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Treatments and drugs

By Mayo Clinic staff

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Illustration of in vitro fertilization In vitro fertilization

Treatment of infertility depends on the cause, how long you've been infertile, the age of the partners and many personal preferences. Some causes of infertility can't be corrected. However, a woman can still become pregnant with assisted reproductive technology or other procedures to restore fertility.

Treatment for couples
These approaches can involve steps related to the male or to the female, or both.

Increase frequency of intercourse. Having intercourse two to three times a week may improve fertility. However, too-frequent ejaculation can lessen sperm quality. Sperm survive in the female reproductive tract for up to 72 hours, and an egg can be fertilized for up to 24 hours after ovulation.

Treatment for men
Approaches that involve the male include treatment for:

  • General sexual problems. Addressing impotence or premature ejaculation can improve fertility. Treatment for these problems often is with medication or behavioral approaches.
  • Lack of sperm. If a lack of sperm is suspected as the cause of a man's infertility, surgery or hormones to correct the problem or use of assisted reproductive technology is sometimes possible. For example, varicocele can often be surgically corrected. For blockage of the ejaculatory duct or in the case of retrograde ejaculation, sperm can be taken directly from the testicles or recovered from the bladder and injected into an egg in the laboratory setting.

Treatment for women
Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. In general, they work like natural hormones — such as follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. Commonly used fertility drugs include:

  • Clomiphene (Clomid, Serophene). This drug is taken orally and stimulates ovulation in women who have polycystic ovary syndrome (PCOS) or other ovulatory disorders. It causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
  • Human menopausal gonadotropin, or hMG, (Repronex). This injected medication is for women who don't ovulate on their own due to the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, which stimulates the pituitary gland, hMG and other gonadotropins directly stimulate the ovaries. This drug contains both FSH and LH.
  • Follicle-stimulating hormone, or FSH, (Gonal-F, Bravelle). FSH works by stimulating the ovaries to mature egg follicles.
  • Human chorionic gonadotropin, or HCG, (Ovidrel, Pregnyl). Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to release its egg (ovulate).
  • Gonadotropin-releasing hormone (Gn-RH) analogs. This treatment is for women with irregular ovulatory cycles or who ovulate prematurely — before the lead follicle is mature enough — during hMG treatment. Gn-RH analogs deliver constant Gn-RH to the pituitary gland, which alters hormone production so that a doctor can induce follicle growth with FSH.
  • Aromatase inhibitors. This class of medications, which includes letrozole (Femara) and anastrozole (Arimidex), is approved for treatment of advanced breast cancer. Doctors sometimes prescribe letrozole for women who don't ovulate on their own and who haven't responded to treatment with clomiphene citrate. Letrozole is not approved by the Food and Drug Administration for inducing ovulation. The drug's manufacturer has warned doctors not to use the drug for fertility purposes because of possible adverse health effects. These adverse effects may include birth defects and miscarriage.
  • Metformin (Glucophage). This oral drug is taken to boost ovulation. It's used when insulin resistance is a known or suspected cause of infertility. Insulin resistance may play a role in the development of PCOS.
  • Bromocriptine (Parlodel). This medication is for women whose ovulation cycles are irregular due to elevated levels of prolactin, the hormone that stimulates milk production in new mothers. Bromocriptine inhibits prolactin production.

Fertility drugs and the risk of multiple pregnancies
Injectable fertility drugs increase the chance of multiple births. Oral fertility drugs such as Clomid increase the chance of multiple births but at a much lower rate. The use of these drugs requires careful monitoring using blood tests, hormone tests and ultrasound measurement of ovarian follicle size. Generally, the greater the number of fetuses, the higher the risk of premature labor. Babies born prematurely are at increased risk of health and developmental problems. These risks are greater for triplets than for twins or single pregnancies.

The risk of multiple pregnancies can be reduced. If a woman requires an HCG injection to trigger ovulation, and ultrasound exams show that too many follicles have developed, she and her doctor can decide to withhold the HCG injection. For many couples, however, the desire to become pregnant overrides concerns about conceiving multiple babies.

When too many babies are conceived, removal of one or more fetuses (multifetal pregnancy reduction) can offer improved survival odds for the surviving fetuses. This presents serious emotional and ethical challenges for many people. If you and your partner are considering fertility drug treatment, discuss this possibility with your doctor before starting treatment.

Surgery
Depending on the cause, surgery may be a treatment option for infertility. Blockages or other problems in the fallopian tubes can often be surgically repaired. Laparoscopic techniques allow delicate operations on the fallopian tubes.

Infertility due to endometriosis often is difficult to treat. Although hormones such as those found in birth control pills are effective for treating endometriosis and relieving pain, they haven't been useful in treating infertility. If you have endometriosis, your doctor may treat you with ovulation therapy, in which medication is used to stimulate or regulate ovulation, or in vitro fertilization, in which the egg and sperm are joined in the laboratory and transferred to the uterus.

Assisted reproductive technology (ART)
ART has revolutionized the treatment of infertility. Each year thousands of babies are born in the United States as a result of ART. Medical advances have enabled many couples to have their own biological child. An ART health team includes physicians, psychologists, embryologists, laboratory technicians, nurses and allied health professionals who work together to help infertile couples achieve pregnancy.

The most common forms of ART include:

  • In vitro fertilization (IVF). This is the most effective ART technique. IVF involves retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a laboratory and implanting the embryos in the uterus three to five days after fertilization. IVF often is recommended when both fallopian tubes are blocked. It's also widely used for a number of other conditions, such as endometriosis, unexplained infertility, cervical factor infertility, male factor infertility and ovulation disorders. IVF increases your chances of having more than one baby at a time because multiple fertilized eggs are often implanted into your uterus so that there is a greater chance one will develop into a baby. IVF also requires frequent blood tests and daily hormone injections.
  • Electric or vibratory stimulation to achieve ejaculation. Electric or vibratory stimulation brings about ejaculation to obtain semen. This procedure can be used in men with a spinal cord injury who can't otherwise achieve ejaculation.
  • Surgical sperm aspiration. This technique involves removing sperm from part of the male reproductive tract, such as the epididymis, vas deferens or testicle. This allows retrieval of sperm if the ejaculatory duct is blocked.
  • Intracytoplasmic sperm injection (ICSI). This technique consists of a microscopic technique (micromanipulation) in which a single sperm is injected directly into an egg to achieve fertilization in conjunction with the standard IVF procedure. ICSI has been especially helpful in couples who have previously failed to achieve conception with standard techniques. For men with low sperm concentrations, ICSI dramatically improves the likelihood of fertilization.
  • Assisted hatching. This technique attempts to assist the implantation of the embryo into the lining of the uterus.

ART works best when the woman has a healthy uterus, responds well to fertility drugs, and ovulates naturally or uses donor eggs. The man should have healthy sperm, or donor sperm should be available. The success rate of ART is lower after age 35.

Complications of treatment
Certain complications exist with the treatment of infertility. These include:

  • Multiple pregnancy. The most common complication of ART is multiple pregnancy. The number of quality embryos kept and matured to fetuses and birth ultimately is a decision made by the couple. If too many babies are conceived, the removal of one or more fetuses (multifetal pregnancy reduction) is possible to improve survival odds for the other fetuses.
  • Ovarian hyperstimulation syndrome (OHSS). If overstimulated, a woman's ovaries may enlarge and cause pain and bloating. Mild to moderate symptoms often resolve without treatment, although pregnancy may delay recovery. Rarely, fluid accumulates in the abdominal cavity and chest, causing abdominal swelling and shortness of breath. This accumulation of fluid can deplete blood volume and lower blood pressure. Severe cases require emergency treatment. Younger women and those who have polycystic ovary syndrome have a higher risk of developing OHSS than do other women.
  • Bleeding or infection. As with any invasive procedure, there is a risk of bleeding or infection with assisted reproductive technology.
  • Low birth weight. The greatest risk factor for low birth weight is a multiple pregnancy. In single live births, there may be a greater chance of low birth weight associated with ART.
  • Birth defects. There is some concern about the possible relationship between ART and birth defects. More research is necessary to confirm this possible connection. Weigh this factor if you're considering whether to take advantage of this treatment. ART is the most successful fertility-enhancing therapy to date.
Coping and support Tests and diagnosis
References
  1. Guzick DS. Evaluation of the infertile couple. http://www.uptodate.com/home/index.html. Accessed April 30, 2009.
  2. Hornstein MD et al. Optimizing natural fertility in couples planning pregnancy. http://www.uptodate.com/home/index.html. Accessed April 30, 2009.
  3. Infertility: Frequently asked questions. National Women's Health Information Center. http://www.womenshealth.gov/FAQ/infertility.cfm. Accessed April 30, 2009.
  4. Swerdloff RS, et al. Causes of male infertility. http://www.uptodate.com/home/index.html. Accessed April 30, 2009.
  5. Kuohung W, et al. Etiology of female infertility. http://www.uptodate.com/home/index.html. Accessed April 30, 2009.
  6. Brassard M, et al. Basic infertility including polycystic ovary syndrome. Medical Clinics of North America. 2008;92:1163.
  7. Lobo RA. Infertility: Etiology, diagnostic evaluation, management, prognosis. In: Katz VL, et al., eds. Comprehensive Gynecology. 5th ed. Philadelphia, Pa.: Mosby; 2007. http://www.mdconsult.com/das/book/body/134799312-6/0/1524/267.html?tocnode=53760021&fromURL=267.html#4-u1.0-B978-0-323-02951-3..50044-3_1301. Accessed April 30, 2009.
  8. Kuohung W, et al. Overview of treatment of female infertility. http://www.uptodate.com/home/index.html. Accessed April 30, 2009.
  9. Thinking about fertility treatment. March of dimes. http://www.marchofdimes.com/pnhec/173_14308.asp. Accessed April 30, 2009.
  10. Understanding menopause. U.S. Department of Health and Human Services. http://www.womenshealth.gov/menopause/stages/premature.cfm. Accessed April 30, 2009.
  11. Uterine fibroids: Frequently asked questions. U.S. Department of Health and Human Services. http://www.womenshealth.gov/FAQ/uterine-fibroids.cfm. Accessed April 30, 2009.
  12. Weng X, et al. Maternal caffeine consumption during pregnancy and the risk of miscarriage: A prospective cohort study. American Journal of Obstetrics and Gynecology.2008;198:5.
  13. Sigman M, et al. Male infertility. In: Wein AJ, et al, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, Pa: Saunders Elsevier; 2007. http://www.mdconsult.com/das/book/body/134799312-10/836106647/1445/22.html#4-u1.0-B978-0-7216-0798-6..50021-2_1518. Accessed April 30, 2009.
  14. Casper RF, et al. Ovulation induction with aromatase inhibitors. http://www.uptodate.com/home/index.html. Accessed April 30, 2009.
  15. Hammer LB. Psychiatric aspects of infertility and infertility treatments. Psychiatric Clinics of North America. 2007;30:689.
  16. Domar AD. The impact of acupuncture on in vitro fertilization outcome. Psychiatric Clinics of North America. 2007;30:4.

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June 27, 2009

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