A complete evaluation is necessary to find the cause of infertility. The treatment recommended by your fertility specialist will depend on the diagnosis.
What are the treatment options?
1. Ovulation stimulation medications:
- Ovulation Induction (OI): is indicated for ovulatory disorders and unexplained infertility.
- Intrauterine Insemination (IUI): may be advised for male factor, hostile cervical mucus and unexplained infertility. IUI is often utilized during ovulation induction therapy to maximize pregnancy rates. Donor sperm IUI is an option when the male partner has no sperm.
- Surgery: such as laparoscopy or hysteroscopy is performed to treat fibroids, polyps, endometriosis, pelvic adhesions, tubal blockage and uterine septum.
- Vitro Fertilization (IVF): is recommended for male factor, unexplained infertility, endometriosis, tubal factor or after failed conventional treatment. Donor egg IVF is advised for women with poor embryo quality and repeated failed IVF treatment, women with Diminished Ovarian Reserve (DOR) and for women over the age of 44.
If the problem is with ovulation, your doctor may recommend ovulation-induction treatment. A “Fertility Pill” such as Clomiphene
(Clomid or Serophene brands) is usually the first choice. When a thyroid abnormality is detected or if a pituitary hormone called prolactin is high, treatment with a thyroid hormone or with a prolactin lowering medication (Parlodel, Dostinex) may be necessary. If they do not correct the ovulation problem (or if they appear to be correcting it, but you still do not become pregnant), gonadotropin injections will be recommended. These are potent hormones, and you must be carefully monitored by an experienced fertility specialist while you are taking them.
How is Clomiphene prescribed?
The standard dose is 50 mg daily for 5 days starting between day 3 and day 5 of the menstrual cycle. Sometimes, Clomiphene is given together with Dexamethasone when the DHEAS hormone level is abnormally high. Clomiphene can also be combined with an insulin blocking medication (Metformin) for those with high insulin or hemoglobin A1c levels and for patients with Polycystic Ovary Syndrome (PCOS).
How is Clomiphene treatment monitored?
Typically a pelvic ultrasound is performed 3-5 days after beginning your period. This is done to make sure that there are no large ovarian cysts present. A pregnancy test is also performed to make sure you are not pregnant.
Clomid is taken daily for 5 days beginning 3-5 days after the onset of menses. An ultrasound is often performed on day 13 of cycle to check on the developing eggs (fig. 2) and to make sure that the lining of the uterus is thick enough to support embryo implantation (fig. 3).
The egg is microscopic and can not be seen on ultrasound. We can tell when the egg is ready for ovulation by measuring the size of the follicle containing the egg. When the follicle size is greater than 16-18 mm, an HCG injection is given to trigger the ovulation which is expected to occur 36-40 hours later.
fig. 1fig. 2fig. 3
What to do when Clomiphene therapy is unsuccessful?
If you did not ovulate or failed to conceive with Clomiphene, you have unexplained infertility or your husband has low sperm count, injectable hormones (gonadotropins) together with Intrauterine Insemination (IUI) may be considered.
What does gonadotropin therapy involve?
Gonadotropin injection therapy is expensive and labor intensive. It consists of several blood estrogen levels and ultrasounds to minimize the risk of hyperstimulation and multiple pregnancies. Using this treatment in conjunction with Intrauterine Insemination (IUI), we have experienced a pregnancy rate of about 15-20% per cycle and a delivery rate of about 18% per cycle.
2. Intrauterine Insemination (IUI)
IUI is frequently utilized to treat infertile couples before considering a more complicated and expensive therapy such as In Vitro Fertilization (IVF). The insemination procedure may utilize the husband’s sperm (AIH) or frozen donor sperm (donor IUI).
IUI is performed as close to the time of ovulation as possible. In preparation for IUI, your husband’s sperm is purified in the laboratory of harmful bacteria, inflammatory cells and dead sperm, and then concentrated into a small volume. The treated sperm is loaded into a soft catheter and injected directly into your uterus.
What are the indications for IUI?
- Male factor
- During an ovulation induction cycle in conjunction with gonadotropin injections or Clomiphene
- Unexplained infertility
- Mild endometriosis
- Hostile cervical mucus
- Donor insemination
Intrauterine Insemination (IUI) is most commonly recommended when male factor infertility is identified – that is, if the sperm count or “motility” (forward movement) is low. The treatment is most effective for mild to moderate reduction in sperm count (between 10-20 million/ml, and is often combined with ovarian stimulation with Clomiphene or injectable hormones (gonadotropin therapy). The ovary is stimulated to produce 2-3 eggs while the insemination procedure increases the number and quality of sperm reaching the eggs, significantly improving the odds of a successful pregnancy.
What if you are among the 5 -10% for whom the diagnosis is never discovered? Treatment with fertility injections with IUI has been helpful in many cases of “unexplained infertility.” If this does not work, you will likely be a good candidate for IVF.
The treatment is also helpful if you have mild endometriosis or if you are found to have “hostile cervical mucus” – that is, if the composition of your cervical mucus examined at the time of ovulation (Post Coital Test or PCT) reveals poor sperm survival
When severe sperm abnormalities are present and you do not wish to undergo IVF, then artificial insemination by donor sperm (donor IUI) using frozen sperm from a sperm bank may be considered
3. When to consider surgery?
If you are found to have a uterine abnormality, such as fibroids, polyps, adhesions, or a congenital abnormality of the uterus (uterine septum), laparoscopy or hysteroscopy can be performed to correct the problem. Similarly, pelvic adhesions can be removed with laser surgery, and fallopian tubes can be surgically opened if the blockage is at the site where the tube inserts into the uterus. When severe tubal disease or endometriosis is the problem, your doctor may suggest going straight to In Vitro Fertilization (“IVF”). Some women who undergo tubal ligation sterilization procedure may regret their decision. In such cases In Vitro Fertilization or reversal of sterilization utilizing minimally invasive robotic laparoscopic surgery may be considered.
Laparoscopy has been utilized to treat the following conditions:
Fibroids can cause infertility, recurrent miscarriages, pain and bleeding. They can be removed by a minimally invasive laparoscopy, a procedure called myomectomy. More recently, computer assisted robotic laparoscopic surgery has made laparoscopic removal of the fibroids easier to perform. When multiple large fibroids are present, a major abdominal surgery (laparotomy) is often recommended.
Endometriosis is a common cause of infertility. With this condition, endometrial tissue (that is, pieces of the uterine lining which are shed during menstruation) is found outside the uterus, in other parts of the abdominal cavity. Endometriosis lesions can be removed by laparoscopic surgery (with CO2 laser), or they can be reduced by taking hormonal medications which suppress menstruation. Mild endometriosis in younger patients may be treated with surgery or medication to suppress endometriosis. If a male factor is also diagnosed, ovarian stimulation with injectable gonadotropin hormones and insemination (IUI) may be advised by your doctor. If pregnancy does not occur within 2-3 treatment cycles, your doctor may recommend IVF as the next step. In older patients or those with severe endometriosis, IVF is often the treatment of choice.
Ectopic (tubal) pregnancy
Laparoscopic treatment of ectopic pregnancy and removal of the tube (salpingectomy) is necessary when the pregnancy ruptures through the tubal wall. In certain cases where the pregnancy has not ruptured, an incision can be made in the tube to remove only the pregnancy, leaving the tube intact. There is a 20% chance of developing another ectopic pregnancy in the remaining tube.
Reversal of tubal ligation
Laparoscopic Robotic assisted reversal of sterilization can now be offered as an alternative to IVF.
Approximately 5% of women undergoing tubal sterilization procedure regret their decision because of a change in their marital status, loss of a child or wanting more children. The most significant factors influencing success rate with reversal procedures are the level of expertise of the surgeon and length of tube remaining after sterilization. Success rates are highest when the length of the tube is estimated to be more than 2 inches
Reversal of tubal ligation
In Vitro Fertilization has largely replaced surgery for women with distal tubal disease (hydrosalpinx) who want to conceive. Laparoscopic removal of the diseased tube (salpingectomy) is necessary before undergoing IVF because inflammatory cells present in the tubal fluid can enter the uterine cavity and prevent implantation of the embryo during IVF. Reconstructive tubal surgery to repair the diseased tube is rarely performed because scar tissue frequently recurs soon after the surgery, resulting in low pregnancy rates and an unacceptable high risk of tubal pregnancy .
Scar tissue or adhesions occur most frequently after pelvic infection, previous surgery or endometriosis. It is estimated that pelvic adhesions occur in between 50 -100% of infertility surgery cases. Adhesions can cause pain and/or infertility when they involve the ovaries or the fallopian tubes. When the adhesions involve the intestines, they may cause bowel obstruction or blockage. If mild scar tissue is found during laparoscopic surgery, it can be removed (lysis of adhesions) at the time of surgery. When severe scar tissue is present, removing it is unlikely to improve the likelihood for pregnancy, and IVF should be considered instead. During laparoscopic surgery, absorbable adhesion barriers are often utilized to cover the surgical area and to minimize the risk of recurrence of scar tissue. It is important that your doctor is an expert in laparoscopic fertility techniques, handling the tissues delicately to avoid further damage and scar tissue formation.
Ovarian drilling for PCOS
Laparoscopic ovarian drilling has been advocated by several investigators to restore ovulation in women with Polycystic Ovary Syndrome. Highly successful ovulation induction therapy utilizing clomiphene and gonadotropins has limited the usefulness of laparoscopic surgery.
Hysteroscopy is indicated for the following conditions:
4. In Vitro Fertilization (IVF)
- Uterine fibroids
- Uterine polyps
- Tubal blockage (proximal tubal occlusion – PTO)
- Asherman`s Syndrome (intrauterine adhesions) Congenital uterine anomalies ( Uterine septum )
- IVF - May be advised to overcome various fertility factors such as tubal problems, sperm deficiencies, endometriosis and unexplained
infertility. If you are 38 or older, IVF treatment may be a more suitable option because of the decline in egg quality as you get older.
- ICSI – For more severe male factor infertility, IVF with Intracytoplasmic Sperm Injection or “ICSI” may be the best option. In this
procedure, the embryologist uses a high power microscope and micromanipulation techniques to inject a single sperm into each egg. The fertilized eggs develop into embryos which are transferred back into the uterus 3-5 days after the procedure.
- TESA – In some men, severe infection may cause scarring of the sperm transporting system resulting in complete absence of sperm in the ejaculate (obstructive azoospermia). Live sperm can be retrieved from testicular tissue (Testicular Sperm Aspiration or TESA) and injected into the egg (ICSI) during IVF resulting in successful pregnancies
- Preimplantation Genetic Diagnosis (PGD) is a diagnostic test for detection of chromosomal (genetic) abnormalities in the embryo
during In Vitro Fertilization (IVF). The embryo biopsy is performed at the blastocyst stage. The biopsy utilizes sophisticated microscopic laser technology to remove peripheral cells, called trophectoderm, which are destined to become the placenta. The cells are then analyzed by Comparative Genomic Hybridization (GGH). The cells destined to become the fetus are not disturbed. Only those embryos which are found to be normal are transferred into the uterus. The abnormal embryos are discarded. Any remaining normal embryos may be frozen for transfer at a later date. Currently, this procedure has not yet been proven to be of benefit for patients with repeated IVF failures, older patients or patients with recurrent miscarriages. Once this technology becomes more cost effective, all embryos may be routinely biopsied to avoid transfer of abnormal embryo
How successful is IVF?
For women under the age of 35, our live birth rate per cycle is about 50%. If you are 36-37 year old your expected live birth rate per cycle is about 35% decreasing slightly to 31% if you are 38-39 years old. Between 40 and 42 years of age the live birth rate is about 20% and 5% if you are 43. Pregnancy rates for older patients are much lower and donor egg IVF may be advised.