disease of the reproductive system defined by the failure to achieve a clinical pregnancy after 12 months or more of regular unprotected sexual intercourse. Important considerations The consideration of 12 months is due to the fact that, the pregnancy rate in couples without infertility problems is of 10 to 20% per month. According to different studies with a wide number of couples, 100% of couples without any infertility problem, reach a pregnancy within 12 months. The consideration of regular sexual intercourse is 2 per week. Show more The effect of age in women infertility Since a woman is born, she has determined number of eggs that, will develop month by month to be ovulated and be fertilized. When time passes by and with every period, the eggs reserve in the ovaries diminishes. At 35 years of age, a slowdown starts until eggs are finished, with the arrive of menopause. The cells that produce the eggs have the peculiarity of, unlike sperm in men, not dividing to produce new eggs. So, the eggs of a 39 year old woman, will be also be 39. So, there is a higher probability of having problems with the eggs at an older age, having then a fertility problem. These problems mainly occur in women above 40 years old.

Understanding infertility It is totally normal that you have lots of questions around infertility. In this section, we give you all the information you need about infertility, so you can learn more about it and make the best decisions. Infertility affects a wide number of people A very common suffering, infertility has been growing in the last years. It is estimated that 2 out of 10 couples suffer from a kind of infertility.Show more Infertility causes and diagnosis Infertility can be caused by a problem in the male partner, in the female partner or in both. All people and couples are different, this makes fundamental to have a personalized diagnosis in a short time.Show more Infertility treatments 9 out of 10 couples can get pregnant when a precise diagnosis is reached and the right treatment is chosen. The younger the woman having the treatment, the better results.Show more Infertility news Find the latest information about infertility and assisted reproduction treatments.Show more

Your trip to FiVER Planning your trip We help you to make your trip more comfortable and relaxed. We offer you different services that will get you closer to Veracruz. We know that your tranquility and trust make our treatments successful, that is why we offer you the following exclusive services: Book your doctor appointment at the date and hour of your convenience Exclusive parking in our clinic Handicaped assistance Personalized service upon arrival Special parking for getting on/off the car just by our door Available installations for all our patients Hotel reservation Very close to our clinic and very close to the sea, our patients can enjoy all that Veracruz has to offer: culture, adventure, sports, entertainment or nature. This will make the dream of having a “FiVER baby” a wonderful experience. To improve your stay, we have special rates with hotels that are very close to our clinic and also to the beach. Contact us through our service “Your trip to FiVER” and we will show you all the options so you can choose according to your needs. FiVER assistance In FiVER, your treatment is performed with the joy and good weather of Veracruz. That is why our service does not end with your treatment in the clinic but also, with “Your trip to FiVER” service, we will inform you of all the touristic opportunities available so you can relax after being treated. The metropolitan area of Boca del Río-Veracruz, has lots of touristic spots to visit: restaurants, bars, museums, malls and of course, the beach. Everything in Veracruz is very close so you can enjoy your stay and treatment at their best.

Andrology lab This is where the semen is received and prepared for study to be used later for assisted reproduction treatments. This lab is key in an assisted reproduction center as it is only used to handle the semen sample. The difference with conventional labs where other samples are handled: blood, fluids, bacteria culture, etc. is that the andrology lab has the environment that protects the sperm from any contamination or affectation. It is essential to go to an andrology lab for the sperm tests, avoiding the conventional labs. In FiVER, we have an andrology lab fully equipped for the assisted reproduction treatments and for the cryopreservation of the sperm. Sperm studies The sperm studies are key for the infertility diagnosis. As 40% of cases are due to masculine causes, these sperm studies become essential. Sperm in urinalysis The urinalysis study allows us to detect if retrograde ejaculation exists. This problem appears when, at the time of ejaculating, the semen goes to the urine instead of going out. This can happen to diabetic patients or patients with neurological problems. This study will allow us to detect this problem and, if needed, use the sperm found in the urine. Sperm preparation Is the preparation of the sperm that will be used in the intrauterine inseminations or in vitro fertilizations. With this method, the seminal liquid is eliminated; the sperm with motility is chosen and prepared to fertilize the egg. Sperm retrieval When a man has little to no sperm in his ejaculate, it may be possible to retrieve sperm from his testicles or epididymis. This is a procedure performed by an urologist. The sperm retrieved can either be frozen for future use or used immediately for an in vitro fertilization cycle. This is the solution for the vasectomy cases. The sperm retrieval is a simple procedure, with local anesthesia and lasts only some minutes. Sperm freezing The sperm freezing allows it to live during years and be used after. The freezing is used in patients that will be subject of testicule or prostate surgery, chemotherapy or radiotherapy due to testicular cancer. This way, these patients can preserve their healthy sperm so, in the future, have a child with the support of assisted reproduction techniques. The freezing is also used in patients that, for some reason, are separated from their couples for long periods of time. This way, intrauterine insemination is possible without the physical presence of the father. Besides freezing the semen, also testicular tissue samples obtained through testicular biopsy are frozen. Semen bank Lot of cases of infertility are due to men not producing sperm. In these cases, a semen sample can be used. This option is also used for women with no male companion that wish to have a baby. The semen bank is formed by young healthy samples that have been through strict medical studies, lab, psicological and genetic studies so any hereditary, infectious or chromosomal disease is discarded. In FiVER, all our donors are closely studied, following strict international standards and all samples have a quarantine period of 6 months before using them. Semen donation is anonymous. It is recommended to choose the donor according to the physical characteristics of the future father.

Egg donation: assisted reproduction technique This infertility treatment is the last step in the assisted reproduction techniques ladder. There are a lot of women whose fertility problem is the lack of egg reserve or, the low quality of the eggs. For these cases, the only possibility of reaching the dream of having a baby is through egg donation. To perform this technique, it is necessary to have an in vitro fertilization in an assisted reproduction center. This center should have an egg donation program. Candidates for egg donation: Aged women After trying 3 cycles of in vitro fertilization Women with ovarian failure, menopause or ovarian surgery Repeat abortions Women with low quality eggs Genetic and chromosomal abnormalities In vitro fertilization with egg donation is the fertilization of the donor’s eggs with the father’s sperm, in order to obtain embryos that will be transferred to the mother’s uterus. This technique has allowed thousands of couples to reach the dream of having a family. There are lot of doubts and, in some cases, even rejection from couples around the eggs donation technique; this is totally normal. As the couples get to know the details and other couple’s experiences, their perspective changes. The couples that decide to try this technique feel very grateful of having had this option to conceive a child. Show more Choosing the egg donor The egg donation is totally anonymous. The objective of the selection is to find a donor with similar physical characteristics to the mother. The donors are young and healthy women with no fertility problems. They are subject of medical, gynecologic and psychological tests in order to discard any sickness. Blood tests and, if necessary, genetic tests are performed to minimize the risk of any infectious or hereditary sicknesses. In vitro fertilization procedure with egg donation The in vitro fertilization with egg donation procedure involves 6 main stages: Endometrial preparation of the receptor Some days after the patient’s period, she will start taking medication orally or through patches. She will go for check ups every 5 to 7 days so, through an ultrasound, we can confirm that the endometrium is developing properly, in order to receive the embryo that she will have transferred. Ovarian stimulation of the donor It consists in stimulating the donor’s ovaries with oral or injected medicines, so she can produce a good number of eggs. When it is observed through ultrasound that the follicles reach the right size, this is the moment when they are ready to ovulate with an injection. The doctor will indicate this exact moment. The eggs extraction will be done 36 hours later, just before ovulation. It is important to synchronize the timing of the endometrial preparation of the receptor and the donor’s stimulation. Show more Laboratoy Sperm preparation The day of the donor’s egg extraction, just a few hours before the procedure, the father’s semen sample is prepared. This sample is prepared in the andrology lab in order to select the best sperm. Once selected, they are prepared to fertilize the egg. Egg ultrasound-guided aspiration: donor’s eggs extraction Before the ovulation, the donor’s eggs are extracted and placed in a culture media inside special incubators in the embryology lab. Eggs fertilization and embryo culture Once the father’s sperm and the donor’s eggs are ready, the fertilization is done in the embryology lab. The fertilization can be done in 2 ways: Conventional in vitro fertilization: in a drop of culture media, the selected sperm and eggs are placed together. The fertilization should happen naturally. Intracitoplasmatic sperm injection: with the help of micro pipettes and a special microscope, an individual sperm is injected into each individual egg. Show more Embryo transfer to the mother After 3 to 5 days in the culture media, the embryos are transferred inside the mother’s uterus. This procedure doesn’t need anesthesia, lasts a couple of minutes and the discomfort is similar to the one of a Pap test. 15 days later, a pregnancy test is performed. The embryos that are not transferred are vitrified (frozen) to preserve them for later use, reducing the need for additional IVF treatment cycles. Show more

In vitro fertilization: assisted reproduction technique This infertility treatment is the third step in the assisted reproduction techniques ladder. This treatment brings the best pregnancy rate. Also called in vitro insemination, this technique is performed in assisted reproduction centers due to its high complexity. Indications for in vitro fertilization Couples that didn’t succeed with 4 intrauterine insemination cycles. Woman with obstructed Fallopian tubes. Moderate or severe decrease in the number and motility of sperm. When men have had a vasectomy in the past. In vitro fertilization consists in impregnating the eggs with the sperm in the lab, in order to obtain embryo that will after, be placed inside the uterus. This technique exists since 1978 when, Louise Brown, first baby to be conceived by this technique, was born in England. Through all these years, this method has improved and is used nowadays in thousands of clinics around the world. When first starting with this technique, the question of affecting the development or growth of the child was a big issue. After some decades, today we know that the use of this technique does not affect the child. 5 million babies have been born through in vitro fertilization since 1978. The objective of this technique is to ensure the impregnation of the egg by the sperm, correcting any factor causing infertility both in the male or female companion. In this technique, both male companion or donor semen can be used. In vitro fertilization procedure The in vitro fertilization procedure has 5 steps: Ovarian stimulation It consists in stimulating the ovaries with oral or injected medicines, making them produce one or two eggs. This stimulation lasts between 8 and 14 days. It is very important to have ultrasounds every 3 or 4 days to control – adjunting the dosis – the number and growth of eggs that are being developed. When it is observed through ultrasound that the folicules reached the right size, this indicates the prefect moment to make them ovulate through an injection. The doctor will indicate the exact moment when the medicine to ovulate should be applied, having the extraction of the eggs done 36 hours before the ovulation. This control should be done by specialists, through vaginal ultrasound, in order to avoid any complication such as a multiple pregnancy or ovaric hyperstimulation syndrome. Show more Semen preparation in the lab The day of the eggs extraction, just a few hours before the procedure, the semen sample is prepared. This sample is capacitated in the andrology lab to select the best sperm. Once selected, they are prepared to impregnate the egg. Ovarian punction: egg extraction Before the ovulation happens, the eggs are extracted and placed in culture media inside special incubators in the embriology lab. The extraction is performed with a needle that is introduced in the vagina with the help of an ultrasound. This step is known as ovarian punction. This procedure lasts about 20 minutes and a light sedative is used in order to ease the pain. It is not necessary any incision so, there will be no scar. After the punction, the patient remains at ease for some hours, waiting for the effects of the sedative to go away. The patient can go home righ after. Insemination of the eggs and embryo culture Once we have the sperm and eggs, the impregnation is done in the embriology lab. This can be done in 2 ways: Conventional in vitro fertilization: in a drop of culture media, some capacitated sperm is placed together with the egg. This way, the Intracytoplasmic sperm injection joins the egg to fertilize it. Sperm Intracytoplasmic sperm injection: with the help of pipettes and an special microscope, one sperm is chosen and injected directly inside the egg After, the inseminated eggs are placed inside incubators and left in the culture during 19 hours, when then they are observed to know if they are fertilized or not. Embryo transfer After 3 or 5 days in culture media, the embryo are transfered inside the uterus. This is a procedure that does not need anesthesia, lasts a couple of minutes and the disconfort is similar to that of a Pap test. 15 days later, a pregnancy test is done.