Infertility Treatment Basics
Infertility Treatment Basics
Richard Paulson (Chief, Division of Reproductive Endocrinology and Infertility, USC) gives expert video advice on: What treatments are available for male infertility?; What treatments are available for female infertility?; Are there specific fertility treatments for women over the age of 35? and more...
What treatments are available for male infertility?
Most important thing for a man who is diagnosed with a low sperm count is to go to a urologist and have a physical examination, because a small percentage of these men will actually have something seriously wrong with their productive track that needs to be evaluated. In one study, one percent of men who presented with infertility were finally diagnosed with some kind of testicular cancer. So we always advise our male partners to go and be evaluated to make sure that there is not something physically wrong with them. But assuming that everything else is normal, male fertilities are either treated with simple treatments or complex treatments depending how bad it is. Mild male factor infertilities and mild decreasing sperm counts can be treated with intrauterine insemination in which the sperm are concentrated and placed closer to the site of fertilization, whereas severe male factor must be treated with assisted reproductive technology in which the sperm can be injected directly into the egg and fertilization achieved in that way.
What treatments are available for female infertility?
As in any other branch of medicine, treatment, of course, has to be focused on whatever the particular problem is. So for example, if a woman has blocked fallopian tubes, then it would be logical that we would try to unblock those, and that kind of repair is of course surgical. If a woman is not ovulating, then a common way to help her is to give her fertility medications, which will help her ovulate. In couples who have unexplained infertility, or in whom there is not a problem with ovulation or with any other obvious kind of issue, we use a treatment called "super ovulation and intrauterine insemination." In this treatment the woman is given fertility medications to help her ovaries release the eggs that are being produced there. And then at the time of ovulation, we take the sperm, concentrated, and put it into the uterus, thereby bypassing the cervix and bypassing a natural barrier to the sperm that sometimes can prevent them from getting up to the site of ovulation and to the site of fertilization. And of course if all else fails, we now have high-tech fertility, and that includes all the different kinds of acronyms: IVF for "in vitro fertilization", or GIFT for "gamete intrafallopian transfer", or ZIFT for "zygote intrafallopian transfer." We have a bunch of these kinds of "alphabet soups" but the principle is always the same. And that is that we take the eggs directly out of the ovary, combine the eggs and sperm in the laboratory, and then put the embryos, or put the egg and sperm back into the woman's body in some kind of fashion. And the high-tech fertility treatments, of course, are the most complex, but they also have the highest probability of success.
Are there specific fertility treatments for women over the age of 35?
For this reason we tend to move fairly quickly through the gambit of treatments on towards the high tech fertility treatments simply because they have so much a higher success rate, such a higher probability of working. So, a women over the age of 35 that will come to the office will be offered the same infertility work up or same infertility treatments. But instead of spending six month to a year giving her simple infertility medications, we would move very quickly to super ovulation and insemination perhaps for a few months and very quickly going on to the high tech infertility treatments. We want her pregnant quickly so that when she needs to come back again in a couple of years, we will still have some time on the biological clock.
What are the emotional consequences associated with infertility treatments?
The human condition of infertility is incredibly stressful for the individuals, and incredibly for the couple. This is an intensely personal aspect of a person's life, and most couples spend their first half of their life worrying about how not to become pregnant, with the assumption that of course as soon as they stop contraception it will happen immediately. Imagine the surprise when it doesn't. Imagine how it brings into question that person's own femininity, or a man's masculinity when something doesn't seem to be working well. We're very sensitive to this and try to guide the couples through this process in a way that is dignified and as reasonable as possible. But, it takes a huge toll and the couples really need to pace themselves and expect that this is very likely going to work because fertility treatment at this time is actually quite successful. But it may not work overnight. So I think managing expectations, and managing the emotional toll is really a big part of what we do in this office, and in this field.
What are the clinical trials currently being done regarding infertility?
The field of infertility is really very new. Virtually everything that we now know about the field we have learned in the last 30, perhaps as few as 20, or maybe even 10, years because the field has expanded so much. The world's first IVF baby was born in 1978. That's nearly 30 years ago, but prior to that the knowledge about how eggs and sperm interact and how all of this happens in the body was really very poorly understood. As a consequence there are still so many things that we do not understand and such a wealth of information that we are gathering really on a year by year basis. My own interest happens to be in embryo implantation; exactly how it is that the embryo interacts with the uterus and allows implantation to occur, because every one of us here is living proof that implantation had to work at that particular point in time. It's a very complicated sort of dance of love, if you will, between the embryo and the endometrium (the lining of the uterus that allows the embryo to implant). There are lots of investigations that are going on; how to help sperm fertilise eggs, how to control egg quality, how to control the number of eggs that a woman produces during any one time. Never mind the follow-up kinds of studies; is all of this safe? Are we causing any harm? Are we doing any damage to the patients themselves? How about the children that are born after infertility treatment; are they, in fact, in any increased danger as a result of the fertility treatment? So, there are as many studies and investigations going on as there are really fertility specialists in the field.
What is "intrauterine inseination" or "IUI"?
Intrauterine insemination, abbreviated, IUI, is a procedure in which the sperm is assisted on their way from the outside world to the site of fertilization, which is in the fallopian tube, by placing them directly into the Uterus. Therefore, intrauterine insemination. This is not a normal place for them to be in so many numbers. They are normally deposited in very large numbers, of course, in the vagina when the couple has intercourse, and then as a result of filtration through the cervix, only a small number of sperm actually make it into the uterus and then out to the fallopian tubes. So, in an IUI procedure, the sperm, the "little swimmers", first must be seperated from the sticky white stuff in which they normally arrive. Those are the prosthetic secretions that the male makes. And those be would not very nice inside the uterus. They would cause lots of cramping and lots of side effects for the woman. So, the "swimmers", the spermatazoa, must be separated from the seminal plasma and they are then injected into the uterus in an IUI procedure. And this results in a tremendous increase of the number of sperm that are available for fertilization at any one time. And as a consequence, they are able to get out to the end of the fallopian tube, get to the egg, and increase their probability of achieving fertilization over that which happens in the natural cycle, in which presumably, of course, the couple is experiencing infertility.
What medications are used for intrauterine insemination?
The intrauterine insemination or IUI procedure is very commonly combined with fertility medications given to the women. The reason for this is that first of all, it makes sense that you would want to stimulate the ovaries to help the eggs come out in an fertility setting. Also, it has been shown in study after study that the IUI procedure is more successful if the woman also takes a fertility medication. So, IUI procedures are most commonly combined with clomiphene citrate, in what we call a clomid IUI cycle. The woman takes clomiphene for five days and then when she ovulates she goes to the doctor's office, and the sperm is washed, concentrated and put inside the uterus. Of course, the IUI is just one way of delivering sperm into the system, so it could really be combined with any of the fertility medications; whether it be bromocriptene or whether it be an injectable form of FSH, such as can be found in HMG, or even any of the other oral medications. It's just a different way of combining the concept of stimulating the ovaries along with increasing the number of sperm that are reaching the site of fertilisation at the same time.