Common Infertility Treatments- Overview
Fortunately, there are many fertility treatments available for the female. A high percentage of infertile women present with ovulatory problems. Ovulatory irregularity is a symptom of many conditions including PCOS, hormone deficiencies or excesses, poor ovarian function, ovarian failure, too much exercise and/or stress, elevated prolactin levels, and others.
Unfortunately, there are no truly effective male infertility medications. Products currently marketed for male infertility have not been shown to increase pregnancy rates or offer any “real additional value”. Male infertility however, can successfully be treated
with ICSI (described below).
The Assisted Fertility Program provides a comprehensive array of reproductive technologies. Your treatment program will depend upon the needs and preferences of you and your partner and may consist of one or a combination of the following options:
Clomid Treatment-The physician may presumptively start the patient on a 3-6 month trial of Clomid. In some cases, IUI may be combined with Clomid. The length of the trial depends upon many factors including patient age, her FSH level, response to Clomid, etc. Clomid is most likely to be effective in the first three cycles and treatment after that point is not recommended. As mentioned earlier, sometimes specialists will prescribe Clomid for six months.
Once a woman is ovulating on Clomid there is no value to further increasing her dose. If she does not ovulate on 50mg of Clomid, the dose may be increased to 100mg or 150mg until ovulation resumes. Unlike FSH, Clomid does not stimulate the ovaries directly. Rather, it works at the hypothalamus to compete with estrogen receptors.
Oftentimes, we ask couples to monitor their cycles using the LH test kits and to plan intercourse around the most fertile times. If 3-6 months of Clomid therapy fails, follicle stimulating hormone (FSH) may be administered in conjunction with an IUI cycle.
Follicle Stimulating Hormone (FSH) Treatment-Dr. Shaykh may elect to treat the patient with FSH usually administered by injection daily and intrauterine insemination (IUI). FSH directly stimulates the ovaries to produce many eggs. She may also receive Lupron, Antagon, or Cetrotide to control the timing of ovulation. FSH should only be administered by a board certified fertility specialist, like Dr. Shaykh, who has extensive clinical experience using these drugs. FSH can produce the serious side effect known as ovarian hyperstimulation syndrome so patients must be closely monitored by ultrasound and blood estradiol measurement.
Most of the high order multiple births seen in the media are the result of FSH IUI cycles where “too many” eggs fertilized and formed viable embryos. Specialists know how to monitor and control the cycle thus greatly reducing the chance of >2 babies. High order multiples are rarely seen in IVF cycles because the physician limits the number of embryos replaced into the uterus. See our Fertility Medications page for more info.
In-Vitro Fertilization (IVF)
Most often, the mass media focuses on IVF, when producing news reports about infertility treatments. This is true even though a relatively small number of women (% varies by practice) will ever require the procedure. We have a separate page on our Web site for IVF.
IVF may be the “first line” treatment in some cases such as male infertility, older females, tubal disease, specific cause of the couple’s infertility and treatment history, etc. Tubal reversal may be an option for women with previous tubal sterilization. In the IVF procedure the eggs are retrieved after the female undergoes ovulation induction with FSH. Once retrieved they are combined with the sperm and fertilization occurs. The fertilized eggs, now embryos, are transferred to incubators until ready for transfer to the mother, usually 3-5 days.
In-vitro Fertilization is defined as laboratory fertilization of eggs. This treatment bypasses the fallopian tubes and is the most effective therapy for patients with blocked, damaged, or nonexistent tubes. In IVF treatment, the woman is given fertility drugs to stimulate her ovaries to produce numerous eggs. Because each follicle, or sac of fluid, contains one egg, the chance of pregnancy is increased if multiple eggs can be obtained and fertilized. The number and size of the developing follicles in the ovaries is measured with ultrasound. The final preparation for egg collection involves a hormonal injection given to the woman 35 to 36 hours before the procedure.
The eggs are collected vaginally using ultrasound guidance under intravenous sedation. The probe is introduced into the vagina, the ovaries are visualized, and an aspiration needle attached to the probe is passed through the top of the vagina into the follicles. The fluid within the follicles is aspirated and then examined in our laboratory for the presence of eggs. In rare situations when the scan indicates that the ovaries are inaccessible, the eggs are collected laparoscopically. Even with the benefits of ultrasound it is often difficult to predict the number of eggs available. More or fewer eggs may be collected than anticipated. In rare cases when no eggs are collected, a follow-up appointment is made with the doctor to discuss treatment alternatives.
After the eggs are collected they are incubated for a short time. The sperm is then added to the eggs and incubated for 24 to 48 hours. If the sperm is normal, fertilization usually takes place. The fertilized eggs, or embryos, are returned to the uterus two to five days after egg collection. This process is known as embryo transfer.
The embryo transfer procedure is one of the most important events in IVF. It is generally a painless procedure similar to a pap smear and takes about 15 minutes. An abdominal or vaginal scan is generally performed to confirm the correct position of the transfer catheter within the uterine cavity prior to transfer. Occasionally, the woman will experience menstrual-like pain during the procedure, but this is generally short-lived.
We encourage partners to be present for the embryo transfer. It is important for you to remember that several, or even none, of the eggs may become fertilized. In these cases, we will discuss other treatment options with you. Learn more about IVF Treatment here.
Minimal stimulation IVF
Minimal stimulation IVF is similar to traditional IVF expect a lower amount of medication is used. You can learn more about this on our Mini-Stim IVF page.
Intracytoplasmic sperm injection (ICSI)
ICSI has revolutionized the treatment of male infertility, offering assistance to couples that previously had to rely on the use of donor sperm. ICSI enables up to 95% of couples to reach embryo transfer. It is important to remember that while ICSI is an effective technique in aiding fertilization, it does not guarantee it. Until recently, the limiting factor in treating male infertility was the difficulty in isolating sufficient numbers of active sperm to mix with the eggs in the laboratory.
With ICSI, very few sperm are required. Additionally, the ability of the sperm to penetrate the egg is not an issue since penetration is bypassed. In ICSI, a high-powered microscope is used to enable the embryologist to perform precise surgical manipulations on the eggs and sperm. A tiny glass instrument called a micropipette is used to hold the eggs in place. The sperm is injected via a microneedle through the outer layers of the egg), past the shell of the egg (zona pellucida) and into the main body of the egg (cytoplasm).
Men with the following abnormalities in their semen are suitable for ICSI:
ICSI cannot be done if the testes do not produce sperm. These cases are very rare. Are there risks of conceiving an abnormal baby with ICSI? During ICSI, the microneedle may pierce the egg and cause damage. Because the damage is evident during or immediately after the procedure, the egg is not transferred, so the possibility of an abnormality is avoided. A link exists between very severe male infertility and the gene mutation that causes cystic fibrosis.
We recommend that patients with an extremely low sperm count be tested for this mutation and for genetic microdeletions. A genetic link exists for some forms of severe male infertility, however, and it is possible for male children to inherit sub-fertility from their fathers. Consequently, these sons may also require infertility treatment.
ICSI is used in many IVF cycles when male infertility is present, the female is older, there have been IVF cycle failures, etc. Using ICSI, a sperm is inserted directly into an egg using a microscopic needle. ICSI is particularly useful in cases of severe male infertility where only a few, or one, sperm may be available. ICSI is the only treatment option for these couples unless they use a sperm donor.
Intrauterine insemination (IUI) or Artificial Insemination
Intrauterine Insemination involves the injection of treated sperm from the partner or donor into the woman’s uterine cavity. It is generally a painless procedure that takes only a few minutes and is performed in our office. The chances of success are increased if the insemination is combined with Controlled Ovarian Hyperstimulation. IUI should be performed when the fallopian tubes are healthy and the sperm preparation is satisfactory. It may also be a treatment option for women who have cervical mucus hostility, and in some cases, for unexplained infertility.
Controlled Ovarian Hyperstimulation
When fertility pills are ineffective, more potent fertility injections may be required to overstimulate egg production. Women receiving fertility injections are monitored with ultrasound and hormone assessment to control egg production and increase the likelihood of pregnancy.
Egg donation, IVF with an Egg Donor, Ovum Donation
Egg Donation is an option for women with inactive ovaries including:
Egg Donation is also an option for women with active ovaries including:
The goal of Egg Donation is to synchronize the recipient’s menstrual cycle with that of the donor, facilitating the most successful outcome. To accomplish this, the recipient is placed on hormone replacement therapy (HRT), which allows us to manipulate her cycle as required. Donated eggs from volunteers are fertilized with sperm from the recipient’s partner. Following fertilization, the embryos are transferred into the uterus or fallopian tubes of the recipient.
The donor undergoes drug treatment to stimulate ovaries to produce several eggs and recipient undergoes drug treatment to prepare the uterus to receive the embryos sperm from recipient’s husband/ partner egg from donor embryo embryo transfer OR freeze for transfer at a later date
The demand for Egg Donation treatment is on the rise and most fertility centers have a waiting list. Because today’s technology does not allow unfertilized eggs to be easily frozen, the supply of eggs is limited. Couples and donors that undergo Egg Donation require extensive counseling, particularly in cases where the donor is known to the recipients. We try to ensure that donors and recipients share similar physical characteristics such as skin, eye, and hair color. Donors should be under the age of 33 and preferably completed their own family. Our donors are carefully screened for HIV, Hepatitis B and C, cystic fibrosis, syphilis, chlamydia, and gonorrhea. The donor undergoes a similar stimulation protocol as described in an IVF cycle, with egg collection usually performed vaginally.
Testicular sperm aspiration (TESA), Surgical Sperm Retrieval
Surgical sperm retrieval may be a treatment option for men with:
In the first three cases, sperm are produced by the testes but are unable to be ejaculated because of blockage, or absence of, the vas. The man can still ejaculate seminal fluid but this fluid will not contain sperm. It is possible to collect sperm directly from the epididymis. Occasionally it is possible to repair the blockage surgically. In the case of non-obstructive azoospermia, very small amounts of sperm may be produced that can be collected directly from the testes. This is done by randomly performing multiple testicular biopsies. These procedures are usually timed to coincide with the female’s egg collection, and the sperm is then injected into the eggs using ICSI. If enough sperm is retrieved it is possible to freeze small amounts for later use. More information is available about TESA and TESE as well as frequently asked questions.
Tubal reversal surgery or Tubal Ligation Reversal
If a patient has elected to have an elective sterilization commonly known as having their “tubes tied”, we offer tubal ligation reversal surgery. The damaged fallopian tubes are carefully reconnected restoring fertility to many patients. See our Tubal Reversal Page for more info.
Reproductive surgery and Endoscopic Surgery
At the Assisted Fertility Program, we perform endoscopic or “keyhole” surgery for those women who require it. Hysteroscopy is used primarily to inspect the condition of the uterus from within. It can also be used to perform surgical procedures such as the removal of fibroids, polyps or adhesion, or to correct congenital uterine abnormalities. Hysteroscopy uses a telescope that is passed through the vagina and cervix into the uterine cavity. Laparoscopy is used to assess the condition of the female pelvis and to diagnose the presence or absence of adhesion, endometriosis, or other pelvic abnormalities. It involves an inspection of the pelvic organs by a telescope passed through a tiny incision at the navel. A separate small incision at the level of the pubic hair is used to introduce a probe to manipulate the pelvic organs. Laparoscopic surgery, which is minimally invasive and leaves only a small scar, can treat any of these conditions.
We also offer:
Your OB/Gyn may also perform these procedures.
Most surgical procedures are now performed using laparoscopy. (See the detailed discussion under “Fertility Tests”). Small surgical openings are made in the abdomen, usually at the pubic hair line and belly button making scars barely noticeable. The laparoscope, a telescope like device, is inserted in one opening and allows the surgeon to visualize the ovaries, tubes, uterus, and other internal structures.
Endometriosis is a common cause of infertility and can often be removed by the reproductive endocrinologist during the diagnostic laparoscopy. Laparoscopy can also be used to “reconnect” the Fallopian tubes depending on how the tubes were severed and patient specific factors. Most fibroids and polyps can be removed laparoscopically. Additionally, many “large surgeries” such as a hysterectomy can be performed laparoscopically. The major advantages of laparoscopy over “open surgery” are: less pain, shorter recovery time, laparoscopy is usually an outpatient surgery, less expense, and less scarring.
Endometriosis and polycystic ovary syndrome treatment
Polycystic Ovarian Syndrome (PCOS) results in highly elevated male hormones (testosterone, etc.) known as androgens. Elevated androgens in the female often result in ovaries covered with cysts, thinning of the hair on the head, dark increased body hair, lowering of the voice, irregular or failed ovulation, and long term health risks mainly from cardiovascular disease.
When PCOS is diagnosed it is often treated with Glucophage (metformin) which lowers insulin levels. PCOS patients are hyperinsulinemic due to the overproduction of insulin which ultimately leads to overproduction of androgens. When insulin levels are reduced with drugs like metformin, normal ovulation will often resume. PCOS patients are often treated using IVF. These patients must be closely monitored by the reproductive endocrinologist as they can have exaggerated and unpredictable responses to follicle stimulating hormone.
Gamete Intrafallopian Tube Transfer (GIFT)
The GIFT procedure is quite similar to IVF up to the point of egg collection. The ovaries are stimulated with fertility drugs to produce an increased number of eggs with ultrasound monitoring of their development. The retrieved eggs are examined and then two or three mature eggs are mixed with the prepared sperm. The eggs are then transferred into the woman’s fallopian tubes through a tiny catheter. In GIFT, fertilization occurs in the natural site – the fallopian tubes. The resulting embryos travel along the fallopian tubes in the normal way to reach the uterus after four to five days.
The remaining eggs are inseminated in-vitro and if fertilization occurs, can be frozen for future use. As the results of IVF become increasingly more successful, it is less common to recommend GIFT as a first-line treatment. We may suggest this technique in special circumstances, such as repeated failure with IVF, unexplained infertility, minimal endometriosis without pelvic damage, or as an incidental procedure at the time of diagnostic laparoscopy
Before implantation the embryo must hatch from its shell to attach to the womb. In some cases the shell is unusually hard, reducing the odds of implantation. Assisted Hatching is a procedure in which the outer layer of the embryo is either thinned or opened to facilitate hatching. It is generally recommended for women above the age of 35 and for women who experienced unsuccessful IVF. While in some cases Assisted Hatching may enhance the pregnancy rate, it is important to realize that some embryos can be damaged as a result of these interventions.
Embryo Freezing and Replacement of Frozen Embryos
Following embryo transfer, surplus embryos can be frozen. The advantage of freezing embryos is that they can be replaced in a future cycle without the woman having to repeat drug treatment and surgery. We recommend embryo freezing if two or more embryos of good quality are available. The final decision, however, remains with the couple concerned. Frozen embryo transfer has been practiced since 1987 and there appears to be no increased incidence of fetal abnormality in babies born following this procedure. About 70% of all frozen embryos survive the thawing process.
Although some couples may have all of their embryos survive in good condition, others may not have any that survive. Embryos are frozen in batches of two or three and are thawed as a group, not individually. Replacement of frozen embryos is relatively simple. The woman’s natural cycle is monitored using an ultrasound scan and ovulation predictor kits to time ovulation. Following ovulation, the embryos are thawed and transferred back to the uterus. If the woman’s cycle is irregular we may recommend HRT, giving us control over the time of transfer.
At the Assisted Fertility Program, embryos can be frozen for up to one year, at which time the embryos may be:
Learn more about Frozen Embryo Transfers and Embryo Freezing here.
Egg Freezing, Sperm Freezing or Fertility Preservation
Egg freezing technology is no longer experimental and vitrification allows us to save unfertilized eggs, for example in women going through cancer treatment.
Semen freezing is useful for men who find it difficult to ejaculate on demand, resulting in an inability to produce a sample on the day of egg collection. By freezing semen prior to treatment, some of the stress associated with producing a sample is alleviated. Semen quality may be reduced after freezing, however, so a fresh sample is preferred on the day of egg collection
The Assisted Fertility Program works in close coordination with Reprotech for long-term storage of sperm, eggs, and embryos. Cryobanking is particularly important for patients who want to preserve their fertility prior to cancer treatment.