Infertility Treatment Decisions
A Couple’s Guide to Infertility
(Dr Eric Daiter, Board Certified in Reproductive Endocrinology and Infertility)
The goal of this guide is to provide a medical expert’s answers to the common questions:
- Do I have infertility?
- What causes infertility?
- How are specific problems with fertility diagnosed?
- Which treatments for infertility are successful and what are their risks?
- What options exist if all of the infertility testing and treatments do not successfully result in a pregnancy?
Which treatments for infertility are successful and what are their risks?
This section of “A Couple’s Guide to Infertility” provides information on (1) the important decisions that should be addressed prior to choosing any infertility treatment plan, (2) successful ovulation treatments, (3) successful male factor (sperm) infertility treatments, and (4) successful pelvic factor infertility treatments.
Decisions, decisions, decisions…
There are many different treatment alternatives for infertility. Therefore, several important decisions should be considered prior to choosing the most appropriate treatment, including
- The treatment should always fit the diagnosis. This is extremely important but is often overlooked. For example, ovulation problems have different treatments than male factor infertility or female pelvic abnormalities. Far too often, I hear that a treatment designed to treat one specific problem is being used to treat an unrelated problem.
- In vitro fertilization (IVF) should not be used as a panacea (universal treatment) for all infertility problems. Specific treatment directed at an identified problem (whether an ovulation problem, male factor, or pelvic problem) is often more effective, less expensive, and has less overall risk. IVF is a wonderful and effective treatment when it is selected appropriately.
- Sometimes you need to decide whether to fix it, replace it, or effectively go around it. This is particularly true when a pelvic problem is encountered. Pelvic repair may restore fertility but involves surgery and success often depends on the skill of the surgeon. IVF is a procedure that can often successfully circumvent (“go around”) an existing pelvic problem (such as a prior tubal ligation or pelvic damage that is not repairable), but generally IVF does not repair any pelvic abnormalities and the couple needs to be comfortable with this type of procedure. Generally, I attempt to identify pathology (problems) and specifically suggest repairing or treating those problems. My outlook is that if I can successfully identify and repair the abnormalities causing reduced fertility then the couple’s natural reproductive potential will be restored.
- Treatment for infertility can differ in terms of cost, character (more or less artificial or natural in character), and medical risks.
Dr. Eric Daiter reviews important criteria in choosing an infertility practice
When a woman has very irregular or no naturally occurring menstrual cycles, there is generally a problem with egg development (maturation). In addition, many women with regular menstrual cycle intervals can have problems with their eggs. Therefore, it is routine to assess ovulation with a thorough history, blood work directed at hormonal imbalances (that may result in an ovulation dysfunction) and egg reserve, and ultrasound examinations. If blood work and ultrasound exams are not accessible, then a complete menstrual and medical history is fairly reliable.
The first line of treatment for an ovulation problem is treating an identified underlying cause, such as
- physical or emotional stress, through guided therapy;
- a hormone imbalance, such as those involving thyroid or prolactin concentrations, which can often be treated effectively with medication;
- dietary intake of large amounts of food containing hormones, especially estrogen like compounds, which can be removed or reduced from the diet; and
- medications that can effect ovulation, which can often be adjusted or changed to similar medication with less effect on ovulation.
If the underlying cause of the ovulation problem is not identifiable, or if it is identified and treated without restoration of normal ovulation, then ovulation induction with medication is usually warranted. The two types of medications that are available and effective are
- Clomiphene citrate (Clomid, Serophene), a pill taken as 1, 2 or 3 pills a day for 5 days. This medication is not expensive, requires little monitoring and has few severe complications. Clomiphene citrate can restore significantly more regular menstrual cycle intervals in about 85% of women, and is often used as a first line treatment for women with polycystic ovarian syndrome and women with presumed stress related ovulation problems (when an adequate egg reserve has been demonstrated). The main side effects include hot flashes, abdominal discomfort, breast tenderness, and moodiness. Complications include multiple pregnancy (twin rate is less than 10% and triplets are uncommon), ovarian cyst development (possibly with significant abdominal distension and pain), or abnormalities of the cervical mucus (which may reduce the sperm’s ability to fertilize the egg in the fallopian tube).
- Injectable monotropins or gonadotropins, which contain FSH to stimulate the development of eggs within ovarian follicles. These medications are generally very expensive, require significant monitoring with blood work and ultrasounds, and have some possible severe complications. Menotropins and gonadotropins are very effective and result in successful egg maturation in up to 90% of women who failed to induce ovulation using clomiphene citrate. Also, since these medications often produce several mature eggs per cycle, there are “more targets” to try to fertilize per cycle. Therefore, injectable medication cycles can also be used for many male factor problems and some pelvic problems. The medications have no common side effects but complications include multiple pregnancies (twins may be as high as 25% of pregnancies and triplets (or more) in up to 5% of pregnancies), ovarian hyperstimulation syndrome with significant fluid shifts (bloating and dehydration) and pelvic pain, and rarely ovarian torsion (twisting of the ovary).
If these medications are ineffective or do not result in a pregnancy, it is possible to also consider donor eggs along with in vitro fertilization. With donor eggs, the chromosomes are those of the female egg donor and not those of the female trying to conceive, so the infertile couple must consider the importance of this fact carefully. Donor eggs should only be used if the couple trying to conceive is comfortable with their use. When donor eggs are used, the eggs are most often retrieved from the egg donor, fertilized in vitro with the husband’s sperm, and transferred into the wife’s uterus so that she can conceive and carry the pregnancy. This treatment is usually extremely expensive, can result in a child carrying a genetic abnormality from the egg donor (even if there is a normal chromosomal analysis since these tests do not discover all genetic diseases), and can result in an infection from the egg donor to the embryo recipient. Although the egg donor is thoroughly tested for most infections prior to the procedures, the eggs are fertilized immediately after retrieval without a 6 months quarantine (as with donor sperm) to allow for further infectious disease testing.
Male (sperm) factor treatments
When a man is found to have abnormal sperm production or function, most often by semen analysis, I routinely obtain a thorough medical history and blood work for the hormones that are involved in normal sperm production.
Ideally, treatment can be directed at an identified underlying cause. Although these are less commonly identified than with ovulation dysfunctions, examples of treatable causes of abnormal sperm include:
- narcotic drug use or abuse, which can be modified or eliminated,
- pituitary FSH or LH secreting tumors, which can be treated surgically if they are looked for and identified,
- hemochromatosis, an excess in circulating iron, which is a very rare cause of sperm abnormalities,
- exposure to excessive heat, including that due to a varicocele, frequent long hot baths, or sitting on heated seats for long periods of time,
- cigarette or alcohol abuse, which can be reduced or eliminated,
- medications or foods containing anabolic steroids and some other medications, which can often be eliminated or changed to other effective medication that does not have a significant impact on sperm production
If no underlying treatable cause is identified, or if the treatment of all underlying causes does not result in restoration of normal sperm production, then several alternatives are available.
- Intrauterine insemination (IUI) is a relatively simple office procedure that places sperm directly into the uterine cavity, next to the opening of the fallopian tube, at the time of ovulation and effectively bypasses the need for sperm placed within the vaginal vault to enter and cross the cervical mucus into the lower uterine cavity. This IUI procedure essentially delivers the available sperm to the end of their natural journey through the female reproductive tract and therefore increases the likelihood that this sperm will find and fertilize an egg within the fallopian tube. The IUI procedure requires sperm washing, which removes the active sperm from the liquid semen (since the semen has components that cause severe uterine cramping). IUI is often successful in couples with a mild to moderate male factor. IUI should be relatively inexpensive, for example, at my office the procedure only costs 200 dollars. Intrauterine inseminations are also safe, with the major concern being an increased chance for transmission of an unrecognized infection from the husband to the wife (since the infectious organism may survive the washing procedure and it might be able to cross the wall of the uterine cavity more efficiently than the wall of the vaginal vault).
- Injectable menotropins or gonadotropins along with intrauterine insemination (IUI), where the female partner is injected with FSH containing medication for several days in order to produce multiple mature eggs (potential targets for the sperm to fertilize) and IUI is performed around ovulation (to deliver active sperm closer to the eggs). These cycles of controlled ovarian hyperstimulation can effectively increase pregnancy rates, however, these medicated cycles are generally very expensive, require frequent monitoring with blood work and ultrasounds, and have risks. The major risks of an injectable medication cycle (controlled ovarian hyperstimulation) include multiple pregnancies (the twining rate is about 25% per pregnancy and the triplet rate may be as high as 5% per pregnancy), hyperstimulation syndrome (uncommon with close monitoring but can involve dehydration and abdominal bloating as a result of major fluid shifts within the body), and twisting of the ovary (rare but can cause severe pain if the ovarian torsion cuts off the ovaries blood supply).
- Assisted fertilization with intracytoplasmic sperm injection (ICSI), places sperm through the outer wall of the egg directly into the egg’s cytoplasm, resulting in successful fertilization and the development of a normal pre-implantation embryo about 70% of the time. The sperm must be living, but otherwise, the success of ICSI is largely independent of sperm quality (even immature sperm heads without tails can be used as long as they are alive). ICSI requires IVF (in vitro fertilization) and is generally extremely expensive. The risk specific to ICSI includes the possibility of passing along a Y chromosome abnormality (that resulted in the male partner’s abnormal sperm production) if the offspring is also male. Studies currently available (2012) have not identified any other congenital abnormality that is increased in offspring born following ICSI.
If these treatments are inaccessible or they do not result in a pregnancy, then anonymous donor sperm is commonly available. This donor sperm is generally frozen and quarantined for at least 6 months while the donor is evaluated for infectious diseases, so it is a bit less efficient compared to fresh sperm in terms of fertilizing eggs. The use of donor sperm also means that the male partner’s genetic heritage will not be passed on to the offspring. Donor sperm varies in cost, largely depending on the available supply for specific samples. Donor sperm is usually delivered into the uterine cavity by IUI and it does not have known risks in terms of increased birth defects or miscarriages.
When there is a problem with the delivery of sperm at intercourse then IUI is usually effective at delivering motile sperm into the uterine cavity.
Treating Pelvic Abnormalities
A pelvic factor problem with either egg fertilization within the fallopian tube or embryo implantation into the uterine cavity is often suggested when there is a fertility problem in a couple with regular menstrual cycle intervals and a normal semen analysis. Essentially, if a couple is infertile and the eggs and sperm appear to be normal, then a pelvic problem is likely. I routinely suggest a hysterosalpingogram (HSG, to evaluate the uterine cavity and to determine whether the fallopian tubes are open) and a postcoital test (to assess whether the sperm is comfortable within the cervical mucus) for all patient couples with difficulty conceiving.
When the hysterosalpingogram reveals an intrauterine filling defect (submucosal fibroid, endometrial polyp, scar tissue) or abnormal fallopian tubes (blocked, dilated, or irregular tubes) then these abnormalities should be repaired. A talented Reproductive Surgeon can usually repair the problem with laparoscopy or hysteroscopy, which are minimally invasive same day surgical procedures that have low risk and rapid recovery periods. If the repair is successful, natural reproductive potential is often restored. If the repair is not performed, then trying to go around the problem with IVF is often unsuccessful or has limited success since these ongoing problems can reduce embryo implantation. An exception is when the female partner has had a prior tubal ligation and now has a normal uterine cavity with blocked tubes on HSG. These women are often very successful at conceiving with IVF.
When the postcoital test determines that the sperm cannot survive and move normally within the cervical mucus, then timed intrauterine inseminations (IUI) will deliver the motile sperm above the level of the mucus directly into the uterine cavity and this should restore fertility (assuming all other factors are normal). The IUI procedure is a low cost office procedure with few risks.
If the hysterosalpingogram (HSG), postcoital test, ovulation tests and semen analysis are normal, or all identified abnormalities have been treated and the couple cannot successfully conceive, then the cause of infertility remains unexplained. In this situation there are two main treatment alternatives, one designed to further investigate the possibility of an unrecognized pelvic factor and the other to circumvent (go around) a possible pelvic factor.
- Pelvic evaluation with two minimally invasive minimal risk same day surgical procedures, laparoscopy and hysteroscopy, to further investigate the pelvis for abnormalities that could not be detected using the previously completed diagnostic tests. Problems that can often be found during a pelvic evaluation (laparoscopy and hysteroscopy) include endometriosis, pelvic adhesions (scar tissue), nonfunctional ovarian cysts, fimbrial agglutinations, and small defects within the uterine cavity (that can not be seen by hysterosalpingography). An experienced talented Reproductive Surgeon can successfully treat most of these abnormalities with restoration of reproductive potential so choose this surgeon carefully. These procedures may also result in decreased menstrual pain, irritable bowel symptoms (like diarrhea or constipation) during menses, and elimination of abnormal uterine bleeding (such as menstrual spotting before or after the menstrual flow). In my experience, these procedures are almost always covered by medical insurance so the out of pocket cost for a patient is minimal. The amount of risk involved with these surgical procedures is minimal, but could include bleeding (these procedures involve so little bleeding that they are often referred to as “bloodless surgery”), infection (these procedures involve very small incisions and they are performed in a sterile environment like an operating room where the surgeons wear sterile gowns so infection is rare), and inadvertent injury to surrounding tissues (the possibility of burn injuries when cautery devices are used is significant so I routinely use a high end CO2 laser that has ultrapulse power settings to virtually eliminate burn injuries to allow more thorough surgery with much less risk).
- In vitro fertilization (IVF) is a procedure that generally involves stimulating the maturation of several eggs using injectable fertility drugs, retrieval of these eggs by needle aspiration under ultrasound guidance, fertilization of the retrieved eggs in the laboratory (in vitro) possibly using assisted fertilization techniques such as ICSI, laboratory culture of the fertilized eggs (preimplantation embryos) for several days within an incubator, and transfer of the developing embryos into the woman’s uterus. In a high quality IVF center, the clinical pregnancy success rate may be greater than 80% per cycle for highly selected donor egg cycles (in which the egg donors are selected specifically for their likelihood of pregnancy success with IVF) and greater than 60% per cycle for couples with entirely favorable characteristics (younger female with an abundant egg supply and good quality sperm). The cost of at least most of the IVF procedures is sometimes covered by medical insurance, but for uncovered components or when IVF is not a covered service the out of pocket cost can be extremely high. At my office we have several patients with no medical insurance undergoing IVF and I try to help out as much as possible with donated medications and discounted rates for services, but the cost still generally remains high for these couples. Risks of IVF include multiple pregnancies (about 20-25% of pregnancies are twins and less than 3% are triplets), ovarian hyperstimulation syndrome (involving potentially serious fluid shifts within the body), and ovarian torsion (twisting of the ovary, which is very uncommon). These risks are taken very seriously and I limit the number of embryos transferred back to dramatically reduce the risk of higher order multiple pregnancies, monitor egg development very carefully and use the latest techniques to trigger ovulation to reduce the risk of ovarian hyperstimulation syndrome when the risk is elevated, and treat ovarian torsion rapidly to try to minimize the damage to the ovary that is caused by twisting around its vascular pedicles.
The final section of this Guide, “What options exist if all of the infertility testing and treatments do not successfully result in a pregnancy?,” is only available on the complete downloaded copy. If you like what you have been reading then download your entire free copy of “A Couple’s Guide to Infertility,” written entirely by Dr. Daiter
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