844 North New Ballas Court, Suite 300
St. Louis, MO 63141
Phone : 314 473 1285
Fax : 314 473 1287
After Hours : 314 277 8782

..where everyone has a chance to start a family

Infertility Sevices

  1. At the Center for Reproductive Medicine and Robotic Surgery, we can offer you a thorough evaluation of your individual fertility treatment needs and provide options on how to reach your goal of having a baby.
  2. We understand this is a stressful time for couples and we strive to help you through this process and guide you on a hopeful journey.
  3. We are a team of fertility experts who are dedicated to your individualized care plan. We are a small group and welcome you to our “family” with compassion and empathy and are always willing to listen.
  4. Your journey begins with an initial consultation with Dr. Jacob, who will discuss your medical history and begin the process of developing your individualized treatment plan.
  5. You will benefit from the educational links on this website and can read about our treatment options in advance of your appointment. We believe this helps couples to alleviate some of the stress that may be associated with stepping into the unknown and sometimes complex science behind fertility treatment.
  6. Whether your care plan includes surgical corrections of underlying causes, such as endometriosis, fibroids, tubal obstructions and other interventions with robotic surgery, or male factor infertility, which is determined by a complex semen analysis, we are here to help.

Male Infertility Female Inferitlity Introduction



«Causes of Infertility
«Basic Workup for the Man
«Post Testing Consultation

About 10% of couples in the United States are infertile. Couples may be infertile if the woman has not been able to conceive after 6-12 months of having sex without the use of birth control. The number of months depends on many factors, such as your age, your partner's age, and how long you have been trying to get pregnant. If you and your partner are trying to have a child and you have not gotten pregnant, you may want to have an infertility evaluation. Tests can be done to find the cause of the problem. Based on the results of these tests, treatment may be needed.

This section explains:

  • What an infertility evaluation involves
  • Testing for infertility
  • Treatment options

The process of becoming pregnant starts with ovulation, the release of an egg from a woman's ovary. In an average 28-day menstrual cycle, ovulation occurs about 14 days after the first day of your last period. Once an egg is released, it can be fertilized for about 12-24 hours. Fertilization can occur if you have sex during or near the time you ovulate. When the man ejaculates during intercourse, his semen releases into the vagina. Semen is the fluid that carries the sperm. Sperm travel up through the woman's cervix, uterus and out into the fallopian tubes. Sperm can live in the tubes for 3 days or more. If a sperm and egg join, fertilization occurs. The fertilized egg then moves through the fallopian tube into the uterus. It attaches there and begins to grow. All these events must take place for pregnancy to occur. If there is a problem in this chain of events, infertility may result.


Causes of Infertility:
Infertility may be caused by more than one factor. Some are easy to find and treat, while others are not. The factor may relate to the woman (40%) or the man (40%). In some cases, no cause can be found in either partner (10%).The couple's age can be a factor. For healthy, young couples, the odds are about 20% that a woman will conceive in any one menstrual cycle. This figure starts to decline in a woman's late 20s and early 30s and decreases even more after age 35 years. A man's fertility also declines with age, but not as early. For this reason, older couples may not want to wait 6-12 months to seek care if they are having problems conceiving. Male factors most often involve problems with the amount or health of the sperm. Abnormal hormone levels may be a cause. Infection or scarring from a sexually transmitted disease (STD) also may be a cause. Female factors also may involve abnormal hormone levels. The ovaries may not produce enough eggs at the right time. Scarring or blockages in the cervix or tubes also may be a cause. Lifestyle factors, such as poor nutrition, anorexia, and obesity can play a part in infertility. Exposure to a drug called diethylstilbestrol (DES) can cause problems. This might be a concern if you were born in the United States before the late 1980s or in another country before the 1980s. Other health problems also can play a role.

The decision to begin testing depends on a number of factors. They include your age and your partner's age, as well as how long you have been trying to get pregnant. You and your partner will receive care as a couple. Testing involves an evaluation as follows: 1. Physical exam of both partners 2. Medical history, 3. Semen analysis, 4. Ovulation check, 5.Tests to check for a normal uterus and open fallopian tubes, 6. Discussion about how often and when you have sex. The basic workup of an infertility evaluation can be finished within 14 days from the start of the menstrual cycle . Please discuss with the Center about the costs involved and find out whether they are covered by your insurance.

Basic Workup for the Man
A general physical examination and semen analysis is a key part of the basic workup for a man. Semen analysis may need to be done more than once. The semen sample is obtained by masturbation. Sometimes it can be obtained at home but usually it is obtained in our lab. Our staff will give you instructions. Our lab will study the sperm using specific criteria for:

  • Number
  • Shape
  • Movement
  • Signs of infection
  • Morphology

Based on the initial evaluation, further testing may be required in the Center, including genetic and chromosomal testing. It is recommended that the man abstain from ejaculation 3- 5 days before the semen test.

Common Tests for Infertility Evaluation
There are many tests to see if ovulation occurs. Some are done by the woman, and others are done by the doctor.

  • Urine test. This test can be done by the woman at home with a kit. It is a way to predict ovulation. This test measures luteinizing hormone (LH), which is what makes ovulation occur. If the test result is positive, it means ovulation is about to occur. Sometimes these kits are used in conjunction with basal body temperature charts.
  • Basal body temperature. This test can be done by the woman at home. It is a way to tell that ovulation has occurred. After a woman ovulates, her body temperature increases a bit. To measure it, a woman takes her temperature by mouth every morning before she gets out of bed (basal temperature). She records it on a chart for two or three menstrual cycles.
  • Cycle day 3 hormone profile. This test helps to evaluate the different hormones involved in oocyte production and ovulation and also useful in evaluating ovarian reserve. They commonly include, FSH, LH, Estradiol, AMH, and Prolactin. Please go to the nearest lab (ie. LabCorp, Quest etc. ) on day 3 of your cycle to get the blood drawn in the morning. Please bring the blood request form with you. If the lab is not open you may draw the blood at the nearest hospital lab. If you are suspected to have PCOS you may be advised to do more blood tests after overnight fasting.

Other tests may be done, depending on a woman's risk factors and symptoms.

Procedures are used to look at a woman's reproductive organs. They check if the uterus is normal and the fallopian tubes are open. The tests you have depend on your factors and symptoms.

  • Trans-vaginal ultrasound/Sono-hysterogram. This test checks the ovaries and uterus by using sound waves to produce pictures of pelvic organs. First, a device (a transducer) shaped like a wand is lubricated and inserted into the vagina. A machine displays an image of the organs. In sono-hysterogram, a fine catheter is introduced into the uterus and the uterine cavity is instilled with saline solution, followed by ultrasound scan. This helps to visualize the cavity of the uterus. This test is commonly done on any day between day 2 and day 7 of your menstrual cycle. Since the Center does not know when you start your period, it is the patient's responsibility to call and schedule these appointments. Please call the Center to make an appointment or click here and schedule appointment through the secure patient portal.

  • Hysteroscopy. This procedure lets the doctor look inside the uterus. A thin telescope-like device, called a hysteroscope, is placed through the cervix. The uterus may be filled with liquid to reveal more information. During this procedure, the doctor can correct minor problems or get a sample of tissue to study. The doctor also may decide other procedures are needed. This test is commonly done on any day between day 7 and day 14 of your menstrual cycle. Since the Center does not know when you start your period, it is the patient's responsibility to call and schedule this appointment. Have your pharmacy information available so we may order pre-medication for this procedure at the time of your call.

  • Hysterosalpingography (HSG). This test is an X- ray that shows the inside of the uterus and fallopian tubes. In most cases, it is done right after a menstrual period. A small amount of dye is placed in the uterus through a thin tube inserted through the cervix. An X-ray is then taken. The dye outlines the inside of the uterus and fallopian tubes. If it spills from the tubes, it shows that the tubes are open. This test is commonly done on any day between day 10 and day 14 of your menstrual cycle. Please call the Center to schedule this appointment.


  • Laparoscopy. This procedure lets the doctor view the tubes, ovaries, and the outside of the uterus. It is usually performed in the hospital under anesthesia. A small telescope-like device, called a laparoscope, is inserted through a small cut (about 1 inch or less) at the lower edge of the navel. Fluid is placed in the uterus to see if it spills from the ends of the tubes. This shows if the tubes are open or blocked. The doctor also can look for pelvic problems, such as endometriosis or scar tissue.

You may be given pain medications for some of these procedures.

Post Testing Consultation

After your basic testing as detailed above is completed, you and your partner will have a post testing consultation with the staff and the doctor. At this appointment, the results of all the tests performed are discussed in detail and a treatment plan is adopted. This may include just waiting for natural pregnancy, ovulation induction with clomid and or injectable medications, intrauterine insemination (IUI) or in-vitro fertilization (IVF). Men with very low sperm count may opt for ICSI procedure with IVF. Once a treatment plan is finalized a protocol is written up with dates and time of all appointments, when to take the medications, etc.

Infertility can be treated in many ways, including lifestyle changes, medication, surgery, and assisted reproductive technologies. After your initial evaluation at the Center, we will discuss with you the appropriate treatment options based on your medical condition, age, personal desires, religious beliefs and financial situation. The common Assisted Reproductive Technologies are:

  • Intrauterine insemination (IUI)
  • In-vitro fertilization and Embryo transfer (IVF-ET)
  • Intra cytoplasmic sperm injection (ICSI)
  • Microsurgical sperm extraction from the testes or epidydimis (MESA/TESA) and ICSI
  • Donor Oocyte program
  • Donor Embryo program
  • Gestational surrogacy program

The choice depends on the cause. After your evaluation, please discuss with the staff at the Center about the best treatment options for you and your partner. You also may choose adoption, foster parenting or other alternatives. Supporting you in whichever decision you make is our priority.


Female Infertility


To understand how the couple is affected by the respective contribution from each individual, we need to understand the main causes affecting each partner. Female infertility is divided into several groups depending on the main source. However, keep in mind that it is common that two or more of those factors may be involved at the same time.

Age and Reproduction

Females are born with a fixed amount of oocytes in their ovaries. Even in-utero, the fetal ovary starts to shed eggs. Those eggs will be lost due to atresia. This happens because the eggs lack the stimulatory influence of the reproductive hormones to continue their growth. The eggs are continually lost all the way through childhood, puberty and adult age until the ovarian pool is exhausted when the woman reaches the menopause. The reduction of the ovarian pool is a reflection of the reduction of fecundity among persons older than 35 years. Studies conducted with women that were inseminated a maximum of 12 times with donor semen indicate that the probability of pregnancy was 55% for those younger than 30 years, 40% for those between 31 and 35 and declined precipitously to less than 10% in those older than 35 years. Data obtained from couples that had IVF treatments show a similar pattern. Not only the number of eggs is reduced but the quality of those eggs is influenced as well. For example, the risk of chromosomal abnormalities increases with maternal age. When the maternal age is 20, 30, 40 and 50 the risk of Down syndrome goes from 1/1667, 1/952, 1/106 and 1/11 respectively. The total risk for chromosomal abnormalities also goes up from 1/562, 1/385, 1/66 to 1/8 respectively. To increase the chances of success and decrease the probability of chromosomal abnormalities on the offspring, women over 40 may consider seriously the alternative of utilizing donor eggs.


Problems with ovulation are present in 25% of female infertility cases. Although there are factors such as chromosomal abnormalities, and endocrine dysfunctions interfering with infertility, perhaps the three most common ones are emotional stress, strenuous exercise and excessive weight loss or weight gain.

Ovulatory factors are often treated with Clomiphene. When that doesn't work, patients usually move to Exogenous (Injectable) Gonadotropin therapy or IVF.


The contribution of tubal and peritoneal factors in infertility is around 35%. Free and open fallopian tubes are necessary for gamete transport and fertilization to occur. Blocked tubes (including surgical tubal ligation), adhesions, and scar tissue are commonly associated with infertility. Endometriosis, appendicitis (especially when ruptured), abdominal or pelvic operations, infectious or non-infectious pelvic inflammatory diseases are among the main common causes in peritoneal factors.An HSG test performed at the Center before 14th day of your cycle can determine if this is an issue for you.The Center has developed expertise in the surgical treatment of blocked tubes including Robotic Microsurgical Tubal Reversal (hyperlink)


Uterine factors are present in about 5% of infertility disorders. Prenatal exposure to DES, abortions, myomas (fibroids), uterine trauma or infections, polyps, and congenital abnormalities of the uterus are the most common factors involved with this type of infertility. Congenital anomalies of the uterus including uterine septum can be corrected by hysteroscopic resection of the septum (Hyperlink to video). Fibroids irrespective of their location may cause infertility including recurrent pregnancy loss. If the fibroid is more than the size of the uterus or if the blood flow to the fibroid is more than half of the total blood flow to the uterus, we recommend surgical removal of the fibroids. The Center has expertise in robotic myomectomies (hyperlink to video).


Recent studies have shown an increased link of infertility with immunological events. In fact, it appears that most of the so called "Unexplained Infertility" may have an underlying immunological component. Although it appears to be generally accepted that there is an immunological component in certain cases of infertility, the treatment options have elicited a great deal of controversy. At this moment there is no agreement on what is the best treatment alternative and it appears in some cases unjustified claims have put some treatments above others. Some of those treatments are particularly expensive and not without danger.


The contribution of environmental factors in infertility is not well quantified. However, it is well documented that smoking not only decreases fertility but also it increases the probability of acquiring other diseases such as cancer, heart and lung diseases. Fertility among light smokers (20 cigarettes / day) was 75% of that of nonsmokers and fertility among heavy smokers (more than 20 cigarettes / day) fell to 57% of that of nonsmokers

  • Recurrent pregnancy loss
  • Secondary infertility (the inability to conceive and deliver a baby following the birth of one or more biological children)
  • Unexplained
  • Tests may include chromosome testing and other genetic profile work ups.
  • IVF/PGD is an excellent source of treatment for AMA and RPL. This includes an IVF cycle with intracytoplasmic sperm injection and assisted hatching. The blastocyst is biopsied on the fifth day of culture and a few cells are removed from the embryo and sent off for chromosome analysis and the results are available the next morning. We can then transfer back to the uterus the embryos that have the normal number of chromosomes. This technology has helped many couples to have ongoing pregnancies and live births.


Male infertility

«Male Offspring

This is a condition that by itself affects up to 40% of couples facing infertility problems. An additional 20% of infertile couples have combined male-female factor infertility. These figures suggest that the relative incidence of male related infertility problems may be approximately the same as female problems. In fact all over the world, the sperm concentration in the ejaculate is dropping and the cause is still unknown. Though this phenomenon has not caused a reduction in the chances of fathering a child, it may do so in the future. Industrialization has been suggested as a cause but solid evidence is still lacking.


The most significant element when dealing with male-factor infertility is to establish the correct diagnosis. We cooperate with your urologist and will assist him/her through our Andrology Laboratory to reach the appropriate diagnosis of your condition. Some infertility problems are just a manifestation of more severe medical conditions that if not diagnosed properly may become life threatening or may affect the offspring. The first step is to have a semen analysis and genital examination done at the Center. Based on the test we could advise you on the appropriate treatment plan.


We seek to help you overcome your infertility problem by offering alternatives that might eventually lead to the birth of a baby. However, we do not treat the causal factors of infertility that the urologist traditionally treats. Once the cause of male infertility has been diagnosed, the Center can help you with a range of seminal tests and evaluations from semen analysis to other specialized sperm function testing. These include hemizona assay, sperm antibody and leukocyte quantitation, in-vitro cervical mucus penetration test, acrosome reaction, SCSA, and sperm overnight culture. Also, we have the capability to freeze your sperm (sperm banking) if it is necessary.


The information generated from the quantitative and functional tests performed at the Center for Reproductive Medicine and Robotic Surgery is utilized by our staff to implement an individualized infertility treatment. The objective of our treatment is to help you and your partner achieve pregnancy. Depending on the severity of the male factor infertility and on the medical history of your partner, we may suggest you utilize the least invasive modalities for infertility such as intrauterine inseminations (IUI), or In-Vitro Fertilization if the counts of motile sperm are such that a series of IUIs may not be effective. Usually these treatments require that the male partner should be able to provide at least two (for IVF) or five (for IUI) million motile sperm. If the sperm counts are below the above limits, there is still the option for sperm banking to overcome this problem. Donor semen is also available.


ICSI is usually the best answer for male factor infertility.

The spermatozoa collected are used to fertilize mature oocytes. Since a low number of spermatozoa may be obtained, the oocytes are fertilized by Intra Cytoplasmic Sperm Injection (ICSI). This procedure optimizes the sperm number since only one motile sperm cell is required per oocyte. Without this method the probability of fertilization and pregnancy for such men is less than 1%. However, when PESA or TESA and ICSI are combined, the probability of fertilization and pregnancy reaches values similar to those observed in conventional IVF.

Treating the most severe cases of male infertility with ICSI

There is a population of patients that may not be able to benefit from IUI or conventional IVF due to inadequate numbers of sperm or fertilizing functional ability of sperm. In the past, the only alternative for patients under this classification was to use donor sperm or to consider adoption. In 1991, a procedure called Intra-Cytoplasmic Sperm Injection (ICSI), which consists of the direct injection of a single sperm into an egg, was perfected. ICSI enhances the probability of achieving pregnancy in even the most difficult of male infertility cases.

When to utilize ICSI

Moderate cases of male factor infertility may be successfully treated by conventional IVF treatment. However, ICSI now offers a new dimension of treatment for all more severe forms of male infertility. ICSI may be indicated when: 1. Patients present low sperm density, motility, poor morphology, sperm antibodies or low scores in functional bioassay. 2. Cases with less than 50% fertilization or total fertilization failure in previous IVF attempts. 3. For azoospermia or lack of spermatozoa in the ejaculate when sperm aspiration is necessary.



Azoospermia may just be a symptom of deeper medical conditions. Therefore, proper identification of these conditions is of major clinical relevance. The four main causes of azoospermia will be discussed in Male Factor Offspring.

Male Factor Offspring

Male Factor Infertility and Your Offspring
In cases such as Acquired Obstructive Azoospermia (vasectomy, failed vasectomy reversal, inflammatory lesions due to infection) or Inability to Ejaculate (spinal cord injuries, surgery, psychological causes or retrograde ejaculation) no major effects on the offspring over naturally occurring rates should be expected. However, in other conditions such as Congenital Absence of the Vas-Deferens or Testicular Insufficiency (low sperm counts and motility) additional tests may be indicated to rule out the presence of other problems that may affect your offspring.Note there are many more genetic abnormalities associated with male infertility, than in the female.

Read below to Learn More about Male Infertility Treatment

Causes of Male Infertility

Today, male infertility is not an uncommon occurrence with almost 40% of all cases of fertility issues being related to the male. In the past, there were not many options available for male infertility treatment. However, recently there have been large improvements in medical technology and options depending on your circumstance. The first step is to determine the cause of male infertility so that these advanced reproductive technologies can be used to achieve your dream of fathering a child.


One of the common problems of male infertility is blockages of the reproductive tract which reduces the amount of sperm that can be ejaculated. Blockages can become so severe that it completely prevents sperm from getting out. Successful treatment for this male infertility involves surgery to remove the blockage. There are also new methods to retrieve the sperm from the testes using microsurgical assisted reproductive technologies.


Varicocele is a condition where dilation of veins in in the scrotum occur which reduces the production of sperm. Men with this condition may produce sperm that are abnormal in shape as well as have poor oxygen and blood supply to the testes. Male infertility treatment for this condition is available by surgically cutting the veins connected to the varicocele to relieve the pressure. Since this surgery is very invasive it is only recommended if the varicocele is very large. It is important to catch this kind of infertility problem early as varicoceles that have been present for a long period of time will often cause irreversible damage.

Hypothalamic and Pituitary Deficiency

In a small amount of cases (about 1 to 2 percent) the cause of male infertility is due to problems producing hormones in the hypothalamus and pituitary gland of the brain. When this occurs men can stop producing sperm altogether. In this case gonadotropin hormone therapy is necessary with human chorionic gonadotropin (hCG) and recombinant human follicle stimulating hormone (rhFSH). With gonadotropin treatment many injections have to be given on a weekly basis for up to six months. Blood tests are often needed to monitor testosterone levels and ensure the proper dose is being given.
This form of male infertility treatment requires a large amount of commitment, sometimes consisting of several years of treatment but the success rate is high. In many instances of gonadotropin treatment, men did begin producing sperm again on their own and could achieve normal fertility. The cost of this treatment can also be very expensive, especially if your health insurance does not cover it.

Male Infertility Treatment Options

Once the cause of the male infertility is determined, a course of action may be possible. Not all cases of male infertility are treatable if they involve severe damage to the testes or are due to abnormal development. But due to recent advancements in reproductive technology, we can extract sperms directly from the testes of men with total azoospermia (total absence of sperms in the ejaculate) using microsurgical testicular sperm extraction. Here using high tech procedures sperms are extracted directly from the testes without even making a cut on the scrotal skin. Hence it has minimal pain and rapid recovery with no skin incision. The sperms obtained are frozen and used in IVF treatment. However, it is important to catch problems as soon as possible as this can impact the available treatments. We have many advanced screening procedures available to find the cause of infertility as well as options for treatment. If you and your spouse are having trouble with fertility, give us a call to schedule a consultation. The Center for Reproductive Medicine and Robotic Surgery is a leading center nationally and internationally in the treatment of male infertility and offers these advanced microsurgical testicular sperm extraction technologies.