THE MONTREAL FERTILITY CENTRE

For your convenience we schedule fertility appointments during business hours Monday through Friday. As both partners may contribute to infertility, we encourage both of you to come to the first appointment. We are centrally situated in Montreal, steps away from metro, train, taxi and bus stations.

Ideally your first appointment should be scheduled during the first five days of the menstrual cycle. You can expect your visit to last 1-2 hours. At your first visit we may recommend that a semen analysis, ultrasound scan, hormonal profile and a prenatal screen be done. If you have previously had any infertility investigations performed or have been treated elsewhere, please bring a complete copy of your medical record with you.

We ask that you arrive for your appointment about 15 minutes early so that you can complete our self-assessment form. If you wish, you can print our self-assessment form online, and bring the completed copy with you when you come to the centre.

If you are a Quebec resident with a valid medicare card, there is no charge for consultation. However, fees for investigations do apply. If you do not reside in the Province of Quebec, or do not have a valid Quebec medicare card, a $100 fee will be charged for consultation.

We choose to see a limited number of patients and allow ample time for appointments so that you can discuss your options and have all your questions answered. Many of the investigations we outline below may also be completed at the Montreal Fertility Centre on the day of your first visit.

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INVESTIGATIONS

There are several reasons as to why you may have difficulties in conceiving. Here we describe the tests we may use to diagnose where the problem may be.

Semen analysis

Thirty to forty percent of all cases of infertility are attributed to the male. In the last several years there have been significant advances in the way sperm is analyzed. We use an advanced computerized semen analyzer that enables us to assess not only the number of sperm in the ejaculate, but also the characteristics of the spermatozoa movements, which are critical for its ability to fertilize the egg. We can generally perform the semen analysis within about 15 minutes of obtaining the sperm sample, and provide you with the results the same day that you do the test.

Moreover, we can show you your sample by projecting the images from the microscope onto a large video screen while your physician explains the results of the computerized analysis.

We perform semen analyses between 7:30 am and 1:00 pm, Monday-Friday. Call us at least 2 days in advance to arrange an appointment for the analysis.

Ideally, a semen sample should be produced after three days of abstinence. The sample should be produced into a sterile container. Containers are available either from our centre or from your local pharmacy (ask for a sterile urine container). For couples where religious restrictions prohibit semen samples produced by masturbation, we can provide a special collection condom.

Ideally, the analysis of a sample should be done within an hour of the sample being produced. If it takes longer than 1 hour from your home to our centre, we advise you to produce the sample in a private area at the centre. If you produce the sample at your home we advise you to keep the sample well wrapped in a cloth close to your body while transporting it.

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Hormonal testing of the female
In women who have cycles shorter than 24 days or longer than 35 days, ovulation may not be occurring. For this reason we may recommend comprehensive hormonal testing. This may include testing of hormones produced by your pituitary, ovary, thyroid and adrenal gland. These tests are typically done on specific days of the menstrual cycle. When your menstruation starts please call us to schedule the testing. In some cases we may also ask you to do the testing early in the morning and/or on an empty stomach.

If your menstruations occur more than 45 days apart, we may provoke menstruation with medication prior to assessing your hormonal profile.

Assessing ovarian reserve
In many cases we may wish to estimate the number of eggs remaining in your ovaries. One way of assessing ovarian reserve is to measure the level of estrogen and pituitary FSH (follicle stimulating hormone) on cycle day 3 with a simple blood test.

Another way in which we may assess ovarian aging is a Clomid challenge test. A Clomid challenge test involves taking a blood sample on the 3rd and also the 10th day of your menstrual cycle. In between the two blood tests (from cycle days 5-9) we will give you a medication called clomiphene citrate (also called Clomid or Serophene). Clomid is an estrogen receptor antagonist, i.e. it blocks the estrogen receptor. In so doing it increases the amount of FSH that your pituitary gland will release, and this in turns stimulates the ovaries. Potential side effects of Clomid include hot flashes, mood changes, irritability, breast tenderness and headaches. Very rarely patients may notice visual changes. If you encounter any visual changes while taking the Clomid please contact us immediately and stop the medication. You should also be aware that if you conceive in a month in which you are taking the Clomid there is approximately a 10% chance of having twins.

What is often done to complement the blood testing described above is an antral follicle count. An antral follicle count is an ultrasound examination on day 2 or 3 of the menstrual period to count how many follicles are present in the ovaries. More than 5-8 follicles per ovary generally indicate a favorable chance of pregnancy, and more than 12 follicles per ovary is consistent with a polycystic ovary (PCO).

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Ultrasound scan

The ultrasound is performed by inserting a small transvaginal probe (size of a regular tampon). This allows a more accurate image of the ovaries and uterus. The test is done with an empty bladder and is usually not painful.
We use the most sophisticated digital ultrasound equipment that allows detection of even minute abnormalities. We will be looking for benign uterine tumors (fibroids), abnormal growths of the endometrial lining (polyps), and the size and appearance of the ovaries. The test is generally done at the beginning of your menstrual cycle. Call us when your menstruation starts and we will perform the ultrasound within the first 4 days of your menstruation.

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Investigations of the of the anatomy of Fallopian tubes and uterine cavity
If the Fallopian tubes are closed, it is very unlikely that sperm will reach the egg. Moreover, if the uterine cavity is malformed implantation is more difficult and miscarriage is more common. Checking the anatomy of the tubes and uterine cavity is therefore important. There are two minimally invasive tests that may be used to confirm uterine and tubal integrity: the hysterosalpingogram and the sonohysterogram.

Both of these tests are generally performed between cycle days 5-12 of your menstrual cycle, i.e. after the bleeding has stopped but before you may have ovulated.

Both of these tests may be uncomfortable and carry a small risk (3-4%) of pelvic infection. For this reason we recommend that you take ibuprofen 1-2 hours prior to these procedures. We may also prescribe an antibiotic for you to take prior to either of these tests. Do not plan to drive or go to work immediately after these tests as you may be too uncomfortable.

Sonohysterogram (SHG, saline infusion ultrasound)
A sonohysterogram involves placing a catheter inside the cervix and then slowly injecting saline under ultrasound guidance. A sonohysterogram allows us to evaluate the anatomy of the uterus, and in particular the endometrial cavity. During the sonohysterogram we may detect fibroids, endometrial polyps, congenital uterine malformations or intrauterine adhesions. With ultrasound we can also assess the ovaries on each side. A sonohysterogram is usually much less painful than a hysterosalpingogram (see next heading), and avoids the potential risk of an allergic reaction to iodine.

Hysterosalpingogram (X-Ray of Fallopian tubes, HSG)

This procedure is done to verify that your fallopian tubes are open. The test involves inserting a speculum into the vagina (similar to a pap test). Thereafter, a small catheter is passed through the cervix and under X-ray visualization an iodine-based fluid is slowly injected into the uterine cavity. This allows the contour of uterine cavity and Fallopian tubes to be clearly visualized (see picture). Films are taken following the injection of the contrast. The radiologist performing the procedure will usually tell you the results of your HSG at the time of testing. An HSG is contra-indicated if you have an allergy to iodine or shellfish.

To book this test call the Ellendale Radiology Clinic (5845 Cote des Neiges suite #190 tel 739-6169) or Radiology Laennec (1100, avenue Beaumont, suite #104 tel 738-6866) on day 1 of your menstruation.

Laparoscopy
This procedure requires a general anesthetic and is therefore used only in selected cases. 3-4 liters of gas are inflated into the abdominal cavity. Thereafter, a long pen-like camera is introduced into the abdomen at the navel and pelvic structures are inspected. At the time of the operation the patency of Fallopian tubes may be verified by injecting a contrast (coloured liquid) through the cervix. Abnormalities are noted, and minor problems may be corrected.

Other Blood Tests (Prenatal Testing)
We routinely check the blood count and blood type for the female partner. We also check to verify that you have antibodies to Rubella (German measles). Women who do not have adequate antibody protection against Rubella will be advised to have a Rubella booster shot before attempting conception, and then to delay becoming pregnant for at least 4-6 weeks.

In addition to testing for antibodies to Rubella, we also routinely ask that both you and your partner have testing for Hepatitis B, Hepatitis C, Syphilis and HIV, unless you have already had this testing in the previous 12 months.

If you work with children (school teacher, nanny, day-care assistant etc) we may recommend to be additionally checked for your immunity to chicken pox (varicella) and fifth disease (parvovirus B-19). If you have a cat you may also wish to be checked for antibodies to toxoplasmosis.

Finally, a blood test for CMV (cytomegalovirus) is required for all patients requiring donor gametes (sperm or eggs). A CMV negative patient must choose a CMV negative donor, as transmission of CMV at the time of conception can cause fetal malformations.

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Psychologist
If you require donor gametes (sperm or eggs) you will be required to have an interview with a psychologist. Although, we accept a report from any qualified counsellor we strongly recommend one of our psychologists who specializes in reproductive issues.

As you are trying to get pregnant you should take folic acid supplement (at least 1 mg every day) to decrease the chances of spinal malformations of your baby.

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