INFERTILITY AND REPRODUCTIVE MEDICINE
TREATMENTS
There are many possible treatments of infertility. In some cases, it may be enough to educate couples or persons about the possible risks of certain lifestyle choices, including alcohol use, smoking or stress. In other cases, medical or surgical treatment might be necessary to address issues such as hormonal imbalance (to induce ovulation) or uterine growths (including endometriosis or uterine fibroids). With the right treatment, about half of the couples or persons who were not able to conceive during the first year will be able to naturally achieve a pregnancy in the second year. If such treatments should not work, assisted reproductive technologies (ARTs) can help with conception. These include techniques such as intrauterine insemination ("turkey baster approach" in which sperm is directly inserted into the uterus on fertile days of the female cycle), in-vitro fertilization or surrogacy.
Medical Treatment
There are medications that can help with fertility. Most of these act on the endocrine system and affect the levels of reproductive hormones released by the body. Medications can be given orally or by injection. In women, they work by stimulating ovulation. Clomiphene, a selective estrogen receptor modulator, is the most commonly used oral medication to treat infertility due to an anovulation (lack of ovulation). Its mechanism of action is not clearly understood, but it is believed to bind competitively to estrogen receptors in the hypothalamus, thereby blocking the receptors and decreasing their ability to bind to endogenous estrogen. Estrogen has an inhibitory effect on the release on GnRH in the hypothalamus. Reduced GnHR release in turn decreases secretion of the gonadotropins - luteinizing hormone (LH) and follicle-stimulating hormone (FSH) - from the anterior pituitary. These hormones play a major role in ovary stimulation and ovulation. Therefore, by preventing estrogen from binding to its receptors in the hypothalamus, GnRH secretion - and thereby indirectly LH and FSH release, are upregulated. This activates the ovaries and induces ovulation. Injections raise ovulation in a similar though slightly more direct way. These medications contain gonadotropins (either FSH only or a combination of LH and FSH) and thereby directly stimulate ovary activity ang egg release. The use of such hormonal ovarian stimulation often induces more than one egg to mature at the same time, and thereby increases the likelihood of multi-gestational pregnancies (such as twins, triplets, etc.). In men, oral testosterone can help improve sperm production. Medications are often the first avenue of treatment if there are no obvious anatomical reasons for infertility, such as uterine masses or tubal or ductal blockages.
Surgical Treatment
If there are anatomical anomalies apparent on imaging, such as endometriosis, uterine fibroids, Fallopian tube obstruction (hydrosalpinx) or ovarian cysts in women, or varicoceles or ejaculatory duct obstructions in men, surgery might be the most straightforward way of addressing such issues and removing potential obstacles to fertility. Depending on the concrete problem, surgeries include endometriosis or uterine fibroid removal surgery, ovarian cyst removal surgery, or clearance of Fallopian obstruction in women. In men, surgeries include varicocele surgery or embolization, or clearance of ejaculatory duct obstruction. Most of the time, such surgeries can be performed as minimally invasive procedures (e.g. laparoscopically through a small incision in the naval).
Assisted Reproductive Technology (ART)
If neither medical (hormone) nor surgical treatment are effective, assisted reproductive technologies (ARTs) may still be able to help patients. The simplest of these forms of treatment is intrauterine insemination. During this procedure, a sperm sample is inserted directly into the uterus (vaginally, after dilation of the cervix) with a long applicator (catheter). This is done during fertile days of the female menstrual cycle, and/or often after ovulation has been induced by gonadotropin (FSH and sometimes LH) injections to maximize efficiency. Once inside the uterus, the sperm move towards the Fallopian tubes where the naturally fertilize the egg, and the embryo subsequently implants in the endometrium. If this method does not work, for instance because of issues with sperm motility or because the Fallopian cilia are dysfunctional and unable to transport the egg and/or embryo towards the uterus, other assisted technologies can be used. During in-vitro fertilization (IVF), the woman first receives a series of gonadotropin injections (FSH and LH, usually over a period of 14 days), followed by an injection of human chorionic gonadotropin (hCG) to induce maturation of the eggs. Once this is achieved, the eggs are harvested from the ovaries in a small procedure. In this, a transvaginal ultrasound probe is used to localize the eggs in both ovaries. Then, under ultrasound guidance, a hollow needle is inserted through the vaginal wall and into the ovaries to collect the eggs. These are aspirated inside the needle by a suctioning device attached outside of the vagina, and thereby removed from the body. After the egg harvesting, progesterone supplements can be taken to start preparing the endometrium for the implantation of the embryo. A sperm sample is obtained, usually through masturbation, but sometimes a testicular needle aspiration may be necessary (for instance if there are erectile or ejaculatory issues). The egg and sperm cells are cultivated in a Petri dish with a nutrient liquid, until the sperm have fertilized the eggs and embryos have formed. Intracytoplasmic sperm injection (direct insertion of one sperm into each egg) might be needed in some cases, for instance if sperm motility is low. Then, a few days later, the embryos are ready to be transferred into the uterus. This is done by inserting a thin transfer catheter (plastic probe) through the vagina and cervix into the uterus and guiding the eggs directly to the plumped up endometrium for implantation. Often two or more embryos are inserted to account for the fact that not all survive the transfer and successfully implant into the uterus. If IVF is not successful, depending on the issue, egg donation, sperm donation or embryo donation might be able to help. It is important to know that in such donation cases, the child will not be the genetic offspring of the parents. Another option is surrogacy, which can be done either in combination with egg donation (i.e. using an egg that is not the genetic material of the woman who will be the social mother) or with the social mother's own eggs (i.e. the child will be carried out by the surrogate, who is not the genetic mother).
