Couples today have many infertility options from which to choose. It was only 20 years ago that male infertility necessitated the use of a sperm donor, while now Intracytoplasmic sperm injection (ICSI) allows men with severe infertility to father genetically related children. Other new technologies, such as donor egg, make it possible for women with ovarian failure to experience the joy of carrying and delivering their children.
Available treatment options depend upon the cause(s) of infertility. If a woman is ovulating irregularly or not at all, Clomid may be a first-line treatment.
If Clomid alone fails, the next treatment option depends on several patient-specific factors. Many couples try intrauterine insemination (IUI). “Stimulated IUI” means that Clomid orFSH will be used to stimulate the ovaries. In many cases, three cycles of IUI will be tried before moving to more advanced treatments, such as IVF.
Some conditions, such as hyperprolactenemia, respond to specific medications. In these cases, Parlodel is given to normalize prolactin levels, allowing ovulation to resume. Sometimes, polycystic ovarian syndrome (PCOS) will respond to treatment with metformin. Metformin sensitizes the cells to insulin, resulting in a lowering of androgen levels (male hormones) and the return of ovulation. PCOS patients often need additional medications, such as FSH.
Contrary to public opinion, less than 30 percent of women seeing a specialist will need IVF. Most will become pregnant using first-line therapies like those described above. There are some women who will require IVF as a first-line treatment, such as those with tubal factor infertility. When this condition is present, the eggs cannot make their journey from the ovaries, through the fallopian tubes, and into the uterus. Using IVF, the tubes are avoided altogether, as the embryo is placed directly into the uterus. Treatments such is IUI would be unsuccessful for women with blocked fallopian tubes.
Surgical intervention to correct tubal damage, or to reverse a tubal sterilization, is sometimes undertaken. In most of these cases, IVF will be recommended as the treatment of first choice because the success rates are substantially higher. Younger women wishing a tubal reversal may benefit from a surgical procedure. They have many natural cycles remaining in which to conceive after the surgery. Older women may have only a few fertile cycles left, and IVF is strongly recommended.
Moderate to severe male factor infertility is another condition that will likely require IVF, in combination with ICSI. Using ICSI, a single sperm is injected into each mature egg, resulting in fertilization that otherwise would not likely occur. This means that even though there are no sperm in the male’s ejaculate, a pregnancy can be initiated using sperm which has been surgically removed from his reproductive tract.
If the male has a varicocele, it will sometimes respond to surgical intervention. A varicocele is a collection of varicose veins in the spermatic cord that interferes with sperm “cooling.” Correction of the varicocele sometimes returns semen parameters to normal. However, sperm require three months to develop and any treatments or changes initiated today will not be seen until after that time period.
Sometimes a couple may know or strongly suspect that they carry a genetic disorder that can be passed to their children. In these cases, preimplantation genetic diagnosis (PGD) with IVF is a recommended treatment. Using PGD, the embryos are screened for a specific genetic disorder or for abnormal or broken chromosomes. A single cell is removed from each embryo and examined using PCR or FISH to identify if the disease is present. PGD is especially effective in cases where the genetic disease is linked to a sex chromosome. Only embryos free of the defect will be transferred to the uterus, thus preventing transference of the disease. If a disease only occurs in males, male embryos will not be transferred.
Donor eggs will be required if a woman has diminished ovarian reserve or premature ovarian failure (POF), usually indicated by a significantly elevated FSH level. Women in their thirties with marginal FSH levels mayl be advised to undergo donor egg IVF, especially if they do not stimulate well with FSH.
There are cases where a woman cannot carry a pregnancy to term. The uterus may be congenitally abnormal or damaged by pelvic inflammatory disease, or there may be severe endometriosis. These women can use a gestational carrier to carry their children. Agencies exist to help find suitable carriers. In the majority of cases, the mother and father produce embryos from an IVF cycle that are then implanted into the surrogate. One delivered, the child is given to the parents.
