For Couples

The decision to start a family may depend on various factors that include: age, economic instability, career, health issues, family obligations, presence/absence of a partner, and feeling of not being emotionally ready.

Couples with fertility issues

The inability of couples or women to have children, termed infertility, has been an issue since ancient times. Infertility affects couples and women of all walks of life and does not discriminate. Although spontaneous pregnancy can occur in women of advancing age (> 43) and there are some documented cases of postmenopausal women naturally conceiving, these are rare. With the consideration of health and the ability to carry a pregnancy to viability, the use of modern technology and genetic engineering techniques have given women hope through their infertility journey. Women are not considered infertile until all options have failed, which is why some authorities use infertility synonymously with sterility. Therefore, at Michigan Fertility Services, we prefer the word subfertility because most women have reduced fertility and often get pregnant with time, albeit some following treatment.

When couples or women decide to start a family, they often expect to be successful within 3 to 4 months. Usually, such individuals do not have knowledge of when best to have intercourse for the purpose of conceiving, and when they do, they often do not appreciate that humans do not get pregnant every month (only about 25% do) they have intercourse; in fact, nobody does. This is how humans are made, as the egg ovulated every month is not always normal, as is the sperm that first encounters the egg. Thus, getting pregnant can take up to 1 year. Given that the proportion of abnormal eggs relative to normal increases with age, we often begin investigation after 6 months of trying in those ≥ 35 years old.

Couples should be aware that the cause of subfertility is distributed equally between both sexes. Subfertility (infertility) is diagnosed in females and males in equal proportion in 35% of couples, and as a combined problem in 20%, while in the remaining 10%, the cause is unknown after baseline investigations are completed and is termed unexplained.
Unexplained infertility only means that no abnormality can be found after basic investigations. Modern technological advances, such as sperm DNA fragmentation testing, IVF, embryo testing, as with preimplantation genetic testing, can shed more light on the reasons for subfertility, and are unknown unless patients go that far in their subfertility treatment.

Expectations for your first visit

Evaluation of subfertility

Your evaluation will be divided into two sections:
1. Investigations to ensure you are in good health, and if any health issues are discovered or you have existing medical issues, optimization of your health to ensure your pregnancy is uneventful or likely complications are known beforehand and plans made to minimize them.
2. Investigations related to optimizing your chances of getting pregnant from whatever treatment you choose to have.

Although preliminary infertility investigation requires semen testing, investigations to ensure the inside of the uterus is normal and the fallopian (uterine) tubes are open, you should know that these investigations are indirect and do not always determine the cause of your inability to get pregnant. For example, we test to determine whether your uterine tubes are open; this is only a physical test because an open tube does not equate a normal tube, and your partner having normal semen analysis results does not reveal all that we need to know about sperm disorders (dysfunction).

Some clients need special consideration, and we handle them individually as necessary. These include, but are not limited to:
1. Women with advanced female reproductive age of 40 years or older.
2. Women with a family history of early menopause because such women may have an older ovarian age compared to their actual age.
3. Patient diagnosed with cancer who needs egg freezing before starting their oncology treatment.
4. Women with recurrent pregnancy loss
5. Women and men with a family history of genetic diseases or who are carriers of inherited genetic disorders who wish to avoid passing this disorder on to their offspring. These couples can undergo IVF, have their embryos tested before one is placed into their uterus, a procedure termed pre-implantation genetic testing.
6. Women with a history of conceiving or delivering chromosomally abnormal babies

What we look at

Ensuring that you are immune to common viruses that can affect your health and infect the baby if you are infected with them when pregnant. These include:
1. Rubella.
2. Hepatitis
3. Chicken Pox
4. Measles

Ensuring that you are in good health and, if any health issues are discovered, ensuring you are adequately treated and put in contact with physicians who are likely to be involved in your care during pregnancy. This includes:
1. Diabetes
2. Hypertension
3. Lungs, Heart, liver, and kidney disease

Evaluating egg quality by ovarian reserve testing. These tests indirectly measure a woman's ovarian age. We usually do not need to test whether a woman is ovulating because we often can ascertain this from taking a detailed history. Ovarian testing involves performing the following tests:
1. In the early part of the menstrual cycle, specifically between days 2 and 5, the pituitary gland (in the brain), as it were, kick-starts the ovary to work every month. The amount of hormones it produces to do this is a function of how difficult it is, and thus, how advanced the ovarian age is. The hormones we measure in this regard are Serum follicle-stimulating hormone and estradiol
2. The other hormone we measure is not cycle day specific and is called anti-mullerian hormone (AMH). Levels below 1 suggest diminished ovarian reserve (DOR).

Evaluation of Sperm: This is performed by analyzing the sperm produced by masturbation under the microscope after no more than 2-7 days of abstinence for concentration, movement, and shape.

Eggs and embryos are transported into the uterus through the fallopian (uterine)tube. The uterine tubes and cavity are assessed by saline infusion sonohysterogram with ultrasound imaging or hysterosalpingogram. Occasionally, a diagnostic hysteroscopy may be necessary to further evaluate the uterine cavity and may be converted to an operative procedure to remove intrauterine polyps, lyse adhesions, and resect the uterine septum.

Couples with recurrent pregnancy loss

Recurrent pregnancy loss (RPL) affects 1-2% of all fertile couples. It is defined as two or more consecutive pregnancy losses in which an appropriately rising quantitative hCG level was documented, pelvic ultrasound had demonstrated intrauterine pregnancy that ultimately fails, or histopathological examination of the product of conception confirmed pregnancy tissue.

The American College of Obstetricians and Gynecologists (ACOG) guideline recommends that after two miscarriages, a thorough physical exam and testing should be performed. This definition does not include pregnancies that are confirmed to be located outside of the uterus, such as in the fallopian tube, called ectopic pregnancies.

While ACOG and the American Society for Reproductive Medicine (ASRM), define RPL as two or more losses, others, particularly in the UK, may define it as three or more consecutive losses. It is recommended that clinical evaluation should begin after two losses, given the emotional and physical pain associated with miscarriage. Most women with two previous consecutive miscarriages would not want to wait for a third loss before seeking a solution.

Another controversy in the definition of RPL is whether or not it needs to be consecutive. For example, patients with livebirths between their two miscarriages should not be labeled as having RPL. The American Society for Reproductive Medicine (ASRM) definition suggests that the miscarriages do not necessarily have to be consecutive. Others, specifically, require consecutive losses, like those from the French National College of Obstetricians and Gynecologists (CNGOF) and the European Society for Human Reproduction and Embryology (ESHRE). To buttress the idea of including nonconsecutive miscarriages in the definition of RPL is that humans with balanced chromosomal translocation (rearrangement) have this in one pair of chromosomes, the other being normal. Such people (male or female) may transfer either the balanced or the unbalanced chromosome to their offspring. When a balanced chromosome is transferred, the baby is normal and does not miscarry as long as other rare causes of miscarriage are absent.

Evaluation of RPL

Evaluation for RPL requires a detailed history, physical examination, and workup, including testing for the following.
1.Autoimmune antibodies
a.Antiphospholipid antibodies
b.AntiPP1Pk antibodies
2.Recurrent pregnancy loss (RPL) occurs in polycystic ovary syndrome (PCOS), which occurs in ∼50% of total pregnancies. Several hypotheses of RPL in PCOS are insulin resistance (IR), obesity, and hyperhomocysteinemia (HHcy).
3.Thyroid function measuring thyroid-stimulating hormone (TSH) and free thyroxine levels
4.Serum Prolactin
5.Hemoglobin A1c (HgbA1c) and if elevated at MFS, we perform a 2-hour 75 G glucose tolerance test with insulin levels.
6.Karyotype for her and her partner to ensure they are not carriers of balanced translocations.
7.Perform saline infusion sonohysterogram between days 6-10 to exclude uterine septum or intrauterine polyps and myomas

Treatment

Couples with Recurrent Pregnancy Losses should be counseled that in more than 50% of cases, we are unable to have a precise diagnosis of the etiology of pregnancy loss, and the most likely cause of early pregnancy loss is genetic abnormalities in the baby. Patients should be reassured that all is not gloomy because, whatever the outcome of the testing, they still have a high chance, up to 70%, of having a live birth with their subsequent pregnancy. Even after having three miscarriages, a woman still has a 60%-80% chance of conceiving and carrying her pregnancy to full term.

Potential Detectable Causes and Treatment: Treatment will depend on the results of investigations and will vary from ovarian stimulation and timed intercourse (TI) or intrauterine insemination (IUI), to IVF. In addition, treatment will depend on the attendant success rates, patients are happy with, how much funding they want to commit to treatment, and whether there is a genetic etiology to the RPL.

For more information on potential detectible causes of RPL, please visit our Educational Resources page.

Couples with a risk of transmitting genetic disease(s) to their offspring

Most, if not all, of us carry or inherit abnormal genes. This is why it is not advisable to have a child with our siblings, our cousins, and even our relatives, for fear of those genes coming together to give rise to recurrent miscarriages or an abnormal child. To buttress this point, there are several communities around the world with high rates of consanguineous marriages with associated increased risk of children being born with genetic disorders and birth defects. In addition, single-gene disorders usually show a pattern of inheritance within a family, race, and ethnicity for specific genetic diseases, such as cystic fibrosis, spinal muscular atrophy, Fragile X, Sickle Cell disease, and Thalassemia.

Genetic screening

At MFS, we recommend that all our female patients have genetic screening that would reflex to testing the male partner to exclude the inheritance of mutations that their spouse inherited.

We also offer patients Preimplantation Genetic Testing (PGT). It helps in the identification and selection of embryos with the correct amount of genetic material, preventing potential miscarriages and the birth of children with congenital anomalies. It also aids in selection of a single healthy embryo for transfer, thereby decreasing the risk of multiple births.

Preimplantation Genetic Testing

There are now four types of Preimplantation Genetic Testing (PGT). In PGT, embryos created from an in vitro fertilization (IVF) cycle can be genetically tested before being implanted in a woman’s uterus. Note that numerous studies show a significant proportion of aneuploid embryos are capable of achieving the highest morphology score and there is no clear distinction made between chromosomally normal and abnormal embryos by morphology assessment alone. The process involves to taking a few cells from the trophectoderm (cells from the shell that is coats the embryo (baby) before it is ached and that is destined to form the placenta. There are now several platforms available for testing the cells obtained by trophectoderm biopsy. These platforms include fluorescence in situ hybridization (FISH), quantitative PCR (qPCR), array comparative genomic hybridization (aCGH), single-nucleotide polymorphism (SNP) arrays, and next-generation sequencing (NGS). At MFS we used NGS for PGT.
1.PGT-A – Used to screen for aneuploidies
PGT-A has platforms to examine all 24 types of chromosomes in cells obtained from biopsy of the blastocysts. 2.PGT-M - (Monogenic/Single-gene) tests. Both single gene mutations (PGD) and the entire DNA complement (PGS/CCS) can be analyzed after embryo trophectoderm biopsy. PGT-M can be used for all monogenic diseases whose responsible gene is known. Specific indications for PGT-M involve X-linked disorders (e.g., Duchenne muscular dystrophy), Y-linked disorders, autosomal dominant disorders (e.g., Huntington disease), autosomal recessive disorders (e.g., cystic fibrosis), mitochondrial disorders, and some severe disorders with high genetic predisposition (e.g., hereditary breast and ovarian cancer). PGT-M can also be used for HLA typing (to identify an HLA-compatible embryo for an affected sibling in need of a transplant), although this generates various ethical concerns. Genetic testing can be used to select embryos free from specific genetic diseases.
3.PGT-SR – Preimplantation Genetic Testing for Structural Rearrangements. It is used on embryos to detect chromosomal structural abnormalities, such as translocations, inversions, and deletions, that might be present in the parents.

If you have genetic inherited disorders, know there is real hope in realizing your dream of having a healthy baby.

For more information regarding genetics, please visit our Educational Resources Page.

Leading Experts

By conducting a thorough fertility evaluation and ensuring optimum health before treatment, Michigan Fertility Services promises to provide real hope for couples with fertility issues. Dr. Awonuga will be actively involved with your treatment to the last detail and will customize your treatment according to your specific situation.

Please contact us to discuss the best treatment options available for treating your infertility issues.

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Our Story

Since 1992, Dr. Awonuga has been helping couples and women achieve their dream of taking a baby home following infertility treatment. Once practiced as Division and Fellowship Program Director at Wayne State University/Wayne Health Reproductive Endocrinology and Infertility practice, he has now opened Michigan Fertility Services. Dr. Awonuga is an active researcher and continues to collaborate with scientists at the C.S. Mott Center for Human Growth and Development at Wayne State University. With extensive experience in the field, at Michigan Fertility Services we will educate our patients and be gentle, ethical, and respectful. These are essential because as inability to conceive and have children is associated with anxiety and psychological stress. Dr. Awonuga understands and will help manage these facets with an appropriate referral if necessary.