Infertility

How is infertility treated? 

Treatment is directed at the underlying problem.

• Damaged or blocked tubes
  

  Under certain circumstances, surgery or cannulation of the tube may ‘open’ up the tubes. If despite treatment, there is no conception or the tubes cannot be unblocked, then in-vitro fertilisation (IVF) will be the treatment of choice.

• Problems with ovulation
  

  Problems with ovulation such as polycystic ovary syndrome (PCOS). Patients with PCOS who are overweight should lose weight as this may lead to resumption of ovulation. Ovulation induction with clomiphene, letrozole or FSH injection may also be used.

• Endometriosis
  

  Patient with large endometriotic cysts (>5 cm) or with severe pain may consider surgery. If there is still no conception 6-12 months postsurgery, then IVF may be the next step. As endometriosis tends to recur, it is advisable to consider medical treatment to prevent recurrence if fertility is not desired.
  
  If the cyst is not large or there is a recurrent cyst after surgery, then IVF should be considered. This is because repeated operations can reduce the ovarian reserve as ovarian tissue may be removed during surgery.
  

• Fibroids and polyps
  

  Fibroids and polyps that distort the womb cavity can be removed through the hysteroscope, a telescope that allows visualisation of the womb cavity. The camera is introduced through the vagina.

• Premature ovarian failure
  

  Premature ovarian failure such that eggs are no longer released. Under these circumstances, an egg donor or embryo donor is necessary as there is no treatment of this condition. Prior to any cancer therapy, women and men are counselled about how they can preserve their fertility. Men can bank their sperm and women can bank their eggs, ovarian tissue or embryo for future use.

• Age
  

  The number and quality of eggs diminish with age. There is no medication that can reverse the effects of age and that is why for women older than 35, infertility investigations may commence after six months of trying.

• Low or no sperm
  

  Hormonal or chromosomal tests may be performed to find the underlying cause. In a small percentage of men, the cause is hormonal and replacement of hormones may allow the resumption of sperm production.
  
  For men with low sperm count, intracytoplasmic sperm injection where sperms are injected directly into the egg at IVF will give the sperm the opportunity to fertilise the egg.
  
  For men with no sperm, sperm may be obtained directly from the testis or eididymis. As the number of sperm retrieved are low, IVF/ICSI is necessary. For those where no sperm is retrieved, sperm donation can be considered.
  
  For men with erectile dysfunction, psychosocial counselling and medication like Viagra may be helpful.

Other treatments

• Intrauterine insemination (IUI)

  This is a treatment where washed sperm is introduced into the womb with a cannula at the time of ovulation. This is indicated for women with patent tubes, with mild sperm problem or couples with problem of nonconsummation or erectile dysfunction.
  
  IUI may also be performed together with ovulation induction with hormonal injection. This is ideal for couples where the women are younger (<35) with patent tubes and no or mild male factor problem. This may also be for couples with ovulation problems or where no known cause is found.
  

• In-vitro fertilisation (IVF)
  

  IVF is a procedure where eggs are retrieved from a woman and are inseminated with the husband’s semen in the laboratory. The resultant embryo is then placed back into the womb.
  
  To make IVF more efficient, hormonal injections are given to the woman to induce more eggs so that it allows for more opportunities for the eggs to be fertilised. IVF is indicated for the following problems:
  1. Blocked tubes
     
  2. Failure of ovulation with ovulation induction or failure to get pregnant despite ovulation induction
  3. Treated endometriosis or endometriosis with small cysts (<5 cm)
  4. Donor egg or sperm cycles
  5. Surgical retrieved sperm or very low sperm counts
  6. No known cause but no conception after three years of trying (female <35 years old) but may be sooner for those older than 35
  
  Despite advances in IVF, the chances of conception vary from 20-35 percent depending on a woman’s age.