Infertility Treatments. About Infertility Treatments | Patient

Synonym: subfertility

Around one in seven couples in the UK is affected by infertility and a small proportion of these need treatment with assisted conception.

The main causes of infertility in the UK are:

In about 40% of cases disorders are found in both the man and the woman. Uterine or endometrial factors, gamete or embryo defects, and pelvic conditions such as endometriosis may also play a role.[2]

For further information on aetiology, prevalence and investigation see the separate articles Infertility - Male and Infertility - Female.

Persistent azoospermia is incompatible with fertility. The couple may wish to consider donor sperm.

Assisted conception broadly refers to procedures whereby treated or manipulated sperm are brought into proximity with oocytes. It includes:

The Human Fertilisation and Embryology Authority (HFEA) has published data showing that there are wide variations in the success rates of IVF clinics.[4] Success depends upon numerous factors, including the woman's age, BMI, previous pregnancy history and lifestyle factors. Around 25% of IVF treatments using a woman's own fresh eggs result in a live birth.

IUI involves the introduction of prepared sperm into the uterine cavity around the time of ovulation (spontaneous or induced).

IUI can be considered as a treatment option in the following groups:

People with unexplained infertility, mild endometriosis or 'mild male factor infertility', who are having regular unprotected sexual intercourse should no longer routinely be offered IUI, either with or without ovarian stimulation. They should be considered for IVF if they have not conceived after trying for two years.

There is insufficient evidence to recommend the use of GIFT or zygote intrafallopian transfer in preference to IVF in couples with unexplained fertility problems or male factor fertility problems.[1]

When IVF-ET is used:

When IVF is used and a top-quality blastocyst is available, a single embryo transfer is now recommended. Currently, double embryo transfer in IVF is the most commonly used strategy in the UK. The new National Institute for Health and Clinical Excellence (NICE) guidelines will change this and, in doing so, will maximise the chance of pregnancy while minimising the risk of a multiple pregnancy.

In ICSI, a single sperm is injected directly into an oocyte. It should be considered for those with severe deficits in semen quality, obstructive azoospermia or those with non-obstructive azoospermia. In addition, treatment by ICSI should be considered for couples in whom a previous IVF treatment cycle has resulted in failed or very poor fertilisation.

Where the indication for ICSI is a severe deficit of semen quality or non-obstructive azoospermia, the man's karyotype should be established (after genetic counselling).

World Health Organization (WHO) Group I ovulation disorder is due to hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism). These women should be advised that they can improve their chance of regular ovulation, conception and an uncomplicated pregnancy by increasing their body weight (for those with a BMI of <19) and/or moderating their exercise levels (if they undertake high levels of exercise). These women should be offered pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation.

WHO Group II ovulation disorder is due to hypothalamic-pituitary-ovarian dysfunction (predominately due to polycystic ovarian syndrome). Clomifene citrate (CC) - an anti-oestrogen - is an initial treatment for the majority of these. Metformin (or a combination of clomifene and metformin) can be also considered. However, those women with a BMI of >30 should be advised to lose weight before starting treatment.

Women who are known to be resistant to CC should consider one of the following second-line treatments, depending on clinical circumstances and the woman's preference:

WHO Group III ovulation disorder is due to ovarian failure - hypothalamic-pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism). Women with ovulatory disorders due to hyperprolactinaemia should be offered treatment with dopamine agonists such as bromocriptine.

Many of the complications are related to multiple pregnancies. Elective single embryo transfer has been shown to be associated with reduced risks of preterm birth and low birth weight compared with double embryo transfer but higher risks of preterm birth compared with spontaneously conceived singletons.[7]

The most serious complication is ovarian hyperstimulation syndrome(OHSS) which may occur when ovarian stimulation techniques are used.[8]It usually presents with lower abdominal discomfort, nausea, vomiting, diarrhoea and abdominal distension. Signs of severe disease, indicating a need for hospital management, include:

Its incidence may be reduced by careful tailoring of the pharmacological agents and embryo implantation techniques used. New strategies are being introduced to try to prevent OHSS from developing.[9]However, a Cochrane systematic review found no convincing evidence for any particular strategy.[10]

NICE recommends that women who are offered ovulation induction should be informed that:

The use of ovulation induction or ovarian stimulation agents is kept at the lowest effective dose and duration of use.

Although the absolute risks of long-term adverse outcomes of IVF treatment, with or without ICSI, are low, a small increased risk of borderline ovarian tumours cannot be excluded.[1]

The couple needs support and reassurance. It can be a very difficult time for them, especially if there is pressure from parents or in-laws, that may be more prominent in some cultures, but can occur in all. Pregnancy probably will occur even without intervention but they must not feel neglected or that nothing can be done. There are many stories of couples who conceive after giving up hope.

Couples who have fertility problems should be informed that they might find it helpful to contact a fertility support group. Counselling may be appropriate for some couples, as fertility problems can cause psychological stress.[1]

Women intending to become pregnant should be informed that dietary supplementation with folic acid (0.4 mg a day) before conception and up to 12 weeks of gestation, reduces the risk of having a baby with neural tube defects. The dose should be 5 mg a day in those women who have previously had an infant with a neural tube defect or those receiving anti-epileptic medication or who have diabetes.

Ovulation predictor kits should be discouraged. Not only do they appear to be ineffective, but making love should be a spontaneous and amorous act, not dictated by a calendar or a kit.

Where conventional medicine offers no help, patients are often tempted by alternative therapies. However, what little evidence there is suggests that they are of no benefit and that, as they have not been properly tested, they may even be teratogenic.

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Infertility Treatments. About Infertility Treatments | Patient