Timed Intercourse Timed intercourse is the simplest treatment option available. However, its success is limited only to those cases where timing is the only possible cause of infertility. It is typically performed using the help of home urine ovulation predictor kits. We recommend starting to test on day 11 of the cycle (in a normal 28 day cycle), to test twice a day, and to have intercourse 24 and 36 hours after a positive test.
Intrauterine Insemination (IUI) IUI also called Artificial insemination is a fertility treatment that uses a catheter to place a number of washed sperm directly into the uterus. The goal of IUI is to increase the number of sperm that reach the fallopian tubes and subsequently increase the chance of fertilization. IUI is a fertility treatment often selected by couples who have been trying to conceive for at least one year with no success. IUI may be selected as a fertility treatment with any of the following conditions:
- Unexplained infertility
- Requirement of donor sperm
- A hostile cervical condition, such as cervical mucus that is too thick
- Cervical scar tissue from past procedures or endometriosis
- In Conjunction with the use of fertility medications such as Clomid or injectable hormones.
- IUI provides the sperm an advantage by giving it a head start, but still requires a sperm to reach and fertilize the egg on its own.
The IUI procedure is simple and may be performed even if the woman is not receiving medication to improve her egg production. Many physicians will encourage women to take medications to stimulate the ovaries to increase egg production in order to improve the chance of achieving pregnancy.
The timing of an IUI is critical. Usually, serial ultrasound examinations are performed over a period of several days to pinpoint the day of ovulation occurs. This can be detected using home urine monitoring kits or sometimes by administering a trigger injection, called hCG, to release the egg at a specified time.
A semen sample will be washed by the lab to separate the semen from the seminal fluid. A catheter is used to inject the processed sperm directly into the uterus. This process maximizes the number of sperm cells that are placed in the uterus, thus increasing the possibility of conception. The IUI procedure takes little time and involves minimal discomfort. The patient is asked to perform a home pregnancy test two weeks after the IUI to check if it was successful.
Women under the age of 35 usually have higher rates of success than women over age 35, but the average success rate for IUI ranges from 10-20% in one cycle. With IUI, as with other methods of artificial insemination, the success rate depends primarily on the health of both the sperm and the woman.
The timing of an IUI is critical. Usually, serial ultrasound examinations are performed over a period of several days to pinpoint the day of ovulation occurs.
Ovulation Induction Ovulation induction is the process by which medications are given in order to help women ovulate. Additionally, a process called ovulation induction can assist women with infertility to ovulate more than one egg in an effort to increase their chances of conception. For women who do not ovulate at all or ovulate irregularly, we use medications – either injections called gonadotropins or pills called clomiphene citrate, to stimulate development of a single follicle and ovulation of a single egg. For women who ovulate normally, clomiphene and/or gonadotropins may improve the chances of becoming pregnant by stimulating the ovaries to produce more than one follicle and the subsequent ovulation of more than one egg. Depending upon the situation, one of several infertility treatments may be recommended. In women who do not ovulate, clomiphene, rather than gonadotropins, is often recommended as an initial treatment. The advantages of clomiphene compared to gonadotropins include ease of oral administration, fewer side effects, lower cost (of the medication itself, as well as the monitoring), lower risk of multiple pregnancies, and reduced time commitment (related to monitoring during treatment). If the woman has tried clomiphene or if clomiphene is unlikely to be helpful, the next step is often to try ovulation induction with injectable gonadotropins. Clomiphene or gonadotropins may be used along with intrauterine insemination (IUI) or in vitro fertilization.
In most cases, you will take the clomiphene or give an injection of gonadotropins once per day, in the evening (between 5 pm and 8 pm, for example). The pill is taken orally and the injection can be given under the skin in most cases. After taking the clomiphene or after a few days of injections, you may be asked to have a pelvic ultrasound to measure follicle growth, and possibly a blood test to measure hormone levels. Depending upon the results of these tests, the gonadotropin dose may be increased or decreased. Blood testing and pelvic ultrasound may be repeated three or more times during a cycle. For women who do not ovulate on their own, the goal is to have one follicle that is approximately 15 to 18 mm in size. If three or more follicles (greater than 15 mm each) are seen, the cycle may be cancelled due to the risk of becoming pregnant with twins, triplets, etc. In some situations, the cycle may be converted to in vitro fertilization, so that the clinician can control the number of embryos that are placed in the uterus.
The side effects of clomiphene and gonadotropins usually are minimal. However, with either the clomiphene or gonadotropins, the ovaries become somewhat enlarged during treatment, which can cause abdominal discomfort, and in more severe cases, nausea and vomiting. The main risks of clomiphene and gonadotropin therapy are the development of ovarian hyperstimulation syndrome (OHSS) and conceiving a multiple pregnancy. OHSS is a condition in which the ovaries become moderately to severely enlarged and multiple follicles develop on the ovaries. In severe cases, the woman may develop severe abdominal pain, vomiting, blood clots in the legs or lungs, and fluid imbalances in the blood. Moderate OHSS occurs in less than 6 percent of cases and severe OHSS occurs in less than 2 percent of women undergoing treatment with gonadotropins and less than 1 percent of women undergoing treatment with Clomiphene.
Tubal surgery In certain cases, the cause of infertility is related to tubal disease. Most often this is due to scarring secondary to a previous infection such as a sexually transmitted disease or previous abdominal or pelvic surgery, such as for an ovarian cyst or appendectomy. The success rate for tubal surgery is unfortunately very low and it is not recommended especially in women over the age of 35. IVF success rates are so high for patients with tubal disease at any age that very few women undergo tubal surgical repair.Patients, who are under 35 and have had tubal ligation, might consider tubal reversal surgery depending on the type of tubal ligation. If the ligation was done with a clip and not burned or cut, then tubal reversal might be considered as an alternative to IVF. The advantages of IVF are many however, even in these good prognosis cases. First, success rate are much higher on a per month basis. Second, there is no surgery involved requiring extended period of recovery. Third, if successful, the patient still has her permanent contraception intact.
Uterine Surgery The most common surgical procedure performed for infertility is myomectomy. It’s a procedure whereby uterine myomas or fibroids are removed either through an open abdominal procedure or through laparoscopy, depending on the number, location and size of the fibroids.Fibroids are benign tumors of the muscle of the uterus and are relatively very common. In the majority of women, fibroids do not interfere with the ability to conceive. However, in certain instances, a fibroid could be located inside the uterine cavity or just underneath the uterine lining, the Endometrium, and hence interfere with implantation. Occasionally, a fibroid can also block the opening of the Fallopian tube or get so large that it might interfere with pregnancy and will need to be removed.
The Initial Consultation: Dr. Michele Evans
During the initial consultation, we can review your medical and reproductive history and review a basic fertility evaluation.