Question: What is a colposcopy and what happens during the procedure?

Answer: If a Pap smear detects cell changes, or if your doctor can see dysplasia during the smear, the next step is to perform a colposcopy. A colposcopy is a medical procedure that allows a physician to view your cervix with a microscope. It is performed right in the doctor's office and takes between 15-30 minutes to complete.

The procedure is done with an instrument called a colposcope. It is simply a small binocular microscope and is not inserted internally. Many colposcopes have the ability to project the image of the cervix on a monitor.

You will be asked to lay down and put your feet in stirrups, as you did for your Pap smear. The doctor will then insert a speculum into the vagina, widening the canal.

Next, an acetic solution (vinegar) will be applied to your cervix with a cotton swab. When the solution is applied, abnormal cells will turn white. This allows the doctor to identify abnormal cells.

If abnormal cells are found, the doctor may decide to do a biopsy. A biopsy means that a small sample of tissue is removed using small forceps. The amount of samples taken depends on the the area of cells that are abnormal. You may feel discomfort as samples as taken. Anesthesia is not usually given.

Please remember that it is important to abstain from douching and intercourse 48 hours prior to the colposcopy. Be sure to inform your doctor is you are pregnant, as this may change the way the procedure is done.

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Q: What is IUI?

An IUI -- intrauterine insemination -- is performed by threading a very thin flexible catheter through the cervix and injecting washed sperm directly into the uterus. The whole process doesn't take very long — it usually only requires the insertion of a speculum and then the catheter, a process that maybe takes a couple of minutes (60-90 seconds to introduce the catheter, then sperm injection, and another 60 seconds or so to remove the catheter — going slowly helps reduce discomfort). Sometimes when the cervix is hard to reach a tenaculum is used to hold the cervix, which makes the process a bit more uncomfortable. A typical "Tomcat" catheter is shown below.

Q: Where is the sperm collected? How long before the IUI?

Usually the sample is collected through ejaculation into a sterile collection cup, but it is also possible to obtain collection condoms for this purpose. Most clinics want the semen to be delivered within a half hour of ejaculation, around the time of liquefaction, so if one lives close enough the sample can be collected at home. If not, one has to make do with a room at the clinic, a bathroom, or any private setting.

There is a delay between when the semen sample is dropped off for washing and when it is inseminated. The amount of time depends on the washing technique used, which takes 30 minutes to two hours, as well as on the clinic's scheduling. Most will perform the IUI as soon after washing is completed as possible.

When is the best timing for an IUI?

A: Ideally an IUI should be performed within 6 hours either side of ovulation — for male factor infertility some doctors believe after ovulation is better, otherwise chances of success are higher with insemination before ovulation with the sperm waiting for the egg. When timing is based on an hCG injection, the IUIs are usually done between 24 and 48 hours later. Typical timing would be to have a single IUI at about 36 hours post-hCG, though some do it at 24 hours, and some clinics are reporting better results when doing the IUI at 40-42 hours post-hCG. If two IUIs are scheduled, they are usually spaced at least 12 hours apart between 24 and 48 hours after the hCG. Some reports show no increase in success rates with two IUIs, but others suggest it may increase success as much as 6 percent.

Some doctors will base timing of IUI on a natural LH surge. In that case, a single IUI at 36 hours is the norm, but doing them at 24 hours is also pretty common since ovulation may be a bit earlier. When two inseminations are planned, they are usually timed between 12 and 48 hours after the surge is detected.

The egg is only viable for a maximum of 24 hours after it is released.

Q: What is the success rate for IUI?

Basically the odds of success are reported to be just under 6 percent and as high as 26 percent per cycle. The low statistics are with one follicle, while multiple follicles resulted in as high 26 percent success. Another influencing factor is sperm count. Higher sperm counts increase the odds of success; however, there was little difference between success with good-average counts and those with high counts. The overall success rate seems to be between 15-20 percent per cycle

Q: What does an IUI feel like?

Most women consider IUI to be fairly painless -- along the same lines as having a pap smear. There can be some cramping afterward, but often what is felt is ovulation-related rather than from the IUI. The catheter usually doesn't feel like much since the cervix is already slightly open for ovulation -- a poorly timed IUI might cause more discomfort at the cervix. See the personal experiences below for more details.

Q: How long does washed sperm live?

Current research indicates that washed sperm can live 24-72 hours; however, it does lose potency after 24 hours. Another issue with IUI is that the sperm can keep on swimming beyond the fallopian tube, so the ideal window is really within 6-12 hours of the egg being released; with a larger margin before ovulation than after since the egg's viability is shorter. Sperm can live up to 5 days in fertile mucus, 2-3 days being pretty common, so combining IUI with intercourse may provide better coverage.

Q: Do I have to lay down after an IUI?

A: You don't have to lay down because the cervix doesn't remain open, but most doctors let patients lay down on the table for 15-30 minutes after the procedure.

Q: Do I need to take it easy after an IUI?

Most people don't need to, but if you had cramping or don't feel well afterward it makes sense to take it easy for awhile. Some people reduce their aerobic activity and heavy lifting during the luteal phase in hopes it will increase the chance of implantation. It is more important to take it easy for a bit after IVF, as that is a more invasive process.

Q: How long before an IUI should the male abstain from intercourse/ejaculating and store up sperm?

This depends on your individual situation, but it usually should not be more than than 72 hours since his last ejaculation in order to ensure the best motility and morphology. Where low sperm count is the reason for IUI, it is generally best to wait 48 hours between ejaculation and collecting sperm for the IUI. With no sperm count issues, it makes sense to wait at least 24 hours. Some suggest trying for about 36 hours to cover the most territory with the highest counts — a common suggestion is to have intercourse around the time of hCG injection.

Q: How soon after an IUI can I have intercourse?

Usually you can have intercourse anytime after an IUI . . . in fact, most doctors suggest having intercourse, when that is an option, soon after the last IUI to help make sure ovulation is covered. Your doctor may suggest waiting 48 hours to resume relations if you had any bleeding during the IUI or if a tenaculum is used.

Q: Can the sperm fall out?

Once the sperm is injected into the uterus, it does not fall out. There can, however, be increased wetness after the procedure because of the catheter loosening mucus in the cervix and allowing it to flow out. Some doctors will insert a cup around the cervix to prevent leakage, but most do not.

Q: How come I feel wetter after the IUI — like the sperm is falling out?

The catheter loosens cervical mucus and lets it come out more easily. It is common to see more fertile mucus after an IUI for this reason, as well as the fact that well-timed IUI should be close to ovulation.

Q: How many follicles give my best chance of getting pregnant?

According to different studies, either 3-4 follicles gives one the best chance of getting pregnant, while more follicles beyond that simply increases the risk of multiples. The U.S. study said 4 follicles, while other countries have data stating 3. The U.S. has a higher rate of multiple births, so 3 may be more likely to be the correct answer.

Q: Does IUI make sense when there isn't a sperm count problem?

IUI can help on Clomid cycles where cervical mucus is a problem, and IUI increases the chance of success on injectable cycles no matter what the sperm count. It does make sense to try IUI if you can and haven't had success with intercourse. It is important to note that with intercourse, only the best and strongest sperm make it through the cervical mucus and up into the uterus and fallopian tubes. With IUI, more sperm will be available for fertilization.

Q: How high a sperm count is needed for IUI?

A count above one million washed appears necessary for success, with a significant reduction in pregnancy rates when the inseminated is count is lower than 5-10 million (in other words, in most cases one should consider 5 million a lower limit for success, 10 million for cost-effective). Higher success rates are with washed counts over 20-30 million, while increasing counts over 50 million did not appear to offer advantage. Advanced Fertility has a chart of success rates for one month of various treatments.

Q: How many IUIs should I try before moving on to IVF?

It depends on what you can afford and what meds you are doing. One might do 3-4 IUIs on Clomid before moving on to injectables, then do 3-4 cycles on injectables. If one doesn't have success after four good ovulatory cycles on injectables with well-timed IUI, it would be time to consider IVF.

Q: Can IUI be done at home?

An IUI shouldn't be done at home without medical supervision because the sperm needs to be washed to prevent infection -- i.e., separated from the semen. A vaginal insemination can be done at home, but is no more successful than intercourse. Some doctors are willing to instruct on doing ICI (intracervical insemination) at home, but it should not be attempted without being taught proper technique. Getting semen or air into the uterus could be quite dangerous -- perhaps life-threatening. One woman wrote in to say there is a midwife practice in Berkeley, CA, that will do inseminations at the patient's home, so it may be worth asking about.

Q: Is bleeding common after an IUI?

 It doesn't usually happen, but it isn't uncommon. It is most common to have some bleeding if the doctor had trouble reaching the cervix. Some women also have light bleeding with ovulation.

Q: How long after IUI should implantation occur?

Implantation generally takes place 6-12 days after ovulation — so 6-12 days after a well-timed IUI. See abstract.

Q: At what size are follicles considered mature?

Many doctors monitor follicle development during IUI cycles. Most trigger when the dominant follicle is within a certain size range. While there is always some difference in doctor preference, the norms are unmedicated 20-24mm, clomiphene citrate 20-24mm, FSH-only meds 17 or 18mm minimum, and FSH+LH would be 16 or 17mm minimum. It is possible for slightly smaller follicles, 14-15mm, to contain a viable egg. Also, follicles continue to grow until they release, usually at a rate of about 1-2 mm per day. A woman may ovulate more than one follicle in a cycle, but the releases will occur within 24 hours. When hCG is not used, only follicles close in size are likely to release. The use of hCG induces ovulation in about 95 percent of women, and will get most mature follicles to rupture.

Q: What are the risks involved in IUI?

The main risks are some discomfort such as cramping, minor injury to the cervix that leads to bleeding or spotting, or introduction of infection (including sexually transmitted disease from the sperm itself — it helps to be sure of the known donor's health, or use carefully monitored frozen specimens). There are also risks of hyperstimulation associated with the use of ovulation induction medications such as clomiphene citrate (low risk) and gonadotropin therapy (higher risk). Proper technique and adequate monitoring reduce risks.

Q: Can I take pain medications before or after the procedure?

Most women don't need medication for pain associated with IUI. If there is cramping, it is best to avoid medications such as ibuprofen and naproxen (NSAIDS), but Tylenol is considered safe (but maybe not that helpful for cramps).

Q: What does "sperm washing" mean?

It is sometimes also called sperm preparation or spinning. It is a laboratory technique for separating sperm from semen, and separating motile sperm from non-motile sperm, for use in assisted reproduction (IUI, IVF).

The washing technique for near normal specimens is mixing the ejaculate after liquefaction with the appropriate washing medium followed by centrifugation. (A centrifuge is a machine that separates materials with different densities by spinning them at high speed.) The supernatant is discarded and the sediment (sperm rich fraction) is re-suspended in more washing medium. This process is repeated 2-3 times maximum. In the final wash, the sediment is re-suspended in 0.5 cc of medium, loaded into a syringe and deposited in the uterus.

The "Sperm Rise" or "Swim-up" technique is one in which two to five cc of medium are carefully layered on top of 0.2-0.5 cc of semen. Motile sperm cells "swim-up" into the culture medium. After some time (30-90 minutes) the medium (containing motile sperm cells) is carefully harvested and centrifuged. If necessary, fresh medium is layered on top of the seminal fluid again to harvest more sperm cells.

The discontinuous gradient centrifugation technique utilizes a dense liquid phase to separate sperm cells from seminal fluid and debris. There are different compounds commercially available that may be used. Semen is deposited on top of this fluid and subjected to centrifugation. Motile sperm cells migrate to the bottom of the tube, which are used for IUI after further washing.

Q: How soon after an IUI can I go swimming?

Since the vagina doesn't open unless something pushes it, it is OK to swim shortly after your IUI but because of how much one has invested in getting pregnant, it probably makes sense to wait 48 hours after your IUIs to go swimming.

Q: Can IUI work after tubal ligation (having "tubes tied")?

No. A tubal ligation is effective birth control because it prevents the sperm and egg from meeting. The process that leads to pregnancy is having an egg released from a follicle in the ovary and then beginning the journey to the uterus through the fallopian tube. Sperm will travel from the vagina, through the cervix, through the uterus, into the tube where fertilization occurs. IUI bypasses the need for the sperm to travel through the cervix, but that's it. It doesn't get the egg to the other side of the obstruction, so fertilization won't take place. The only way to get pregnant after tubal ligation is by having reversal surgery or an assisted reproduction technology that includes egg retrieval, such as in vitro fertilization (IVF).

What is infertility?

Most experts define infertility as not being able to get pregnant after at least one year of trying. Women who are able to get pregnant but then have repeat miscarriages are also said to be infertile.

Pregnancy is a complex chain of events

• A woman must release an egg from one of her ovaries (ovulation).
• The egg must go through a fallopian tube toward the uterus (womb).
• A man's sperm must join with (fertilize) the egg along the way.
• The fertilized egg must attach to the inside of the uterus (implantation).
• Infertility can result from problems that interfere with any of these steps.

Is infertility a common problem?

About 12% of women aged 18-44 had difficulty getting pregnant or carrying a baby to term 

Is infertility just a woman's problem?

No, infertility is not always a woman's problem. In about one-third of cases, infertility is due to the woman (female factors). In another third of cases, infertility is due to the man (male factors). The remaining cases are caused by a mixture of male and female factors or by unknown factors.

What causes infertility in men?

Infertility in men is most often caused by:
• Problems making sperm -- producing too few sperm or none at all 
• Problems with the sperm's ability to reach the egg and fertilize it -- abnormal sperm shape or structure prevent it from moving       correctly
• Sometimes a man is born with the problems that affect his sperm. Other times problems start later in life due to illness or injury. • For example, cystic fibrosis often causes infertility in men.

What increases a man's risk of infertility?

The number and quality of a man's sperm can be affected by his overall health and lifestyle. Some things that may reduce sperm number and/or quality include:

• Alcohol
• Drugs
• Environmental toxins, including pesticides and lead
• Smoking cigarettes
• Health problems
• Medicines
• Radiation treatment and chemotherapy for cancer
• Age

What causes infertility in women? 

Problems with ovulation account for most cases of infertility in women. Without ovulation, there are no eggs to be fertilized. Some signs that a woman is not ovulating normally include irregular or absent menstrual periods.

Less common causes of fertility problems in women include: 
Blocked fallopian tubes due to pelvic inflammatory disease, endometriosis, or surgery for an ectopic pregnancy
Physical problems with the uterus
Uterine fibroids

What things increase a woman's risk of infertility?

Many things can affect a woman's ability to have a baby. These include:

• Age
• Stress
• Poor diet
• Athletic training
• Being overweight or underweight
• Tobacco smoking
• Alcohol
• Sexually transmitted diseases (STDs)
• Health problems that cause hormonal changes

A laparoscope is a special telescope designed for medical use. It is connected to a high intensity (fiber-optic) light source as well as a high-resolution television camera. This allows the surgeon to view the abdominal cavity. The laparoscope is placed into the abdominal cavity through a hollow tube (trocar) and the image is viewed on a TV monitor.

What are the advantages of laparoscopic surgery?

There are many advantages over traditional open surgery. People who undergo laparoscopic procedures often have a shorter hospitalization. On average 1 to 2 days for laparoscopic versus 5 to 7 days for open surgery. Also, since laparoscopy utilizes much smaller incisions, the risk of wound infection is less and consequently the risk of hernia formation is less. While postoperative pain is different for everybody, patients often report much less pain after laparoscopy.

What are the complications associated with laparoscopic surgery?

The most frequent complications of any operation are bleeding and infection. There is a small risk of other complications that include, but are not limited to, injury to the abdominal organs, intestines, urinary bladder or blood vessels. As with any laparoscopic procedure, there is a chance of "conversion" to the open procedure. Most often this occurs to people that have had many previous abdominal surgeries and have a lot of scar tissue. In the hands of experienced laparoscopic surgeons conversion to open is very rare.

What procedures (operations) can you do laparoscopically?

Procedures

I have had surgery in my abdomen before. Am I a candidate for laparoscopic surgery?

.While you will be at a higher risk of being "converted" to an open operation, we believe that most patients deserve the opportunity to have a laparoscopic procedure. Some surgeons will not attempt laparoscopic surgery on patients with previous open abdominal surgery. With our experience, we have learned that many patients can be done laparoscopically.

I was told that I was not a candidate for laparoscopic surgery. Can you do it laparoscopically?

There are not set guidelines on who should be done laparoscopically. Various factors play a role in laparoscopic surgery. If one surgeon does not believe that he/she can perform the operation laparoscopically, we would be happy to give our opinion for your individual circumstance. The vast majority of procedures we perform (95%) are done laparoscopically.

Is the pain similar to "open" procedures?

Laparoscopic surgery is not "pain-less", but rather "less-pain". In traditional open surgery, often a large 6 to 8 inch incision is made on the abdomen. During laparoscopic surgery, 4 to 6 quarter-inch incisions are made on the abdomen. These incisions allow special instruments to be placed in to the abdominal cavity that will allow the surgeon to complete the case.

What can I expect after surgery?

Most people go home within 1-2 days (depending on the procedure performed). When you go home you will have some soreness around the incisions; this is normal. Your pain will get better every day, even though you may still need to take oral pain relievers. You will be able to shower (no baths/pools/soaking in water for 10-14 days). You will be able to go up and down stairs and you will be able to drive when you feel up to it, as long as you are not on narcotic pain relievers. You will receive detailed postoperative instructions as well as contact information. We are available 24 hours a day even after you go home.