We are proud to announce that our Laboratory passed its physical College of American Pathology accreditation inspection with no deficiencies in 2003. Told by the inspectors that this was “unheard of for a first-time inspection,” it shows the thoughtfulness and thoroughness of our laboratory and clinical team. This thoroughness is extended throughout all laboratory procedures, from simple blood hormone assays to embryo culture and cryopreservation. We work hard to ensure the safety and quality of specimens received here is kept to the utmost standards.

Patient Specimen Integrity
Each service provided by the laboratory consists of many procedures. To ensure the safety of specimens, everything that the specimen touches is individually labeled with unique patient identifiers. Disposable items, such as culture dishes, tubes, and syringes, are used only once and discarded immediately. There are strict operating procedures in place that must be followed by the laboratory as part of our Quality Control and Assurance program to ensure patient specimen safety which are constantly followed and improved upon.

Laboratory Services
The role of the laboratory and the services they perform is often a mysterious one to patients. Click on the following services to read a description of what they entail both for the patient and the lab.

Semen Analysis:
The male partner, after abstaining from ejaculation for 2-7 days, gives a semen specimen to the laboratory. It can be collected at home in a container provided by the lab, or in a private collection room at our office. The laboratory then counts the sperm, determines what percentage are swimming and how they swim. These aspects of the analysis are done within one hour of collecting a sample. The shapes, or morphology, of sperm are evaluated by preparing a stain of immotile sperm on a slide.

This preparation takes a couple days. The andrologist then evaluates the entire specimen based on these main points, comments on the specimen, and prepares and sends a report to the physician within 10 days of receipt of the specimen.

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Sperm Preparation for Intrauterine Insemination (IUI):
This procedure is in conjunction with the artificial insemination of the female partner. The insemination does not need to be with our physician, we will perform referral sperm preparations. First, when the female partner is ready to be inseminated, the male partner will provide a sample to the laboratory one hour prior to the insemination appointment. The andrologists do an estimated count and percentage of swimming sperm. The semen is then placed in a tube that contains two solutions of different densities.

This density gradient allows live, swimming sperm to be separated from the semen and dead sperm. Sperm with severely abnormal morphology will usually be left behind as well. The resulting pellet of good sperm is then rinsed in another solution twice before being concentrated in a small amount that is used in the insemination procedure. The sperm are counted again to be sure there was a good yield from the original amount of sperm seen.

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Semen Cryopreservation and/or Storage:
We currently freeze sperm and store it at our facility if it is going to be used for a procedure in our office. We will freeze sperm for men who will be undergoing a procedure that will render him “sterile” (vasectomy, chemotherapy, prostate surgery, etc.) or for other banking reasons. However, the patient must set up a storage account at a sperm bank on the mainland where we will ship all specimens once they are frozen.

Freezing sperm consists of mixing a semen specimen with a Cryoprotectant, a solution that protects the sperm from the extreme cold, and freezing it to a temperature of –270 C. Prior to freezing, an estimation of sperm count and motility is done. Typically, half of the live sperm from the original semen specimen will survive the freezing and thawing process. Sperm from a donor that has been purchased can be stored here during the time that the specimens will be used for procedures (usually artificial insemination).

Hormone Assays:
For convenience and consistency, our clinic does all testing of reproductive hormones during treatment at our clinic. When needed, a blood sample is drawn from the female partner and processed by the embryology staff. The serum from the blood is placed on the Access II machine where the necessary tests are run. The results are usually available within 2 hours of the blood being drawn.

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Egg Retrieval:
During the In Vitro Fertilization process, the female partner’s ovaries are stimulated with hormones to produce multiple follicles. When they have reached a certain size, the follicles, which house individual eggs in the ovary, are drained during an egg retrieval. The embryologist’s role in this procedure is to locate the eggs from the aspirated fluids and move them into a warm culture media to be kept in controlled incubators. The eggs are kept in the incubators until insemination occurs 3-4 hours later.

Insemination:
If the male partner’s semen specimen on the day of egg retrieval is good, the embryologists will add sperm directly to the eggs in a droplet of media and allow them to interact and fertilize the eggs on their own. The semen sample is processed in the same manner as for IUI (or artificial insemination) to remove the live swimming sperm from all the other parts of the semen sample. The live sperm is concentrated into a small volume of culture media.

After processing, there needs to be a minimum of 10 million live, forward swimming sperm in order for them to successfully fertilize eggs on their own, anything less than this amount, ICSI must be applied. There are other indicators for ICSI that you can consult with our physician and embryologists.

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Intracytoplasmic Sperm Injection (ICSI):
ICSI is a procedure whereby a single sperm is placed into a single egg. It is recommended for situations where the sperm is having difficulty penetrating the egg. This is in cases with low numbers of sperm, abnormally shaped sperm, anti-sperm antibodies and other subtle fertilization defects. In men that are not producing sperm or in those who have had a vasectomy, sperm can be extracted from the epididymis or testes and then used to fertilize the egg with ICSI. The fertilization rate with ICSI in our laboratory is often greater than with conventional fertilization.

ICSI was developed in order to assist couples with male factor infertility to fertilize their female partner’s eggs. The sperm is usually processed in the same manner as for regular insemination; however there are far fewer sperm in the resulting pellet. Sometimes, sperm are extracted directly from the testes either by aspirating the epididymis (a part of the testicle) in a procedure called PESA, or a biopsy of the testicle itself is used to find sperm (called TESA).

These procedures can be done in our office by a Urologist. Sperm obtained in these procedures must be injected directly into the eggs using ICSI. For the ICSI procedure, the cells surrounding the eggs are removed in order to more clearly see the eggs. Mature eggs, which have removed the first polar body, are the only eggs ready to accept sperm. Sperm are placed in a solution that slows them down, allowing the embryologist to pick them up in a small, sterile, glass needle. The sperm tail is carefully nicked with the glass needle, to prevent them from swimming in the egg, just prior to the injection.

A single, mature egg is held with a second sterile glass needle called a holding pipette. The sperm is injected by piercing the egg with the glass needle and slowly expelling the sperm into the egg. This is performed by using a high power microscope and micromanipulator. The fertilization rate of this procedure is typically not different from that of conventional insemination. This depends, however, on the severity and reason for the male factor infertility and the quality of the eggs.

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Extended Embryo Culture:
Media, or solutions, in which human embryos are grown have reached a new level. Where most clinics used to keep embryos in the lab for only 3 days, it is now possible to grow them for up to 6 days after the egg retrieval, these embryos are now called “Blastocysts.” There are two reasons to do so. Our current blastocyst formation rate (the embryo stage that is reached on day 5 or 6) is at 50%. Therefore the number of embryos that will reach this stage is half of the fertilized eggs.

If a woman has 6 or more “good” quality embryos on the second day after egg retrieval, it is difficult to choose 2 or 3 “good” embryos to put back into the uterus. If, however, they are grown for 3 or 4 more days, the “good” embryos will select themselves by making it to the blastocyst stage whereas “poor” embryos will not continue to develop. If a couple has less than 6 good quality embryos on day 2 of development however, we would rather perform the embryo transfer on day 3 than take the chance that none of the embryos make it to the Blastocyst stage.

A second reason to grow embryos out to blastocyst is that fewer embryos can be put back into the uterus. The pregnancy rate is at least the same as a day 3 transfer, but whereas more embryos are usually transferred on day 3 (typically 4-5), a day 5 or 6 blastocyst transfer can reduce the risk of a high order multiple pregnancy, as typically only 2 or 3 embryos are transferred.

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Assisted Hatching:
There have been studies which found that culture of embryos in vitro, as well as increasing maternal age, may contribute to the “toughening” of proteins in the shell, or zona pellucida, of the egg. For all patients 35 years of age or older, or if you have had a failed IVF attempt previously, hatching will be done on your transferred embryos.

Before the transfer of embryos on day 3, we will hatch all embryos with more than 6 cells with a very light acid or laser. The hole that results in the shell of the embryo is about half the diameter of a cell. The embryo will not come out at this time; rather the embryo has a starting point at which to hatch on day 6-8 of development. If your embryos are transferred on day 5 or 6 at the blastocyst stage, assisted hatching will not be performed as the embryo’s cells are much closer to the shell and are smaller, more delicate, and easier to damage.

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Embryo Transfer:
Embryo transfer is the day when the embryos that have been diligently growing in the lab are placed back into the female partner’s uterus. The transfer typically occurs 3 or 6 days after the eggs are retrieved.

The transfer usually occurs in the mid-morning. The numbers of embryos that are transferred are determined on the day of the transfer and depend upon a number of factors. The number of good embryos, the reason for infertility, the age of the female partner, and the desires of the couple are all taken into account and discussed between the couple and physician. A nurse will also be in attendance at the transfer to hold an abdominal ultrasound probe in place in order to see the uterus during the transfer. The embryologist loads the selected number of embryos into a new catheter in a very small amount of culture media.

The catheter is delivered to the physician who completes the placement of embryos into the uterus. After the catheter is emptied, the catheter is checked under the microscope to be certain all the embryos have been transferred. Any remaining embryos (if a day 3 transfer) will be grown to day 5 or 6 to see if any good blastocysts form; they can then be frozen on that day if patient desires. If the transfer was on day 5 or 6, any remaining good blastocysts can be frozen after the transfer.

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Pre-Implantation Genetic Diagnosis (PGD):
A relatively new procedure, PGD is the testing of genetic content of embryos before they are transferred back into the female partner. It has been found that many embryos from women of approximately 34 and above have some degree of aneuploidy (the presence of an incorrect number of chromosomes). The embryos are tested for the number of chromosomes for X, Y, 8, 9, 13, 15, 16, 18, 21, and 22. This is done through the removal of one cell from a day 3 embryo that has at least 6 cells. The cells are fixed to a slide and sent to a lab for fluorescent labeling of the above chromosomes.

Normal embryos will have 2 each of the numeric chromosomes, and either 2 X’s (for a “girl”) or an X and a Y (for a “boy”). It takes about 2 days for the results of the test; therefore, all embryos are grown to day 5 or 6 before transfer. Each embryo is grown in individual droplets in order to keep them corresponding to the cell that was removed and tested. Each of the numeric chromosomes that are tested is known to cause either miscarriage or severe birth defects.

It is an option for women who failed IVF previously, experienced repeated miscarriages, are over the age of 34, or couple with prior history of children born with or they themselves having hereditary (genetic) disease, to have PGD done during their IVF cycle. This will allow the couple to be at least 95% certain that the embryo they received is genetically normal. Although there is a 3-4% misdiagnosis rate when performing PGD, the chances are much better that the embryo transferred is normal rather than not.

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Embryo Cryopreservation and/or Storage:
Extra, good quality embryos that develop during an in vitro cycle may be frozen for future attempts at pregnancy. This maximizes the eggs retrieved from one stimulation cycle. Embryos are typically frozen at the blastocyst stage of embryo culture. There are other reasons for freezing embryos. For instance, if the female partner becomes ill and cannot receive the embryos at the time the embryos are being cultured, or if the female partner’s uterine lining is not ready, embryos may be frozen for later use.

Embryos, much like sperm, are added to a cryoprotectant that dehydrates them as much as possible; protecting them from ice crystal damage during the freezing process. They are then slow-cooled in a cryogenic freezer, and then plunged and stored in liquid nitrogen. If a couple has frozen embryos stored at another facility, they may be shipped and stored here until the couple is ready to use them.

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In vitro fertilization may be a covered benefit by your insurance carrier. To become eligible for coverage, you must be lawfully married and the patient’s eggs must be fertilized with the husband’s sperm. To qualify for this benefit, you must have at least one the following medical conditions contributing to your infertility:

• Endometriosis
• Exposure in utero to diethylstilbestrol, commonly known as DES
• Blockage or, or surgical removal of one or both fallopian tubes
• Abnormal male factors
• Couple has a history of infertility of at least five years duration

Your estimated share with the insurance coverage will vary based upon the type of insurance plan you have. An average co-payment ranges from $1,500 to $3,500. The approximate cost of one cycle of in vitro fertilization without insurance coverage is approximately $8,000 to 10,000 plus medications.

In Vitro Consultation
We are committed in helping you achieve your goal of starting your family and look forward to our first meeting with you.

The initial office visit will consist of a consultation with Dr. Vu or Dr. Hall to review your medical records, give you their recommendations and answer any of your questions. You will also meet with the in vitro nurse coordinator who will obtain your medical history and go over the complete in vitro procedure with you. Our financial coordinator will speak with you as well to inform you of your estimated out of pocket costs and insurance and payment requirements. Please be sure your spouse accompanies you on this visit. If you have any questions prior to your scheduled appointment, please feel free to contact our office.

The following is a list of some of the insurance carriers with whom Hawaii Center for Reproductive Medicine and Surgery participates:

• Aetna Health Plans
• Blue Cross Blue Shield
• Connecticut General
• Hawaii Electrician’s Health And Welfare
• Hawaii Laborer’s Health And Welfare
• HMA
• HMAA
• HMSA
• Kaiser
• MDX
• Summerlin
• UHA
• United Health Care

If your insurance carrier does not appear on this list, please contact our office for our participation status.

Insurance FAQ’s
Q. Does my healthcare insurance pay for any infertility treatments?
A. Hawaii is one of the few states that has mandated healthcare for infertility. However, benefit coverage varies per employer. Please allow our helpful staff do a complete benefit check and review your benefits at your financial consultation.

Q. If my insurance is involved, would I still have some financial responsibility?
A. Patient financial responsibility depends on what benefit coverage your insurance plan contains. Each insurance plan is different in what they choose to provide as covered benefits. Our insurance specialists will verify your benefits so that you will be able to understand your insurance coverage and financial responsibility during your financial consultation.

Q. What insurance companies and medical groups do you belong to?
A. We are a contracted provider to all of the major insurance companies and even some smaller insurance companies through a third party provider in the state of Hawaii.

Q. If I don’t have health insurance coverage, how can I afford the cost of infertility treatment?
A. The costs can vary dependent on what type of treatment is needed by the patient. HCRMS offers a discounted services and assistance program for patients that qualify.

Q. Who is responsible for getting my insurance pre-authorization, you or I?
A. Your insurance healthcare provider usually requires a pre-authorization to see a fertility specialist. You need to obtain this referral for your initial consult. Our helpful staff will obtain any further pre-authorizations and paperwork that you may need.

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Our nursing staff, front office staff, and laboratory staff are all ready and willing to discuss with all couples about any questions or concerns they may have during their treatment at our facility. We realize there is a large amount of stress that is felt by couples in the treatment of infertility and strive to make everything they experience easier.

Your Privacy
For many of our patients, privacy is a key concern. Our windward Oahu offices are completely private and self-contained. We have our own full service lab so you won’t be sent “all over the building? to have your lab tests. We also have a private entrance if you want to avoid our main reception area altogether.

Location, Location, Location
We make every effort to accommodate patient’s schedules and location preferences. At our comprehensive clinic, all blood tests, ultrasounds, and other IVF related activities are provided to avoid multiple visits to outside services. We can then give our undivided attention to the couples’ IVF treatment procedures, creating unsurpassed accuracy and consistency.

Services are provided at the Castle Medical Center’s Medical Plaza and Wellness Center in Kailua. The office hours are listed below and may change as our patients’ needs do.

Office Hours:
Patients may call to schedule an appointment for most procedures during the following hours:

• Monday – Friday: 8:00 a.m. – 4:30 p.m.
• Saturday: 8:00 a.m. – 11:00 a.m.
• Sunday as needed

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Medical Director:
Kenneth Vu, M.D., F.A.C.O.G.

Laboratory Director: Charles E. Cornwell, MS, ELD

Please visit this page to read about Dr. Vu, and Mr. Cornwell.

Practice Manager: Faye Chin

Nursing Staff
Audrey Kanemori, R.N., B.S.N., IVF Nurse Coordinator
Erin Nakayama, R.N., B.S.N., IVF Nurse Coordinator

Laboratory Staff
JooHee Chesmore, B.S.

Office Staff
Emily Wong

Faye Chin has been with our practice since its inception. As our practice manager, Faye keeps our office running efficiently and patient friendly. Besides making sure the staff is well supported and the schedule is well organized, Faye coordinates practice activity and meets patients’ needs with regards to insurance and patient resources. There isn’t much Faye doesn’t know about our practice and will be happy to answer questions you may have.

Audrey Kanemori, R.N., B.S.N. was born and raised in Hawaii. She earned her Bachelors of Science degree in Nursing at the University of Hawaii. Her professional career has always focused on women’s health with experience in maternal and child health, surgery, post-anesthesia care, pre-operative patient education, infertility and in-vitro fertilization. She is an active member of the American Society for Reproductive Medicine and regularly attends educational conferences.

I am one of the IVF nurse coordinators who will help to make your IVF experience as pleasant as possible. During this exciting and anxious time, I will provide guidance and answer any questions that you may have. I will be teaching you how to self-administer medications, will be present with you during your egg retrieval, and will provide your post- anesthesia care. I hope that the concept of continuity of care may reduce the anxiety and stress of infertility treatment.

Erin Nakayama, R.N., B.S.N. received her Bachelor of Science in Nursing from the University of Hawaii at Manoa. Her area of interest is in women’s health with experience in maternal and newborn nursing. Her role as a nurse here at HCRMS is multi-dimensional, which includes being a nursing team member, patient counselor and coordinator, educator, and advocate. She is here to answer questions, provide ongoing patient care and support throughout their treatment cycle.

JooHee Chesmore, B.S. is a graduate of the University of Hawaii in Biology. JooHee or “Jamie” is our Hematology Specialist. Trained specifically in the use of the Access II System, Jamie handles test performance and maintenance of our in-house Endocrinology blood tests. She is also a trained Andrologist and Embryologist.

When you visit us at Hawaii Center for Reproductive Medicine and Surgery, I’ll be happy to assist you and answer questions regarding insurance coverage and estimated out of pocket expenses for in vitro fertilization treatment. I look forward to meeting with you.

Emily Wong has been working in the infertility field for the past 10 years and has been with HCRMS since 1999. She is the sweet friendly voice that makes most of our appointments for the office. Due to her wide range of experience, she can also discretely answer questions regarding insurance and patient account information. Please feel free to contact her.

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Stimulation of Ovaries
The woman will then be given medications to stimulate her ovaries to form multiple eggs-your doctor will monitor this process with blood tests and ultrasound. Your doctor will discuss with you which medication protocol might work best for you. You will then be given one or more medications known as gonadotropins, which can stimulate your ovaries to produce many eggs. This is important, as your doctor will need to transfer multiple embryos into your uterus to get a reasonable success rate. The gonadotropins are given daily as an injection in your abdomen or thigh. Your doctor will determine the most appropriate dose for you and will inform you of the possible risks, side effects, and benefits of these medications. Your fertility doctor, or a nurse at the fertility clinic will train you and your partner to give the shots.

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Egg Retrieval and Fertilization
Egg retrieval is a surgical procedure performed in an operating room. An anesthesiologist will be present during the procedure to give you an intravenous sedation.

During the egg retrieval procedure, your doctor will place a needle along with an ultrasound probe into your vagina. The needle will be gently moved through the back of your vagina into each mature follicle in your ovaries. Since the retrieval of eggs is done through the vagina, you will not have a cut or incision in your abdomen. The fluid from each follicle-along with the egg-is drawn through the needle. The egg retrieval procedure usually takes about 20 to 30 minutes, depending on the number of mature follicles you have.
The eggs are placed in a special dish in an incubator for a minimum of three hours prior to insemination. Emergency power is available to the incubator in case of power loss.

On the day of the egg retrieval, your male partner will need to produce a sperm specimen for the IVF laboratory to use to fertilize the eggs. He should abstain from ejaculation for three to five days before the egg retrieval. In the cases of male factor infertility, standard insemination techniques may not be successful. If the man’s sperm counts are very low or fertilization has failed to occur with a prior IVF attempt, special egg insemination techniques may be used to help the sperm fertilize the eggs. After the egg retrieval procedure, you will most likely be asked to rest in the recovery suite for about one hour. You should arrange for someone to drive you home, where you should rest for the remainder of that day. Some women experience light vaginal bleeding and lower abdominal pain after egg retrieval.

Starting the day after your egg retrieval you will need to start taking a progesterone supplement as this helps to prepare the uterine lining for attachment of the embryos. Progesterone can be taken as a daily injection, or as a vaginal gel and should be continued until the day of your pregnancy test. Your nurse will give you directions for the use of progesterone. If conception has occurred, further hormonal supplementation will be given.

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Embryo Transfer
The day after retrieval, the inseminated eggs are studied for evidence of fertilization. To allow further cell division and growth, eggs are cultured for another 48 hours before the resulting embryos are considered ready for transfer. Embryos are generally transferred on day three, five, or six. Your doctor will discuss the condition of your embryos and how many will be transferred into your uterus. In general, your doctor may transfer multiple embryos, depending on your age and other factors, such as the condition of your uterus, prior IVF cycles, and quality of the embryos. The embryos are transferred to your uterus through the cervix, using a catheter. The process is guided using ultrasound. The procedure is generally not painful and may require that you have a full bladder.
Following the embryo transfer procedure, your doctor may recommend that you rest in bed for one to two days. Following this, you should avoid strenuous exercise as well as not engage in sexual intercourse until the day of your pregnancy test.

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Assisted Hatching
Early embryos are surrounded by an outer coating, or shell called the zona pellucida. The zona holds the cells of the embryo together. After the embryo arrives in the uterus, the outer coating of the zona dissolves, allowing the embryo to “hatch” and grow larger. Implantation of the embryo into the wall of the uterus cannot occur until the embryo hatches. Natural hatching within the uterus is less likely to occur for the following reasons:

• In women of advanced age, usually considered 38 or older
• In women with an elevated FSH level on day 3
• The embryos of women with endometriosis
• Poor quality embryos

Assisted hatching may help embryos from these women implant in the uterus during an in vitro fertilization (IVF) cycle. The process involves thinning the zona pellucida of the fertilized egg, prior to transfer into a woman’s uterus. If an embryo has not started the thinning process naturally, a small “window” is made in the wall of the zona, using a weak solution of acid that is placed onto the surface of the embryo using an extremely fine glass needle. The embryos are then implanted normally into the uterine cavity.
In selected cases, assisted hatching may improve the percentage of embryos that implant.

Blastocyst Embryo Transfer
A blastocyst is an embryo that has developed for approximately five days after fertilization. Embryos that reach the blastocyst stage have a higher chance of implanting in the woman’s uterus. Also, since fewer blastocysts are usually implanted, the possibility of a woman having multiple pregnancies is reduced.
However, some embryos will not develop to the blastocyst stage in vitro (in the dish in the IVF laboratory). Up to 50 percent of good quality embryos will develop into blastocysts. However, there is a risk that none will succeed. New techniques to support the growth of blastocysts are being developed which might allow for higher rates of successful blastocyst formation and transfer.
The decision to allow embryos to go on to the blastocyst stage is based on a woman’s age, and embryo number and quality.

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Pregnancy Test
Your doctor will schedule a pregnancy test about two weeks after your egg retrieval and embryo transfer procedure.

Frozen Embryo Transfers/Embryo Cryopreservation
Cryopreservation or freezing offers a way to store embryos for a subsequent IVF cycle. Couples who have extra embryos available after an IVF procedure need to decide what to do with them. The extra embryos may be frozen, or cryopreserved, after fertilization. The embryos can be thawed and transferred into your uterus during a future cycle.

Frozen embryos may be stored for five years or more. To use frozen embryos, they must be thawed and examined to see if they survived freezing. Typically, 10-20% of the embryos do not survive the freezing and thawing process. Pregnancy rates with frozen embryos have been shown to be similar to non-frozen embryos of equal quality. However, sometimes the best quality embryos are transferred to the uterus in the IVF cycle and the excess embryos frozen-this may be associated with a somewhat lower pregnancy rate.

Cryopreservation has several benefits-during a frozen embryo transfer cycle, the woman does not need to use medications, such as gonadotropins to stimulate her follicles, and the cycle is less physically demanding. In addition, the cost of a frozen embryo transfer cycle is much less than the cost of a regular IVF cycle.

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Dr. Vu is a graduate of Loma Linda University School of Medicine in 1988. He completed a residency program in Obstetrics-Gynecology at William Beaumont Army Medical Center in 1992. Dr. Vu completed a formal fellowship program in Reproductive Endocrinology and Infertility at the prestigious Johns Hopkins University and Medical Institution and served as an instructor from 1993-1995. Dr. Vu has been a Fellow of the American Board of Obstetrics and Gynecology. To fulfill his military obligation, Dr. Vu served as Chief of Reproductive Endocrinology and Infertility at Tripler Army Medical Center OB-GYN Residency Program in Hawaii from 1995 to 1999 where he started a successful assisted reproductive technology program for the military in the Pacific region with the first IVF performed in January 1997.

In 1999, Dr. Vu joined Pacific In Vitro Fertilization Institute as the reproductive endocrinologist and Medical Director and founder of Hawaii Center for Reproductive Medicine and Surgery (HCRMS) in Honolulu. He also served as Associate Professor and reproductive endocrinologist in the Department of Obstetrics and Gynecology, University of Hawaii John A. Burns School of Medicine, and reproductive endocrinology/infertility consultant for Hawaii Kaiser Permanente. Since August 2001, Dr. Vu has served full time as the Medical Director of HCRMS where he expanded the modern IVF laboratory with extended culture media (blastocyst), implementing pre-implantation genetic diagnosis (PGD), laboratory and clinical research projects.

Laboratory Director
Charles E. Cornwell, MS, ELD

Charles E. Cornwell, MS, ELD, has worked in the field of reproductive medicine for over fifteen years. He is well known for his very high pregnancy success rates in the laboratories that he has developed. He completed his undergraduate work at the University of Utah and received his Masters degree in embryology from Danube University in Krems, Austria. He is an active member of ASRM, the European Society for Human Reproduction and Embryology, and ALPHA-Scientists in Reproductive Medicine. He has specific clinical and scientific interests in the fields of ICSI, blastocyst culture, and cryopreservation of embryos.

Causes of Infertility
Treatment of Infertility
Artificial Insemination
In Vitro Fertilization
Egg Donation

CAUSES OF INFERTILITY

Q. What is infertility?
A. A couple is unable to conceive after one year of frequent coitus. However, if the female partner is over 35 years of age, the couple should consult with a physician (reproductive endocrinologist) after six months of trying. One may contact the fertility specialist sooner depending her individual circumstances.

Q. What causes infertility?
A. Infertility may be due to a single factor in either the male or the female, or a combination of factors affecting both partners. Research studies suggest that the male partner alone is infertile about 23 percent of the time and that both partners contribute in about 30 percent of infertility cases. Most of the time a cause can be found for your infertility. For some couples, no obvious cause of infertility is found. This is called unexplained infertility. Couples with unexplained infertility do actually have a cause for their problem, we just are not able to find it due to the limitations of current testing methods.

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Q. What are some common causes of female infertility?
A. Blockage of Fallopian Tubes (Tubal Occlusion) – Scarring and blockage of the fallopian tubes may interfere with pregnancy by preventing, or stopping the passage of the fertilized egg/embryo from traveling into the uterus. In women, about 30 percent of infertility is caused by problems in the fallopian tubes.

Pelvic inflammatory disease (PID) is an infection of the female reproductive organs including the uterus, fallopian tubes, cervix and ovaries. The condition is one of the most common causes of infertility involving the fallopian tubes.

Endometriosis – Endometriosis is a common yet poorly understood disease that can affect women of any socioeconomic class, age, or race. It is estimated that between 10 and 25 percent of American women of childbearing age have endometriosis. While some women with endometriosis may have severe pelvic pain, others who have the condition have no or minimal symptoms. The name endometriosis comes from the word “endometrium,” the tissue that lines the inside of a woman’s uterus. If a woman is not pregnant this tissue builds up and is shed each month-it is discharged as menstrual flow at the end of each cycle. In endometriosis, tissue that looks and acts like endometrial tissue is found outside the uterus, usually inside the abdominal cavity. Tissues surrounding the area of endometriosis may become inflamed or swollen and the trapped blood may lead to the growth of cysts. The inflammation may produce scar tissue around the area of endometriosis. Endometriosis is most often found in the ovaries, on the fallopian tubes and the ligaments supporting the uterus, in the internal area between the vagina and rectum, on the outer surface of the uterus, and on the lining of the pelvic cavity. Endometriosis usually causes pelvic pain especially around the time of menses.

Problems with Ovulation – Ovulatory dysfunction is a condition in which ovulation, the release of an egg from the ovary, does not occur regularly or is absent. Ovulation is a complex process and is essential for pregnancy to occur. Anything that interferes with the normal hormonal regulation of the female menstrual cycle may result in ovulatory dysfunction. Infrequent ovulation and other ovulation problems may account for up to 30 percent of female infertility.

In many women with ovulatory dysfunction, the cause is related to an imbalance of hormones. Any changes or abnormalities in how reproductive hormones are produced or function, may affect ovulation.

The following conditions or problems may interfere with normal ovulation. Most of them in some way affect the functioning of a woman’s pituitary gland and cause a deficiency or imbalance of FSH and LH.

• Disorders of the thyroid gland
• Elevated prolactin levels (hyperprolactinemia)
• Polycystic Ovarian Syndrome (PCOS)
• Recurrent Pregnancy Loss
• Eating disorders
• Excessive exercise
• Medications
• Premature Ovarian Failure (POF)
• Increasing age

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Q. What are some common causes of male infertility?
A. For men, one of the more common reasons for infertility is a problem with sperm-no or few sperm may be produced, the sperm that are produced may be malformed and die before they can reach the egg, or the sperm may appear normal but function poorly. Problems with the delivery of sperm from the penis into the vagina may also be a cause of infertility. These include erectile dysfunction, problems with ejaculation, or blockage of the ejaculatory ducts.

TREATMENT FOR INFERTILITY

Q. What are the different fertility treatment options?
A. For some couples a specific cause for their infertility cannot be found, treatment options are not available to correct the underlying problem, or attempts to restore fertility in either partner have not worked. Your fertility doctor may then offer you and your partner one of several procedures that are known as “assisted reproductive technologies”, or ART. Some of these techniques are simple others are complicated. Which technique your doctor recommends depends on the reasons for the infertility, the woman’s age, the condition of the woman’s ovaries, fallopian tubes and uterus, as well as male sperm factors.
The following types of ART are available:

• Intrauterine Insemination (IUI)
• In Vitro Fertilization (IVF)
• Gamete Intrafallopian Transfer (GIFT)
• Zygote Intrafallopian Transfer (ZIFT)
• Intracytoplasmic Sperm Injection (ICSI)
• Egg Donation

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Q. What is IUI?
A. Intrauterine insemination, or IUI, refers to the placement of sperm directly into the uterus, just where the fallopian tubes begin. It is a relatively simple treatment for infertility designed to get more sperm to meet the egg. IUI is performed near the time you ovulate.

IUI may be useful if there is a problem with a woman’s cervical mucus. IUI may also be an option when the man is not able to ejaculate inside the vagina because of erectile dysfunction, premature ejaculation, or other medical conditions. Sometimes, IUI may also be recommended if your infertility is unexplained.

The insemination procedure is a relatively simple therapy. Your doctor may recommend fertility medication before the procedure to stimulate ovulation. During this process, your doctor will monitor the maturity of the follicles with blood tests and ultrasound. A hormone shot may also be given to help release the egg when it is mature. The IUI is then timed to coincide with ovulation.

The male partner will be asked to provide a semen sample about one hour before the insemination. This is done by masturbating into a sterile container at the doctor’s office, or at home, if preferable. The semen is then processed, or washed, to separate the sperm from the seminal fluid. This concentrates the sperm into a small volume.

The washed, or processed sperm is placed in the cavity of the uterus using a thin, soft catheter. Many women find the procedure similar to having a PAP smear.

If you do not become pregnant, IUI may be repeated over several cycles, between 3 to 6 times. About 5 percent to 25 percent of women who undergo IUI conceive. The pregnancy rate from IUI depends on sperm quality and ovarian factors, which are controlled by age, pelvic of the woman, ovarian reserve status and response to fertility medications.

The risks and side effects of IUI include pelvic cramping from ovulation, spotting or infection due to introducing bacteria through the vagina. Also, the use of fertility drugs may increase your risk for multiple pregnancies and developing ovarian hyperstimulation syndrome (OHSS). In addition, some men may find it difficult to provide a sperm sample on demand.

Q. How difficult is it to go through infertility treatment?
A. In general, a couple does not need to seek medical advice for infertility until they have been trying to conceive for at least six months or have some obvious problem or condition that is interfering with conception. However, a woman may wish to consult with her doctor sooner if she is concerned about her fertility and is over age 30, has irregular or absent menstrual cycles, a history of painful periods, miscarriage, pelvic inflammatory disease, endometriosis, polycystic ovarian syndrome (PCOS), or uterine fibroids.
Initially, many women seek help from their gynecologist and men from their family doctor or a urologist. Further evaluation or treatment of a specific problem often requires the expertise of a reproductive endocrinologist who is specialized in infertility treatment.

A thorough evaluation of infertility may take 2 months, or longer, to complete and may require a significant commitment from a couple. Procedures may be physically and emotionally uncomfortable and expensive. The procedures may not be reimbursed, or paid for, by many health or insurance plans.

And, although success rates for conception are constantly improving, there is no guarantee that an evaluation will determine the cause of your infertility or that conception will occur. However, a complete and thorough evaluation is likely to indicate a cause for your infertility usually about 80 percent of the time, and help you and your doctor determine the most appropriate treatment.

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ARTIFICIAL INSEMINATION

Q: What is artificial insemination?

Artificial insemination is an insemination technique called by many names: artificial insemination by donor (AID) or therapeutic donor insemination (TDI). Both of these techniques utilize screened sperm samples from anonymous donors. The treatment is primarily used in cases of male infertility where the male partner of the couple has no sperm severely abnormal sperm. National statistics suggest that 1 out of every 8 infertile couples are treated in this way.

IN VITRO FERTILIZATION

Q. What important things should I expect during an IVF cycle?
A. In vitro fertilization, also commonly known as IVF, is the treatment of choice in cases of infertility when both fallopian tubes are blocked. However, IVF may also be used for unexplained infertility, endometriosis, cervical factor infertility, ovulation disorders, or when a man has a low sperm count. Basically, IVF involves taking mature eggs from the woman, fertilizing them with sperm in a dish in a laboratory and then transferring the resulting embryos back to the woman’s uterus 2 to 6 days after fertilization is confirmed. Of all ages, approximately 35 percent of women who try in vitro fertilization conceive -however, the likelihood of success can vary from 0 percent to 70 percent depending on such factors as ovarian reserve status, the man’s sperm, the women’s age, the reason for the infertility, and the experience of the IVF program.

IVF can be physically and emotionally draining, however stress and anxiety can be reduced if you and your partner have a clear understanding of the procedures. Your fertility doctor may recommend that you and your partner learn as much as possible about the IVF process. Please read a detailed description in our Services section.

EGG DONATION

Q: What is egg donation and when should donated eggs be used?
A: Egg (oocyte) donation involves the use of eggs supplied by a donor for in vitro fertilization and transfer to a matched recipient. Egg donors may be either known or anonymous. Currently most egg donors are young women who are recruited and paid for their services. Most donate their eggs anonymously.

The first pregnancy from donor eggs was in 1984. The conditions for egg donation consideration are premature ovarian failure, diminished ovarian reserve and in women of advanced reproductive age or menopause.

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Many of these treatments are covered by insurance, however some are not. Our financial advisor will assist you with questions you may have regarding coverage. If, during the course of your care, there is something you wish to pursue, but don’t see listed here, please discuss it with our physician; we may be able to accommodate your needs.

Click on each of the services below to read more about it:
Comprehensive Infertility Evaluation
Intra-Uterine Insemination
In Vitro Fertilization
Donor Egg Program
Donor Sperm Insemination
Endometriosis Treatment
Fibroid Treatment

Comprehensive Fertility Evaluation
During your initial visit, or consultation, your medical history and records will be reviewed with you, and you, as a couple, discuss your goals and needs with Dr. Vu. You may then proceed to some of the treatment options listed below based on you as an individual or couple. We may request a semen analysis if one has not been done recently, and either a physical exam of the female partner or a blood test may also be done at this time. Depending on your subsequent treatment, different tests may need to be performed. The physician will discuss all this with you.

Intrauterine Insemination (IUI)
If the female partner’s tubes are not blocked, and the male partner has sufficient number of sperm, the couple may decide to try intrauterine insemination (IUI). Also known as artificial insemination, the female is placed on medication and monitored for developing eggs. When ready, she will receive a shot to mature the egg (or eggs) and ovulate. The male partner will provide our laboratory with a semen sample when the egg(s) are ready and the laboratory will prepare it for insemination. Your physician then inserts the sperm directly into the uterus with a small catheter through the cervix. It is a painless procedure; about the same as a pap smear.

In-Vitro Fertilization (IVF)
This is the process of stimulating the female partner’s ovaries to produce multiple eggs, removing them when ready, and fertilizing them in the laboratory with the male partner’s sperm. The resulting embryos are grown in the lab for a number of days (3 to 6) and a few of them are transferred back into the female partner’s uterus. Procedures may include:

• Intracytoplasmic Sperm Injection (ICSI)
• Assisted Hatching
• PESA/TESA (sperm extraction procedure)
• Extended Embryo Culture (Blastocyst Transfer)
• Pre-Implantation Genetic Diagnosis (PGD)

Donor Egg Program
As women age, their eggs become fewer and it becomes difficult to become pregnant with them. An alternative is to use eggs from a younger woman. This can be done through our donor egg program. We work with a local agency, Pacific Connection Fertility Services, or any agency of your choice, through which couples may choose an egg donor which best suits their needs. The anonymous donor is then stimulated to produce a number of eggs that are fertilized in the lab with the recipient male partner’s sperm. The resulting embryos are then transferred into the recipient female partner’s uterus.

Donor Sperm Program
Donor insemination is a technique utilizing screened sperm samples from anonymous donors. The treatment is primarily used in cases of male infertility where the male partner of the couple has no sperm or severely abnormal sperm.

Endometriosis Treatment
Women who have endometriosis, the growth of uterine lining cells in areas outside of the uterus, may be treated. This treatment may coincide with infertility treatments in order to improve attempts at pregnancy or primarily treating endometriosis symptoms. Treatment of endometriosis ranges from medication to surgery. Endometriosis treatment need not only be done for those who wish to have children, as it can be a painful disease. It is, therefore, a part of our gynecological care as well.

Fibroid Treatment
Fibroids are non-cancerous masses found in the uterus or cervix. Uterine fibroids are commonly found in one out of every four women in their 30s or 40s. Fibroids have been known to cause tubal blockages, prevent the embryo from attaching to the uterine wall and could possibly cause miscarriages. The effect fibroids have on a woman’s fertility depends upon their size and the location of the fibroid.

Treatment for fibroids is usually done surgically through laparoscopy, hysteroscopy and or myomectomy. Drug treatment with GnRH agonists (like Lupron) have been used to reduce the size of the fibroids (they suppress the secretion of estrogen), however when the treatment is discontinued, the fibroids have been observed to return. Low dose oral contraceptives have also been used to control the growth of fibroids.

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Our Center

In October 2001, we opened our state-of-the art in vitro fertilization laboratory and reproductive service facility at the Castle Medical Center’s Medical Plaza and Wellness Center on Oahu. It is here that we can offer the Hawaii community the most comprehensive reproductive center in Hawaii.

Our center is certified by and a member of the:
Society for Assisted Reproductive Technology;
American Society for Reproductive Medicine;
College of American Pathologists;
American Association of Bioanalysts.

Modern Medicine
One of the first clinics in Hawaii to provide PGD (Pre-Implantation Genetic Diagnosis), the HCRMS is dedicated to providing innovative technologies to help patients attain their goals. The first successful IVF with PGD for Aneuploidy Screening in Hawaii was performed at our center in September 2003. We understand that good medicine is not all science, and with compassion and caring we seek to provide that “personal touch”? during your visit with us. We strive to give our patients every conceivable chance to succeed in their infertility treatment.

We welcome you to our clinic’s family. Please enjoy your tour through our web site. We hope to be able to assist you with your dreams of having a family.

Our Assisted Reproductive Technology Program (ART) is one of the most respected and successful programs in Hawaii and the United States. We have specialized in developing the technique of blastocyst culture and offer this to all our couples when appropriate. We have also led in the treatment of difficult male factor infertility, including sperm aspiration, epididymal and testicular sperm retrieval and intercytoplasmic sperm injection.

Emotionally, physically and financially, infertility treatment can be a big investment to anyone. At the Hawaii Center for Reproductive Medicine and Surgery, we specialize in making your experience as simple, pleasurable, and private as possible. We work diligently to provide the understanding and utmost care in helping you to realize your dreams.

We are truly thankful for the time that you have spent with us. We hope that our web site will give some answers to your questions. There will probably be more. Please write them down. Your next step is to schedule a consultation by calling (808) 261-4166. We look forward to working with you to achieve your dream of a successful pregnancy.

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