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Checkups for Infertility couples

  • Female
 Hysteroscopy (H-scopy)
H-scopy uses a hysteroscope to examine if the uterus and uterine lining are normal. There is a direct correlation between the condition of the uterus and embryo implantation. 

Patient will be asked to lie on her back on the examination table with feet raised and supported by stirrups, similar to a pap smear or vaginal exam. An optical instrument connected to a video unit with a fiber optic light source is inserted to check the conditions of the uterus.

If only a simple examination is required, there is no need for anesthesia. The whole process takes about 3 mins, after which, the patient is asked to rest for another 30 mins. For further examination and operation, anesthesia will be administered and the process will take about 5 mins. Resting period is an additional 1-2 hours.

When to test:
Best time to test is after the last menstrual cycle and before ovulation takes place for the next cycle. If it is a regular cycle of 28 days, the best time will be in the morning of the 7th to 11th day.

Cervical cultures

Inflammation of female genital tract includes viginitis, cervicitis, salpingitis and pelvic inflammatory disease (PID). Chronic inflammation may cause endometirum polyp(s), tubal adhesion, obstruction and/ or hydrosalpinx, etc. Bacteria, Chlamydia trachomatis and human papillomavirus (HPV) are 3 most common pathogens.

Auto-immune system 

Through blood tests, we can determine whether patients' immune system is normal or not. Some patients' immune system will attack embryo after implantation, which will affect its bedding procedure or even cause miscarriage.

We suggest blood tests if you have any of the following symptoms : 
1. infertility with unknown reason, advance age, premature ovarian failure, constitution allergy
2. Recurrent miscarriage or habitual abortion ※Def :  ≥ 2 miscarriages within AP20wks 

What items are included in the blood test ? 

1. Anti-Thyroglobulin antibody (ATA)
2. Anti-Thyroid peroxidase antibody (Anti-TPO)
3. Anti-Extractable nuclear antigen antibody panel (Anti-ENA)
4. Anti-Thyroglobulin antibody (ATA)
5. Anti-Thyroid peroxidase antibody (Anti-TPO)
6. Anti-Extractable nuclear antigen antibody panel (Anti-ENA)
7. Anti-Phospholipid antibody (APS)
     -Anti-b2 glycoprotein IgG/IgM (B2GP)
     -Anti-cardiolipin IgG/IgM (ACA)
     -Lupus anticoagulant

Blood test for couples’ chromosome
Based on stats, over 70% of spontaneous abortion are related to abnormality of fetus’ chromosome. It is important to check for couples’ chromosome if you have any of the following symptoms:
  1. Infertility with unknown reason, poor sperm quality, azoospermia 
  2. Fail implantation with accumulated 4 GBR or 2 blastocysts with normal chromosome
  3. Recurrent miscarriage or habitual abortion Def :  2 miscarriages within AP20wks

  • Male 
Blood test- hormone levels
For patients that cannot find sperm at multiple sperm analyses, doctor collect the first will collect urine sample after ejaculation, to eliminate the possibility of obstructive azoospermia. After that, blood tests are suggested to evaluate patient’s spermatogenesis.  

How to read the reports?

Dysfunction of hypothalamus or pituitary gland (lack of hormone to produce sperm)
Blood test results
Low in FSH & LH
Low in Testosterone
High in PRL
Treat with injections (retain hormone supplies)
Treat with medicines
 Transfer to oncology after Docotr`s evaluation
Dysfunctional testiculus   
Blood test results
 High in FSH & LH
Testosterone normal or lower than average
High in PRL
Treat with injections + MESA /TESA
IVF with donated sperm
Treat with medicines

Ductus deferens blockage

Blood test results
Normal in FSH & LH
Normal in testosterone

Blood test for couples’ chromosome
Based on stats, over 70% of spontaneous abortion are related to abnormality of fetus’ chromosome. It is important to check for couples’ chromosome if you have any of the following symptoms:
  1. Infertility with unknown reason, poor sperm quality, azoospermia 
  2. Fail implantation with accumulated 4 GBR or 2 blastocysts with normal chromosome
  3. Recurrent miscarriage or habitual abortion Def :  2 miscarriages within AP20wks

Stork Fertility Center Stork Fertility Center Author

Endometrial Receptivity Array (ERA)

Have you ever heard the phrase of personalized precision IVF?
Nowadays, the individualized medication is more prevalent.

Embryo implantation is a highly complex process incorporating with a healthy embryo, a receptive endometrium, and a molecularly communicative dialogue in between. Until 2016, Stork Fertility Center has comprehensive applied individualized COSIMSI/ICSI, blastocyst culture, PGS/PGDdonor gametes, and frozen embryo transfer for the cases with specific indications. Moreover, all patients would be requested to take the hysteroscopyhysterosalpingograrphy, and cervical bacteria culture before entering the transfer cycle. However, still, some patients failed after couples of transfers. 
Except for the quality of embryos and the physically normal observation of uterus and endometrium (EM) through ultrasound, a hidden culprit must exist in between—the dialogue for permitting implantation. Actually, the human endometrium is a dynamic tissue, which undergoes changes during multiple levels in a menstrual cycle. The changes in histological markers, biochemical markers, molecular markers, and transcriptomics (Omics) have been reported in the previous articles. Generally, the period of EM receptivity is known as the "window of implantation, WOI," which opens during the cycle day 19 or 20 and remains open for 4-5 days. During WOI, the EM becomes functionally competent for the embryo implantation.

Using the assisted statistical tool, principal component analysis (PCA), hundreds of transcriptome (gene expression) during different phase of EM (proliferative [PE], early secretory [ESE], mid-secretory [MSE], and late secretory [LSE]) could be analyzed and clustered into four groups: proliferative, pre-receptive, receptive, and post-receptive.

Through examining these transcriptomes in EM biopsies from different people, several studies found that the WOI is not fixed, as was believed before. It means that a fixed transfer protocol to all the patients could not be applicable. Thus several clinical approaches for detecting the receptivity of EM tissue were developed recently, and the endometrium receptivity array (ERA) was one of them. The ERA was used to analyzed the expression of 238 genes in an EM biopsy obtained from either an HRT or natural cycle. After priming of progesterone in an HRT or of LH in a natural cycle, the EM would be biopsied and analyzed. If the result showed receptive, transferring embryo at the same time in another cycle would be recommended. If the result showed non-receptive, transferring time would be adjusted according to the expressions of pre- or post-receptivity.

Based on the clinical trial of IGENOMIX, a leading team of reproductive genetics in Spain, around 30% in the population had a WOI which is not located in the general frame (P+5 or LH+7), and four-fifths of these non-receptive are pre-receptive (80%). The introduction of ERA has been reported to solve the problem in part of patients suffering from repeated implantation failure, and thus to increase the success rate in IVF.

At Stork Fertility Center, the indications for ERA is as below:
A. Repeated implantation failure after undergoing hysterosalpingogram, hysteroscopy and autoimmune examinations. B. Repeated failures after transferring four Day 5 blastocysts graded over BB in accumulation
The pregnancy rate of transferring a good blastocyst with PGS+ERA can reach at 80%. On the other hand, 10~20% increase compared to those with PGS, only 60~70%. This is the Third generation IVF Plus: “precise selection + precise implantation”.

C. Repeated failures after transferring two euploid blastocysts in accumulation
D. Elderly women over 43 years old.

The pregnancy rate of transferring a good blastocyst with PGS+ERA can reach 80%. On the other hand, 10~20% increase compared to those with PGS, only 60~70%. This is the Third generation IVF Plus: “precise selection + precise implantation”.

Stork Fertility Center Stork Fertility Center Author

Basic Examination

To realize the cause of infertility, we suggest both of the spouses undergoing the following basic examinations:

Preparation for a newborn
The process of pregnancy creates the strongest bonding of mother and baby. Women’s body is designed as a palace welcoming the new birth. The most important 3 factors of a pregnancy are: ovaries, fallopian tube and uterus.


Hormone Study
To estimate the rate of potentially successful pregnancy and if there are any hormonal imbalanaces that causes infertility.
3 indexs of ovarian function:

1.       Prolactin (PRL)
Secreted by pituitary gland, PRL is considering as antagonist of hormone regarding the growth of follicles. Therefore, higher PRL level would inhibit the ovulation, and leads to infertility.

2.       Thyroid-stimulating hormone (TSH)
Secreted by anterior pituitary, higher TSH is usually associated with hypothyroidism. Since the structure of TSH is similar to ovulation related hormone such as LH and FSH, higher TSH would also affect the function of ovarian.

3.       Testosterone
Excessive androgenic hormone due to PCOS or congenital adrenal hyperplasia would lead to female infertility.

Ovarian Reserve Examination
The number of oocytes of a female is fixed after birth. There are about a million of primary oocytes on both sides of the ovaries. As getting older, the number of oocytes would decrease gradually. By taking a blood draw, ovarian reserve examination allows us to realize the ovarian function, which also can be interpreted as a reference for the following treatment.

2 Major Index of Ovarian Reserve
  1. Anti-Mullerian hormone (AMH)
AMH, secreted by follicles, is the most important index of the ovarian function. AMHlevel would be lower as the number of follicles decline.
The correlation between AMH and age
International Facilities
above 6
Stork Fertility Center
above 6

2.       Follicle Stimulating Hormone (FSH)
FSH is one of the hormone that stimulate the maturation of follicles. Secreted by pituitary gland, FSH is also an ovarian reserve index. To rule out the fluctuation, FSH is suggested to test on day 1-3 of the period and repeated for 2-3 times. When FSH>10 mIU/mL, the ovarian function is considered as hugely decline. (NoteFor patients who have done the ovarian surgery or endometriosis, FSH would not be able to represent the ovarian function)

Antral follicle counts (AFC)
AFC is examined on day 1-3 of the period by ultrasound.

Fallopian tube is the spot where the sperm meet the oocyte. Therefore, the patency of the fallopian tubes is important for the following treatment. Intrauterine Insemination(IUI) and Timed Sexual Intercourse(TSI) are both applicable if the fallopian tubes are patent.  However, if there are obstruction or hydrosalpinx in the fallopian tubes, the chances of ectopic pregnancy would increase. Also, the embedding of the embryo would be affected because the inflammatory fluid may flow into the uterus. The best solution of patients with blocked fallopian tubes is to undergo a Salpingectomy and IVF.
HSG is an X-Ray test to examine the condition of the fallopian tubes and uterus to determine if there are any blocked tubes, abnormal uterine structures or growths. It’s recognized as a simple, convenient and with 80%-90% accuracy.

 HSG must be conducted after menstrual period and before ovulation. If cycle is regular (28 days), it is best to conduct the HSG on the 7th -11th day of the cycle. If doing the HSG after day 11 is inevitable, contraception measures must be fulfilled throughout the cycle in case of pregnancy.
The test is usually done in 5-10 minutes, and the doctor will explain the result on the same day.

Transvaginal Sonography(TVS)
Sonography (sona) is used to check the interval reproductive organs for any abnormalities, including the cervix, uterus, ovary and endometrium lining. It is also used to estimate ovulation period and measure uterine wall thickness.
Day 1-3
Size of follicles and ovaries
Ovarian function assessment
Day 12
Number and size of the follicles
Prediction of ovulation
Day 12
Endometrium thickness
Environment of embryo embedding
No discharge
Structure and size of uterus
Environment of embryo embedding
 The sona technician will cover the probe with a condom and gel, and then, insert it into the vagina slowly. The probe sends out sound waves, reflecting body structures to the computer, creating pictures. The procedure would take about 3 minutes.


Semen Analysis

Semen Analysis is done according to 2010 WHO regulations in order to test the forward motility, quality and quantity of sperm collected.
·         Total Sperm number: >39 millions/ ejaculate 
·         Total Motility: >40% motile
·         Progressive Motility: >32% with forward motility
·         Sperm Morphology: >4% normal forms

The formation of sperm cells requires 72-75 days. The quality of sperm is easily influenced by external factors, such as: change in seasons, temperature, body condition and living standards. Handling of semen sample is delicate.
It is not suggested to rely on the results on the first testing due to above possible factors affecting the result. It is better to undergo at least 2-3 examinations.

When could I have the sample collected?
Make an appointment with the fertility center after consultation with the doctor. Please avoid sexual intercourse for 2-7 days prior to the intended day for sample collection.
Where to do the examination?
At Stork Fertility Center – We will arrange a private and cozy room for you. Please collect the sample into a sterilized cup we provided by masturbating.
At your own place - By masturbation, collect the ejaculated sperm in the sterilized cup. Within 60 minutes from time of ejaculation, retrieved sperm sample must be submitted to the clinic. Ideal temperature for transporting sample is around 25

Stork Fertility Center Stork Fertility Center Author