Fertility Problems
Treatment Overview
Before you and your partner start treatment for infertility, talk about how far you want to go. For example, you may want to try medicine but do not want to have surgery. While you may rethink this end point during your treatment, it’s a good idea to have an idea where you want to draw the line. Many couples do not think about this in the beginning and become emotionally and financially drained from trying a series of treatments.
Treatment for fertility can also be quite expensive, and insurance often does not cover these expenses. If cost is a concern for you, find out how much medicines and procedures cost and if your insurance covers any costs. Talk with your partner about what you can afford.
Keep in mind that some infertility problems are more easily treated than others. In general, as a women ages, especially after 35, her chances of getting pregnant decrease and her risk of miscarriage markedly increases.
If you are 35 or older, your doctor may recommend that you skip some of the steps younger couples usually take because your chances of having a baby decrease with each passing year.
Also, understand that even if you are able to get pregnant, no treatment can guarantee a healthy baby. On the other hand, scientists in this field have made many advances that have helped millions of couples have babies.
Your doctor will first try to find why you have not been able to get pregnant. He or she will do tests to look for a cause. Sometimes doctors do not find a problem with either the man or the woman and don't know why a woman cannot get pregnant.
Treatment for female infertility
Problems with ovulating. If your doctor finds that you have a problem with ovulating, he or she may first recommend that you try the medicine clomiphene (Clomid, Serophene, Milophene). This medicine (which you take as a pill) stimulates your ovaries to release eggs, so it improves your chances of getting pregnant. It is often tried first because it is considered safe and effective.
Clomiphene has more side effects than gonadotropins but clomiphene costs less, has a lower risk of ovarian hyperstimulation syndrome, and is less likely to result in a pregnancy with more than one baby.
If you're not ovulating because of a condition called polycystic ovary syndrome (PCOS), your doctor might suggest you take a drug such as metformin in combination with clomiphene. For more information, see treatment of women with polycystic ovary syndrome (PCOS).
Unfortunately, clomiphene does not always work. Typically, hormone shots are the next medication tried. You and your partner can weigh the risks and benefits of proceeding to this next step. You start the first series of daily shots at the beginning of your menstrual cycle. You will probably have mild side effects, such as feeling sick to your stomach and bloating. Some women have more serious side effects due to multiple, large ovarian cysts (ovarian hyperstimulation syndrome). While clomiphene increases your chance of having twins or triplets (especially twins), women who take hormonal injections are even more likely to have twins, triplets, or more babies.
Unexplained infertility. If your doctor cannot find out why you and your partner have not been able to get pregnant, he or she may start out by giving you clomiphene. The steps for treating infertility are essentially the same as for women who have ovulation problems. The next step is to try hormone injections. But at this step your doctor may recommend insemination, putting the sperm directly into the uterus, to improve your chances of getting pregnant. If these treatments don't work, your next step is deciding whether to have IVF (in vitro fertilization).
Blocked or damaged tubes. Your doctor may do tests to check your fallopian tubes. Blocked or damaged tubes can prevent the egg from being fertilized by the sperm. If the blockage of your tubes is slight, your doctor might recommend tubal surgery to try to correct the damage. In these cases, between 20% and 60% of women have successful pregnancies after the surgery, depending on what part of the tube was blocked.5 But in many cases, doctors recommend skipping tubal surgery and having IVF for more severe blockages. IVF is also often recommended first for women over 34 (regardless of the type of blockage) because tubal surgery and natural conception may use up precious time if in vitro fertilization might be used later.
Endometriosis. If you have mild to moderate endometriosis that seems to be the main reason for your infertility, your doctor may use laparoscopic surgery to remove endometrial tissue growth. If surgery does not work, or if you have severe endometriosis, you will need to decide whether to try in vitro fertilization, commonly called IVF. But understand that IVF doesn't work as well for women with endometriosis as with other causes of infertility.
For more information about endometriosis, see the topic Endometriosis.
In vitro fertilization (IVF). Many couples who have problems getting pregnant arrive at a common point: they must decide whether they want to try IVF. IVF is the most common form of a group of similar procedures called assisted reproductive technology, or ART. If you have not already considered adoption, this might be a time to think about it. Some couples decide at this point to spend their resources on adoption instead of IVF. Other couples see IVF as the best option.
For more information about this decision, see:
In IVF, the man's sperm is mixed with the woman's eggs in a lab. Sometimes donor sperm or donor eggs may be used. If the egg and sperm join, it is called fertilization. Your doctor then puts one or more fertilized eggs (now called embryos) into your uterus so that they can grow, just as in a normal pregnancy. (Usually, more than one embryo is put in the uterus to increase your chances that one will develop into a baby.)
IVF increases your chance of having more than one baby at a time. Your chance of having twins with IVF is between 1 in 3 to 1 in 4. That means that 1 out of every 3 to 4 women who become pregnant with IVF has twins. The chance of having triplets or more is higher than normal but much less than the chance of having twins. Your chances of multiple births depend on how many embryos are placed in the uterus at one time.
Overall, in vitro fertilization (IVF) is emotionally and physically taxing. You must have regular blood tests, daily hormone injections (some of which are quite painful), and frequent monitoring by your doctor. You will probably have side effects like bloating, weight gain, and nausea, and you risk having serious side effects such as liver and kidney problems. The embryos may not grow into babies and the IVF must be repeated.
The good news about IVF is that about 1 out of 3 women per IVF cycle has a baby (or babies). IVF success depends on your doctor’s skill and experience and your age. For the woman, the older you are, the less likely that IVF will work unless you use donor eggs. Also, the cause of your infertility can affect the success of IVF.
Treatment options that are not as common include gamete or zygote intrafallopian transfer (GIFT or ZIFT). GIFT is the transfer of eggs and sperm into a fallopian tube through a small abdominal incision. ZIFT is the in vitro fertilization of an egg, which is transferred to a fallopian tube through a small abdominal incision. These procedures are rarely done in the United States. Nearly all couples choose IVF, in which the fertilized egg or eggs are placed in the woman's uterus through the cervix. IVF is less expensive than GIFT or ZIFT. It is also less risky because it is not a surgical procedure.
Treatment for male infertility
A semen analysis will be done to see whether the sperm are healthy and if the sperm count is sufficient. Your doctor might recommend that you try insemination first. The sperm are collected and then concentrated to increase the number of healthy sperm for insemination.
If insemination does not work, your doctor may recommend that you try ICSI (say "ICK-see"). ICSI stands for intracytoplasmic sperm injection. In a lab, your doctor injects one of your sperm into your partner’s egg. If fertilization occurs, the doctor puts the embryo into your partner's uterus, just as in vitro fertilization (IVF).
Your doctor may also recommend ICSI if you have had a vasectomy or you have retrograde ejaculation. In retrograde ejaculation the semen is ejaculated into the bladder instead of out through the penis. In these cases, sperm can be taken from the testicles so that they can be injected into an egg.
Also for retrograde ejaculation, the sperm can be recovered from the bladder, washed, and used for insemination.
In very rare cases, infertility problems are caused by hormonal imbalances. Men are then treated with medicine or hormones, such as GnRH, gonadotropins, and bromocriptine, that help the hypothalamus and pituitary gland start normal sperm production.
When healthy sperm are not available or ICSI does not work, your doctor may recommend you use a donor's sperm. Other couples might choose adoption.
For more information on making the decision about treatment, see:
What To Think About
Both medicine and assisted reproductive technology, such as IVF, increase your risk of having twins, triplets, or more babies. Currently, about 20% of multiple pregnancies occur naturally, while the other 80% are the result of using fertility drugs or assisted reproductive technology. The majority of these pregnancies are twins, but there are also more triplets (or more) than in the general population.
Complications of multiple pregnancy become more likely with each additional fetus. For more information, see the topics Multiple Pregnancy: Twins or More, Preterm Labor, and Premature Infant.
Other rare complications—such as ovarian hyperstimulation syndrome—can result from hormone shots used to stimulate ovulation, usually for assisted reproductive technology such as IVF.
Infertility treatment success is influenced by many factors, including your doctor's skill and experience, and the cause or causes of your infertility.
Infertility treatment centers are not widely available in some parts of the country, especially in rural areas. You may need to travel for treatment. See the complete Centers for Disease Control and Prevention (CDC) listing of U.S. infertility clinics online in the latest Assisted Reproductive Technology Success Rates report at http://apps.nccd.cdc.gov/ART2005/clinics05.asp.
When you review clinic success rates, be aware that clinics treating more severe infertility problems may have lower success rates. So, it's possible for a clinic with a lower success rate to have greater overall expertise than clinics with higher success rates.
When you review treatment success rates, remember that live birth rates are always lower than ovulation and pregnancy rates. Miscarriages are common among all women and are more likely in women with risk factors such as older age or a poorly controlled chronic health condition.
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| Author: | Bets Davis, MFA Sandy Jocoy, RN | Last Updated: March 21, 2008 |
| Medical Review: | Sarah Marshall, MD - Family Medicine Kirtly Jones, MD - Obstetrics and Gynecology | |
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