The therapy recommended by your fertility specialist will depend on your diagnosis. It is important to have a complete "fertility evaluation" prior to undergoing treatment.
Infertility treatment consists of the following options:
- Stimulation of ovulation - for
ovulatory disorders,
male factor and unexplained infertility.
- Intrauterine insemination - for male factor, hostile cervical mucus and unexplained infertility
- Surgery – for
fibroids, uterine polyps,
endometriosis, pelvic scar tissue (adhesions), tubal blockage and uterine septum.
- In Vitro Fertilization (IVF) - after failed conventional therapy and for
male factor, unexplained infertility and as a first option in cases of severe
endometriosis or severe tubal disease.
- Donor egg IVF –
for women of advanced reproductive age, women with high day 3 FSH level, poor embryo quality or repeated
failure of IVF treatment using the woman’s own eggs.
Ovulation Induction therapy
Ovulation stimulation treatment includes:
- Clomiphene Citrate tablets
- Injectable gonadotropin hormones
 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 Polycystic Ovary Syndrome (PCOS).
How is Clomiphene treatment monitored?
Ultrasound is done on day 12-14 of the cycle to measure the size of the follicles (eggs), and thickness of the lining of the uterus (ideally, thicker than 8mm). When a follicle measures 18 mm, the egg within the follicle is ready for ovulation, an HCG injection may be given to trigger ovulation. A progesterone level of equal or greater than 15 ng/ml, measured a week after ovulation confirms normal ovulation. A pregnancy rate of about 30% is expected after 3-4 cycles of Clomiphene therapy.
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, requiring several blood estrogen levels and 2-3 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 23% per cycle and a delivery rate of about 18% per cycle.
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 done 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:
Endometriosis
Endometriosis is a common cause of infertility. With this condition, endometrial tissue  (that is, pieces of the uterine lining which is 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.
Uterine fibroids
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.
Reversal of tubal ligation
 Outpatient laparoscopic
reversal of sterilization utilizing
robotic laparoscopy can now be offered as an alternative to
In Vitro Fertilization.
Ectopic (tubal) pregnancy
Laparoscopic treatment of ectopic pregnancy and removal of the tube (salpingectomy) is necessary when the pregnancy ruptured through the tubal wall. In cases where the pregnancy has not ruptured, an incision can be made in the tube to remove only the pregnancy, leaving the tube intact.
Tubal disease
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 .
Pelvic adhesions
 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.
What is Hysteroscopy?
Hysteroscopy is a minor outpatient surgical procedure performed for various uterine and tubal conditions associated with infertility.
Hysteroscopy is indicated for the following conditions:
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