Infertility Treatment

Treatment of infertility depends on the cause, the duration of the problem, the age of the partners and their specific wishes. Some causes of infertility can't be corrected. However, various means of insemination or embryo transfer may be possible so that a woman can still become pregnant.

Nonsurgical fertility treatment falls into two main categories:

• Restoring or bringing about fertility
• Assisted reproductive technology (ART)

Restoring or bringing about fertility
These approaches can involve steps related to the male or to the female, or both.

Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation. Increasing the frequency of intercourse increases the chances for conception.

Other approaches that involve the male include:

• Treatment of general sexual problems. Addressing impotence or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.
• Addressing lack of sperm. When the source of infertility lies in the man's sperm, or lack of it, restoring or initiating fertility is sometimes possible. For example, in some instances, surgical correction of a varicocele will restore fertility. Problems with the testicles, prostate gland, seminal vesicle and urethra also can be treated. When sperm production is impaired because of damage to the sperm-producing areas of the testicle, drug treatment has little benefit. In rare instances when sperm production is impaired because of a pituitary problem, treatment with pituitary hormones called gonadotropins may help. When infection hampers sperm production, both you and your partner will need treatment.

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In vitro fertilization

• Clomiphene citrate (Clomid, Serophene). This drug is taken orally and stimulates ovulation in women who have PCOS or other ovulatory disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
• Human menopausal gonadotropin, or hMG (Repronex, Pergonal). This injected prescription medication is for women who don't menstruate on their own due to the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, which stimulates the pituitary gland, hMG and other gonadotropins directly stimulate the ovaries. This drug contains both FSH and LH.
• Follicle-stimulating hormone, or FSH (Gonal-F, Follistim, Bravelle). FSH is essentially hMG without the LH. Like hMG, it works by stimulating the ovaries to mature egg follicles.
• Human chorionic gonadotropin, or hCG (Ovidrel, Pregnyl). Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to release its egg (ovulate).
• Gonadotropin-releasing hormone (Gn-RH) analogs. This treatment is for women with irregular ovulatory cycles or who ovulate prematurely — before the lead follicle is mature enough — during hMG treatment. Gn-RH analogs deliver constant Gn-RH to the pituitary gland, which alters hormone production, so that a physician can induce follicle growth with FSH.
• Letrozole (Femara). This drug is in a class of medications called aromatase inhibitors, which are approved for treatment of advanced breast cancer. Doctors sometimes prescribe letrozole for women who don't ovulate on their own and who haven't responded to treatment with clomiphene citrate. Letrozole is not approved by the U.S. Food and Drug Administration for inducing ovulation. The drug's manufacturer has warned doctors not to use the drug for fertility purposes because of possible adverse health effects. These adverse effects may include birth defects and miscarriage.
• Metformin (Glucophage). This oral drug is taken to boost ovulation. It's used when insulin resistance is known or suspected.
• Bromocriptine. This medication is for women whose ovulation cycles are irregular due to elevated levels of prolactin, the hormone that stimulates milk production in new mothers. Bromocriptine inhibits prolactin production.

Injectable fertility drugs significantly increase the chance of multiple births. The use of these drugs requires careful monitoring with a combination of blood tests of hormones and ultrasound measurement of ovarian follicle size. Generally, the greater the number of fetuses, the higher the risk of premature labor. Babies born prematurely are at increased risk of health and developmental problems. The risk is greater for triplets than it is for twins or single pregnancies.

The risk of multiple pregnancies can be reduced. If a woman requires an hCG injection to trigger ovulation, and ultrasound exams show that too many follicles have developed, she and her doctor can decide to withhold the hCG injection. For many couples, however, the desire to become pregnant overrides concerns about conceiving multiple babies.

When too many babies are conceived, removal of one or more fetuses (multifetal pregnancy reduction) can offer improved survival odds for the surviving fetuses. This presents serious emotional and ethical challenges for many people. If you and your partner are considering fertility drug treatment, discuss this possibility with your doctor before starting treatment.

There may be a link between fertility drugs and an increased, long-term risk of ovarian cancer. However, the association between fertility drugs and ovarian cancer hasn't been confirmed.

Surgery
Depending on the cause, surgery may be a treatment option for infertility. Blockages or other problems in the fallopian tubes usually can be surgically repaired. Laparoscopy allows delicate operations on the fallopian tubes.

Infertility due to endometriosis often is more difficult to treat. Although hormones such as those found in birth control pills are effective for treating endometriosis and relieving pain, they haven't been useful in treating infertility. If you have endometriosis, your doctor may treat you with ovulation therapy, in which medication is used to stimulate or regulate ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.

Assisted reproductive technology (ART)
ART has revolutionized the treatment of infertility. Each year thousands of babies are born in the United States as a result of ART. Medical advances have enabled many couples to have their own biological child. An ART health team includes physicians, psychologists, embryologists, laboratory technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.

The most common forms of ART include:

• In vitro fertilization (IVF). This is the most effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended as a first-line therapy and is the treatment of choice if both fallopian tubes are blocked. It's also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility, male factor infertility and ovulation disorders.
• Electroejaculation. Electric stimulus brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who can't otherwise achieve ejaculation.
• Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if blockage is present.
• Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.
• Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus.

ART works best when the woman has a healthy uterus, responds well to fertility drugs, and ovulates naturally or uses donor eggs. The man should have healthy sperm, or donor sperm should be available. The success rate of ART gradually diminishes after age 32.

Complications of treatment
Certain complications exist with the treatment of infertility. These include:

• Multiple pregnancy. Although the most common complication of ART is multiple pregnancy, ART isn't the direct cause of a number of the extreme cases of septuplets or octuplets reported in the media. The number of quality embryos kept and matured to fetuses and birth ultimately is a decision made by the couple. If too many babies are conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.
• Ovarian hyperstimulation syndrome (OHSS). If overstimulated, a woman's ovaries may enlarge and cause pain and bloating. Mild to moderate symptoms often resolve without treatment, although pregnancy may delay recovery. Rarely, fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. This accumulation of fluid can deplete blood volume and lower blood pressure. Severe cases require emergency treatment. Younger women and those who have polycystic ovary syndrome have a higher risk of developing OHSS than do other women.
• Bleeding or infection. As with any invasive procedure, there is a risk of bleeding or infection.
• Low birth weight. The greatest risk for low birth weight is a multiple pregnancy. In single live births, there may be a greater chance of low birth weight associated with ART.
• Birth defects. Significant concern exists regarding the possible relationship between ART and birth defects. More research is necessary to confirm these findings. Weigh this factor if you're considering whether to take advantage of this treatment. ART is the most successful fertility-enhancing therapy to date.