WVFC – Non IVF Treatments
In Vitro Fertilization (IVF) usually receives most of the attention when fertility treatments are discussed. Nevertheless, most infertile couples who require treatment will achieve a pregnancy without IVF. These non IVF treatments are:
Ovulation Induction
Ovulation induction is performed for the treatment of infrequent, irregular or absent ovulation. Since disorders of ovulation accounts for 40% of the causes of infertility in women ovulation induction is by far the most common treatment performed. Clomiphene citrate (Serophene or Clomid) is the most common medication used for ovulation induction, and has been in clinical use since 1967. It is taken orally and is quite effective in inducing ovulation. Approximately 80% of women who are not ovulating will respond to clomiphene citrate, and half of the women who ovulate will achieve a pregnancy.
The risk of multiple pregnancies (mostly twins) with clomiphene citrate is approximately 6%. This medication is usually well tolerated, but common side effects are transient hot flushes and mood swings. Severe complications are rare with clomiphene citrate.
Gonadotropin preparations are used for ovulation induction in patients who don’t respond to clomiphene citrate, and in patients with hypothalamic amenorrhea. For all practical purposes women with hypothalamic amenorrhea have no effective communication between the area of the brain that controls ovulation (hypothalamus) and the ovaries. These patients don’t respond to clomiphene citrate and need gonadotropin therapy for ovulation induction. The gonadotropins are similar to the gonadotropins secreted by the brain (pituitary gland) to induce normal ovulation. There are two types of gonadotropin preparations, (1) recombinant gonadotropins that are manufactured in the laboratory, and (2) highly purified gonadotropins that are extracted from the urine of postmenopausal women. Both gonadotropin preparations are administered by subcutaneous injection (under the skin) and stimulate the ovaries directly to induce ovulation. The use of these medications requires transvaginal ultrasound monitoring of the ovaries to assess the ovarian response to treatment, and when needed, to adjust the dosage of the medication. A common side effect of the gonadotropins is discomfort and or redness at the injection site. The risk of multiple pregnancies when gonadotropin therapy is used for ovulation induction is approximately 15%. The most serious complication associated to gonadotropins is Ovarian Hyperstimulation Syndrome (OHSS). OHSS is the result of an exaggerated response of the ovaries to the gonadotropins. This syndrome is characterized by enlarged ovaries, abdominal swelling (distention), abdominal discomfort, nausea and occasional vomiting. OHSS is usually self-limited and resolves spontaneously within a few days, but may last longer if the patient is pregnant. In severe cases hospitalization is needed for the management of this condition.
Super Ovulation or Controlled Ovarian Hyperstimulation (COH)
This treatment is frequently recommended to couples with unexplained infertility. These couples have completed a standard infertility evaluation and no explanation for their infertility was found. Unexplained infertility accounts for 10 to 15% of all causes of infertility. The goal of COH is to increase the chances of conception by increasing the number of eggs released at the time of ovulation. COH for unexplained infertility is usually performed in combination with intrauterine insemination (described below). In these patients this combination results in a higher pregnancy rate than when COH is performed in combination with timed intercourse. Both clomiphene citrate and the gonadotropin preparations are employed for COH. Clomiphene citrate is used in COH cycles at a dosage higher than usually needed to induce ovulation. Nevertheless, clomiphene citrate is not as effective as the gonadotropin preparations in inducing multiple ovulation, and as a result, in couples with unexplained infertility the pregnancy rate is higher in gonadotropin cycles as compared to clomiphene cycles. The risk of multiple pregnancies when gonadotropin preparations are used for COH is approximately 25%. With clomiphene citrate the risk for multiple gestations remains approximately 6%.
Artificial Insemination (IUI, ICI)
Artificial insemination involves the placement of sperm in the female reproductive tract by means other than sexual intercourse. AI is a simple and painless procedure that can be an effective treatment for some types of infertility. The sperm sample can be placed in the vagina (vaginal insemination), the cervix (cervical insemination or ICI) or inside the uterus (intrauterine insemination or IUI). For vaginal insemination and ICI the sperm sample doesn’t need any special preparation prior to insemination. For IUI a “sperm wash” is needed prior to insemination. During the “sperm wash” the sperm is separated from the seminal fluid, is concentrated, and then contained within a very small amount of liquid. This very concentrated sperm sample is gently inserted through the cervix into the uterus. The main advantage of the IUI over the other types of insemination is the higher concentration of sperm that is achieved within the uterus. This is not possible with the vaginal or cervical insemination, and is responsible for the higher pregnancy rate seen with IUI as compared to the other types of insemination. For this reason vaginal and cervical inseminations are rarely performed. IUI is commonly performed for mild to moderate male infertility, therapeutic donor insemination, retrograde ejaculation, male or female sexual dysfunction, cervical abnormalities, and “hostile” cervical mucus. In addition, IUI is in combination with COH is frequently employed for the treatment of unexplained infertility.
The IUI needs to be performed around the time of expected ovulation, and the timing is critical for a successful outcome. LH testing with an ovulation predictor kit or active follicular monitoring can be used for the timing of the IUI. Luteinizing Hormone or LH is the gonadotropin that triggers the process of ovulation. LH is always present in the blood stream, but just before ovulation, its concentration in blood markedly increases. Ovulation will occur 24 to 36 hours after the LH “surge” or “spike”. The ovulation predictor kit predicts ovulation by detecting the increased concentrations of LH that occur just before ovulation. The kit does not detect ovulation, it only detects the increased level of LH present (LH surge). Active follicular monitoring consists of the sequential use of transvaginal ultrasound to monitor changes in follicle size to determine when an egg (or eggs) is (are) ready for ovulation. Once the egg (or eggs) is (are) ready the ovulation is triggered with the injection of a substance quite similar to LH. The insemination is then performed 36-40 hours after this injection when the induced ovulation is expected to occur.
Which is best, LH testing with an ovulation predictor kit or active follicular monitoring is certainly open to debate. In general, LH testing is commonly performed in natural (no fertility drugs) or clomiphene citrate cycles, and active follicular monitoring is performed in all gonadotropin-stimulated cycles. In addition, active follicular monitoring is performed when the patient is unable to detect her LH surge, or when in previous cycles her IUI timing is suspected have been wrong.
Surgery
For women who have tubal damage the treatment options are tubal reconstructive surgery and In Vitro Fertilization (IVF). Over the last 25 years the pregnancy rate associated to IVF has markedly increased and now far exceeds those that could be achieved with tubal reconstructive surgery. As a result, IVF is the treatment of choice for most couples with tubal damage. Nevertheless, tubal reconstructive surgery is still an appropriate option for certain cases of tubal damage, and when moral, ethical, or religious objections, or financial pressures prevent IVF.
Laparoscopy
The diagnostic laparoscopy probably is the most common surgical procedure performed as part of the infertility evaluation. It is generally regarded as the definite test for the evaluation of tubal factors. It is usually performed under general anesthesia and involves the thorough exploration of the pelvis organs (uterus, ovaries, fallopian tubes and peritoneal surfaces) and documentation of tubal patency. At laparoscopy suspected abnormalities such as tubal obstruction, pelvic adhesions or endometriosis can be confirmed and documented. In many cases during the diagnostic laparoscopy tubal surgery or endometriosis treatment can be performed. The types of tubal procedures that can be performed will depend on the skill of the surgeon. Common procedures are (1) division and or removal of scar tissue, (2) re-opening of an obstructed fallopian tube(s), (3) destruction of implants of endometriosis, and (4) removal (cystectomy) or incision and drainage of ovarian cysts. The more severe the abnormality treated at surgery the lower the expected pregnancy rate associated to the procedure.
Hysteroscopy
Two types of uterine surgery are commonly performed, the hysteroscopy and the myomectomy. The hysteroscopy consists of the inspection of the uterine cavity with a small optical instrument inserted through the cervix. A liquid solution is used to distend the uterine cavity and facilitate its inspection. The hysteroscopy can be performed in the doctor’s office or in a hospital or outpatient surgery center. At the doctor’s office minimal or no sedation is employed and the procedure is only diagnostic. The uterine cavity is inspected, findings documented, and if a surgical correction is needed it is performed later at the hospital. The hysteroscopy is frequently performed at the hospital or outpatient surgery center under conscious sedation or general anesthesia. In this setting operative procedures such as the removal of polyps, fibroids (submucosal) and scar tissue (adhesions) can be performed. In addition, operative hysteroscopy is performed for the treatment of a congenital malformation of the uterus called a septum. This malformation creates a wall or partition within the uterus and has been associated with miscarriages. The repair by hysteroscopy of this anomaly improves the reproductive outcome of women with frequent miscarriages associated with uterine septum.
Myomectomy
The myomectomy is a surgical procedure for the removal of uterine fibroids. Three types of myomectomy can be performed: abdominal myomectomy, laparoscopic myomectomy, and hysteroscopic myomectomy. The abdominal myomectomy requires an abdominal incision usually of the “bikini” type, and through the incision the fibroids are removed from the uterus. This abdominal approach is the best procedure when fibroids are large, numerous, and or located deep within the muscle of the uterus. Fibroids can also be removed by laparoscopy, and this type of myomectomy is best when fibroids are few in number, superficial in location and small in size. Hysteroscopic myomectomy is recommended when most of the fibroid is located within the cavity of the uterus (submucosal). A myomectomy is a relatively safe procedure that results in few serious complications. Postoperative adhesion formation is a common complication and good surgical technique combined with adhesion-prevention barriers should be routinely used at myomectomy.
Tubal Sterilization Reversal
Elective tubal sterilization (ligation) is one of the most common forms of contraception in the United States. The objective of the tubal sterilization is to create an interruption in each fallopian tube that will prevent conception. This can be achieved by: (1) removing a segment from each fallopian tube; (2) applying an occlusive device (clip, ring, band) to each fallopian tube; or (3) burning (coagulating) part of each fallopian tube. Because of its destructive nature, the tubal sterilization is considered a permanent form of contraception. Approximately 1 million women have an elective tubal sterilization procedure in the U.S. each year. Many regret their decision and about 1% will later request a reversal. As a result, surgical techniques have been developed to reverse most forms of tubal sterilization.
The sterilization reversal is a major surgical procedure performed under anesthesia (epidural or general) through an abdominal incision. The re-connecting of the fallopian tubes is performed with meticulous microsurgical technique, including the use of an operating microscope and very fine sutures. Because of the delicate nature of this operation, the sterilization reversal usually takes about 3 to 4 hours. The woman is usually discharged home after a 23-hour hospital stay. She continues her recovery at home for 2 to 3 weeks. Surgical complications with sterilization reversal are rare.
The likelihood for a successful pregnancy is affected by the age of the woman, the type of sterilization procedure, and the final length of the reconnected fallopian tubes. Younger women whose sterilization procedure was performed with clips, rings, or bands have the best prognosis. While older women or those with more destructive procedures such as burning or coagulation do worse. In properly selected candidates, the pregnancy rate seen after a sterilization reversal is quite good and usually between 40 to 80% with an associated 5 to 10% incidence of tubal (ectopic) pregnancy. Most patients who conceive do so in the first 12 months following the operation.
Unfortunately, not all tubal sterilization procedures are reversible. Some procedures can be quite destructive to the fallopian tubes such as burning or when removal of a large amount of the tube leaves too little tube to be re-connected. To determine if your particular tubal sterilization is reversible or not, a copy of the operation report of the sterilization is needed. This report describes the sterilization operation in detail, and usually gives all the information necessary to determine if a reversal is possible or not. A copy of the operation report can usually be obtained by writing to the hospital where the operation took place. When the operation report is not available, or it doesn’t give enough information to decide if the reversal is possible or not, a diagnostic laparoscopy is recommended. At laparoscopy the fallopian tubes are visualized and inspected to see if they can be re-connected or not. When reversal is not possible, In Vitro Fertilization is then the only alternative available to achieve a pregnancy.
Expectant Management
Expectant management is a period of “wait and see” (no intervention or treatment) before attempting any fertility test, procedure or therapy. This approach is recommended to couples with unexplained infertility of short duration when the woman is under 35 years of age. In this group, the likelihood of a spontaneous pregnancy within a 2 to 3 year period is very good. These couples have a pregnancy rate of 35-50% after two years, and 60-70% after three years of observation. It is important to note that these rates decrease as the female partner's age and the duration of infertility increase. Treatment is recommended when no pregnancy occurs after an adequate period of observation.
In our experience most couples decline expectant management in lieu of further testing or treatment. Nevertheless, this is an option that is discussed with couples diagnosed with unexplained infertility.
Adoption
The treatment of infertility can be stressful and expensive. After a long and unsuccessful journey in the path to fertility adoption may become an alternative to childlessness. People making this decision face many challenges: stopping fertility treatment, making peace with the loss of the dream of making a baby, and facing fears and concerns about adoption and the adoption process which can be both confusing and intimidating.
Resolve - The National infertility Association - offers a very comprehensive guide to adoption as well as links to adoption agencies. We encourage you to explore these resources available at their website.
We want you to understand what all your options are (including IVF) in order that you might make an informed decision. Ultimately, our goal is to match you with the best treatment option consistent with your personal goals.