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Treatment options

    MALE
  1. Male factor infertility 56
    FEMALE
  1. Ovulation problems
  2. Tubal damage
  3. Uterine problems
  4. Cervical mucus hostility


    BOTH
  1. Immunological infertility
  2. Unexplained infertility

The treatment options available to infertile couples

Treatment options for infertility.

Discovering that you have an infertility problem can be very stressful. You become faced with many difficult decisions to make. There are usually five options available to choose:

After various examinations and investigations, your doctor may be able to diagnose the problem and offer some form of treatment, taking into account many factors such as: the woman's age, cause of infertility, how long they have been trying for a baby, previous pregnancy and the cost of treatment.

The decision regarding the management of your infertility is yours and yours alone. But it should be noted that the provision of fertility treatments at public health services varies greatly from country to country and even in the same country from region to region. Before you agree to a fertility treatment, we recommend that you consider the following questions:

What is the cause of your infertility?

Why and how the treatment will be given?

What are the alternatives?

What is your chance of achieving a pregnancy and a live birth without treatment and how much will the proposed treatment improve your chances of success?

How much will the treatment cost?

What are the possible risks and complications?

How long will you have to undergo treatment in order to give it a reasonable chance to work?

Will the insurance cover the cost?

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Male factor infertility

There are several treatment options available to patients with male factor infertility. In some cases the cause of infertility is correctable, while in others it is not. Treatment options may include one of the following techniques: following health advice, drugs, surgery, IUI, IVF, ICSI, donor insemination and adoption. The choice that is right for a couple is not always clear and other factors such as the age of female partner and the presence of other infertility factors such as tubal blockage need to be considered when making a decision.

Health advice

This may include e.g. cut down or stop smoking and alcohol consumption, loose weight if overweight, avoid hot baths and takes shower instead, wear loose boxer shorts, avoid exposure to chemicals, stop taking social drugs etc. These simple measures are sometimes sufficient to improve the sperm count and quality. But, it is important to remember that it may take up to 3-6 months before any improvement in sperm is seen.

Drugs

Many drugs have been used empirically in the treatment of male infertility without firm evidence that they work e.g. clomiphene (clomid)tamoxifen, masterolone (pro-viron), steroids, antibiotics, etc. Owing to the long duration of the sperm cycle (about 70 days), the treatment must be continued for a period of up to six months. In addition, there may be unpleasant side effects. It is not possible to predict whether or not a patient will respond to this sort of treatment. However, in a few cases some drugs have been shown to be very effective such as:

Tablets

For example bromocriptine for men with sexual dysfunction due to excess production of prolactin.

Injection

Combination treatment is required including FSH, hMG and hCG. These drugs are effective for men in whom the pituitary glands do not produce enough FSH and LH which are needed for the production of sperm (about 0.5% of cases). GnRH pumps can be used as an alternative treatment. The disadvantage being that the treatment has to be continued for several months and that the injections are expensive.

Surgery

There are a number of surgical procedures that may be used in restoring male fertility. If surgery is successful it would allow for conception through intercourse, allows the couple to have subsequent children without additional medical treatment. Furthermore it avoids the risks associated with treating female partner such as multiple pregnancy and ovarian hyperstimulation syndrome.

Varicocele ligation

This is a simple operation where the distended veins surrounding the vas are either tied off or injected with a chemical solution to block them. It is carried out under a general anesthetic and is usually performed as a day-case surgery. Percutaneous embolization is a new technique that aims at blocking off the refluxing internal spermatic vein(s) using a coil or a balloon. It is a mini invasive surgical procedure. It is done in the X-ray department. None of the two methods has been proven to be superior to the other. Surgical treatment of varicocele may be of benefit to men who have large varicocele and low sperm count. Most studies have reported improved semen quality following varicocele repair. Pregnancy rates of up to 60% within one year following surgery are claimed.

Reversal of vasectomy

This is a simple operation, which is done under a general anesthetic and involves rejoining the two ends of the vas together. The best results are achieved when microsurgery techniques are used. The operation is usually successful in about 70-90% of cases but not all of them will achieve a pregnancy. The longer the time since the vasectomy the greater the chance that sperm production may be permanently damaged. Also, the presence of high levels of antisperm antibodies may adversely affect the outcome. Pregnancy after vasectomy reversal usually occurs naturally after 6-9 months unlike surgical sperm retrieval immediate result. Vasectomy reversal is much cheeper than IVF and ICSI (Fertility and Sterility journal 1997).

Unblocking the vas (vasovasostomy) and connecting the vas to the epididymis (vasoepididymovasostomy).

The operation involves removing the obstructed tissues and joining the ends together using a microsurgical technique. If the obstruction in the vas is near the epididymis, the vas may be rejoined to the epididymis. The operation is performed under a general anesthetic. The patient may need to stay in the hospital for 1-2 days and should be able to resume normal activities in 1-2 weeks. The result of the operation will depend on the extent and site of the obstruction. The operation may be considered as an alternative to surgical sperm recovery and IVF.

Transurethral Resection of the Ejaculatory Ducts (TURED)

This is a surgical procedure and involve the insertion of a minitelescope through the urethra and cutting both ejaculatory ducts. The procedure may be recommended to treat ejaculatory duct obstruction . It can be done under a general or a spinal anesthetic.

Intrauterine insemination

The procedure intrauterine insemination is an effective treatment in men with borderline sperm quality or quantity.

IVF

In vitro fertilization, IVF, is the main form of treatment.

IVF with ICSI

Intracytoplasmic sperm injection, known as ICSI, may be considered if the sperm count is low.

IVF with ICSI and surgical sperm retrieval

Techniques like PESA or TESA may be used.

Donor insemination

If there is no sperm, or a genetic abnormality is carried by the man,donor insemination may be considered.

Adoption

Finally, adoption may be considered.

Accepting a childfree living.

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Ovulation problems

Ovulation induction by Bromocriptine / Cabergoline / Quinagolide

Bromocriptine is given as daily pills

The drugs Bromocriptine, Cabergoline and Quinagolide do not stimulate ovulation by itself, but reduce prolactin secretion. They are prescribed to women who have ovulation problems and are producing excess prolactin. When prolactin levels are normalized, ovulation returns and the chances of pregnancy become normal.

Bromocriptine is given as daily pills; cabergoline and quinagolide are longer acting drugs, more efficient and have fewer side effects compared to bromocriptine. Few patients experience side effects with bromocriptine. The side effects include: nausea, vomiting, dizziness and occasionally blackout. The chance that these symptoms occurring can be reduced by starting the drug a a small dose and gradually build up to a maintenance dose. Prolactin levels need to be checked to confirm that they have been brought down to normal.   Neither ovarian hyperstimulation syndrome nor an increased risk of multiple pregnancy is a side effect of these drugs.

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Ovulation induction by Clomid (Clomiphene)

The drug Clomid is the most commonly used fertility drug; Clomiphene has been in use since the 1960s. Clomid is the first-line treatment for ovulation induction in women with ovulatory failure. Clomid is cheap, effective, easily available and well tolerated. Clomid blocks the estrogen receptors on the hypothalamus causing them to "think" there is estrogen deficiency. Hence the hypothalamus sends messages to the pituitary gland to release follicle stimulating hormone (FSH) and luteinizing hormone (LH) which causes the growth of the follicles.

How to take Clomid?

Clomid (Clomiphene) is usually given as one 50 mg pill a day for five days e.g. from day 2 -6 or days 5-9 of the menstrual cycle. If the patient has no period or her periods come very infrequently it is essential to exclude pregnancy before taking Clomid. If you are not pregnant your doctor may prescribe progestogen tablets to be taken orally to induce a withdrawal bleed so you can take the tablet on day 2 of the withdrawal bleed. The Clomid dose can be doubled or trebled subsequently if ovulation does not occur. It is important to determine whether you have responded to the treatment (i.e. ovulated) by measuring blood progesterone levels around day 21 to 23 of the treament cycle or performing an ultrasound scan. The starting dose of Clomid should only be increased if their is no response after the second cycle of treatment because of those women who will respond to 50 mg dose, only two thirds will do so in the first cycle. If the Clomid drug treatment is successful, ovulation tends to occur about a week after the last pill.  You are advised to have intercourse every other day for about a week, starting five days after the last pill. Though clomid induces ovulation in about 70-80% of appropriately selected patients, the pregnancy rate is about 30-50% following up to six cycles of treatment. The risk of twin pregnancy is about 10% and the risk of high order of multiple pregnancy is about 1%.

What are the side effects of taking Clomid?

Side effects of taking Clomid are uncommon; some women may get hot flushes, nausea, mood changes, headaches, flashes of light or abdominal discomfort.  It is normally recommended that clomid should not be used for more than 12 months (in some countries, the licensed recommendation is 6 months) because of the increased risk of ovarian cancer.

Clomid in high doses and in some women may alter the quality of cervical mucus, making it thick, and may also affect the endometrium making it less receptive.It is recommended that if ovulation has not been achieved after four treatment cycles, the patient is considered unresponsive and treatment using Clomid is discontinued.

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Ovulation induction by FSH
(follicle stimulating hormone)

FSH is given by injection.

The drug FSH is similar to hMG but it contains only the hormone FSH e.g. metrodin. It stimulates the ovaries to produce multiple follicles. HP-FSH is highly purified FSH and can be given subcutaneously by self-injection.

Recombinant FSH is a synthetic FSH produced by recombinant DNA technology and is the latest and purest of the hormones e.g. Gonal F and Puregon (Follistim). It is also given subcutaneously and is at least twice as expensive as urinary FSH.

The use of FSH and hMG should only be performed in clinics that can closely monitor ovarian response; this is because of the increased risk of OHSS and multiple pregnancies. Despite intensive monitoring, multiple pregnancies occur in about 20% of the treatment cycles, of which a third is triplets or more.

The Committee on Safety of Medicines in the United Kingdom has advised that no medical products using urine sourced in a country that has reported cases of human variant CJD (the human form of mad cow disease) be used in the UK.

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Ovulation induction by GnRh analogues

These are structural modifications of the natural GnRh. GnRh analogues are often given with other drugs such as FSH to enhance ovulation stimulation for IVF cycles and prevent a spontaneous LH surge. This has been shown to decrease the cancellation rates of the treatment cycles and improve pregnancy rates. In addition, a greater control of the cycle is achieved. There are two types of GnRh analogues that are used: GnRh agonists and GnRh antagonists.

GnRh-agonists

These stimulate the GnRh receptors on the pituitary gland, resulting in an initial secretion of LH and FSH from the pituitary gland ('flare up'). However, continued treatment with GnRh-agonists leads to "damped down" down-regulation of the GnRh receptors.

Agonists are administered in the form of: nasal sprays such as synarel (nafarelin) and busereline, daily subcutaneous (under the skin) injections e.g. buserelin, intramuscular or subcutaneous depot (one depot lasts about a month) such as Zoladex (gosereline), prostap (leuprorelin) and Decapeptyl (triptorelin).

GnRh-antagonists

These occupy the GnRh receptors, but do not stimulate them. This prevents the natural GnRh from occupying and stimulating the receptors. This results in complete, immediate suppression of FSH and LH secretions. GnRh antagonist is administered by subcutaneous injections such as cetrorelix (cetrotide) and Orgalutran (Antagon). GnRH antagonists are usually given by subcutaneous injection about 4-5 days after starting stimulation with gonadotropins when high oestradiol levels may induce an LH surge. The GnRH anatgonist permits a simplified and shorter treatment cycle than GnRH agonists. The use of GnRH agonists has been shown to be associated with reduced pregnancy rates.

There are different treatment protocols for giving these medications. It should be noted that the side effects include: hot flushes, vaginal dryness, mood changes and depression.

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Ovulation induction by pulsatile GnRh (gonadotropin releasing hormone)

The hypothalamus gland secretes GnRh (gonadotropin releasing hormone) in a pulsatile fashion (in small amounts every hour or so) to stimulate the pituitary gland to secrete FSH and LH. This in turn induces follicular development. Commercial GnRh preparations are produced synthetically e.g. Fertiral can be given to a patient subcutaneously (underneath the skin) via a programmable infusion pump that can be worn day and night without discomfort; it gives intermittent doses of GnRh for several days. Monitoring of treatment is usually carried out by ultrasound scanning.

GnRH pump.

Synthetic GnRh can be given in selected cases instead of hMG or FSH e.g. patients who have polycystic ovarian syndrome and did not respond to other drugs, and in those patients who do not ovulate and have hypothalmic failure.

Synthetic GnRh is an effective drug (over 90% of cycles are ovulatory and a pregnancy rate of about 80-90% after 6 months). In contrast to FSH and hMG, it usually stimulates only one follicle to grow and so the risk of multiple pregnancy and ovarian hyperstimulation syndrome are lower.

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Ovulation induction by hCG
(human chorionic gonadotropin hormone)

The drug hCG (human chorionic gonadotropin hormone) is similar to LH; it is normally produced from human placenta. It is a highly purified extract from the urine of pregnant women. It is given in the form of an injection either intramuscularly or subcutaneously by self-injection e.g. profasi and pregnyl.

The administration of hCG is timed according to the size of the leading follicles, the development of endometrium as measured by ultrasound scanning, as well as the levels of estrogen in the blood.

hCG administration helps the follicles to burst and release the eggs about 36-48 hours after the hormone is given. hCG is usually given after the woman has already received ovulation drugs such as Clomiphene, hMG, FSH or a combination of these drugs.

Ovidrel (Ovitrelle) is the first recombinant human hCG and is given by subcutaneous rather than intramuscular injection. Recombinant hCG achieves similar results to urinary hCG in terms of pregnancy rates and the incidence of OHSS. However, recombinant hCG is more costly than urinary hCG.

The Committee on Safety of Medicines in the United Kingdom has advised that no medical products using urine sourced in a country that has reported cases of human variant CJD (the human form of mad cow disease) be used in the UK.

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Ovulation induction by hMG (human menopausal gonadotropin)

This is a powerful and effective drug. hMG (human menopausal gonadotropin) contains both FSH and LH hormones e.g. pergonal, menogon. It is a purified extract from the urine of postmenopausal women. It stimulates the ovaries to produce multiple follicles. It is usually offered in selected cases, e.g. if clomiphene treatment has been unsuccessful and for women whose pituitary glands produce no FSH and LH of their own. The treatment is complex and expensive.

It is given by injection repeatedly over several days in the first half of the cycle. The dose required varies from woman to woman and even the same patient may not respond in the same way from cycle to cycle. There is an increased risk of many eggs being produced in the same cycle. This is why women who are given these drugs need careful monitoring during their treatment cycles. 

HMG induces ovulation in about 75-85% of appropriately selected patients.

Despite intensive monitoring, multiple pregnancies occur in about 20% of the treatment cycles. And of that, one-third is triplets or more.

Some women are concerned that the drug causes them to run out of eggs and will go to early menopause. This is not true as in a natural cycle, about 40-60 eggs start to mature but only one mature while the rest die. hMG helps to rescue some of these eggs which would otherwise have died.

A possible association between ovulation induction with hMG and ovarian cancer remains uncertain. Furthermore, the Committee on Safety of Medicines in the United Kingdom has advised that no medical products using urine sourced in a country that has reported cases of human variant CJD (the human form of mad cow disease) be used in the UK.

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LH (luteinizing hormone)

hCG is given by injection.

The luteinizing hormone (LH) is normally secreted by the pituitary gland to induce ovulation. Until now, LH has only been available as part of urine sourced menopausal gonadtropin (hMG).

Luveris is the world's first human recombinant LH. It is indicated for use in combination with recombinant FSH such as Gonal F and Puregon. Luveris is given by subcutaneous rather than intramuscular injection.

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Surgery for polycystic ovarian syndrome (PCOS)

This is suitable for women with ovulation problems due to polycystic ovarian syndrome (PCOS) and who did not respond to treatment with clomiphene. Women who have experienced ovarian hyperstimulation syndrome (OHSS) can also be effectively treated with surgery.

Laparoscopic ovarian drilling for polycystic ovarian syndrome

This is a keyhole surgery where a fibre-optic telescope is introduced through the abdomen to see the inside of the  abdomen and then another probe is introduced to drill small areas of each ovary by diathermy (burning) or laser. The procedure is performed under a general anesthetic. Ovulation occurs in about 70-90% of cases. The main advantages of the procedure is that it there is no additional risk of multiple pregnancy or ovarian hyperstimulation syndrome compared to FSH or hMG. The main disadvantage is the development of adhesions from the surgery, which may affect fertility. Other potential complications include the risk of burns to the bowels and blood vessels during the procedure.

Ovarian drilling by laparoscopy.

Ovarian wedge resection for polycystic ovarian syndrome

This surgery is performed  under a general anesthetic. The procedure involves a slice (wedge) being taken from each ovary, through a cut in the abdomen and the sliced area then being stitched back together. The operation was done much more frequently in the days before effective drug treatment had been discovered.

The procedure can be effective but as with the laparoscopic drilling it may result in the development of adhesions around the ovaries and tubes (about 10-20% of women will develop adhesions after the surgery).

After the surgery, some discomfort may be felt but this is relieved by painkillers. Normal activities can be resumed in 2-5 days. The use of laparoscopic techniques has advantages over classic resection, as it is cost saving and has a lower risk of adhesions. 

It is not clear why women with PCOS ovulate after ovarian drilling or wedge resection. If ovulatory cycles fail to be restored after the surgery, your doctor may restart you on ovulation induction again.

Egg donation

Women with complete ovarian failure (can not produce eggs) may choose to opt for egg donation. For example, women with premature menopause may be offered donated eggs.

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Endometriosis

There are several treatment options available for patients suffering from endometriosis. Treatment should be tailored to individual women. It is worth remembering that there is a considerable spontaneous pregnancy rate in infertility associated with minimal and mild endometriosis. Treatments for endometriosis may include one of the following techniques: drug treatment, surgery, intrauterine insemination and IVF.

Drugs

Drug treatment allows the endometriosis to "dry up" and heal. There are a number of drug therapies. These are taken for several months. Each drug therapy has its own advantages and side effects. Some of the commonly used drugs include: contraceptive pills, progesterone, danazol and GnRh agonist e.g. nafareline, buserelin (these drugs need to be taken every day, without a break). Long-acting GnRh agonists such as zoladex can be given as a monthly implant. These drugs put a temporary stop to the production of certain monthly hormones. Obviously while the patient is taking the medication she can not get pregnant, but the aim of the treatment is to reduce the extent of endometriosis in the hope that the patient will conceive soon after she stops the medication. The main problems associated with suppressive drug therapy include: the length of time it takes (about 6 months), which could be a problem especially in infertile women. Treating endometriosis with drugs has its own limitations; large chocolate cysts are less likely to respond to medication and drugs will not remove scar tissues. In addition, there are unpleasant  side effects. Some specialists believe that the medical treatment of minimal or mild endometriosis does not enhance fertility. It is important to use cap or condoms for contraception while taking the GnRH agonist or Danozol, since pregnancy is not advised.

Surgery

To destroy the endometriotic nodules and divide adhesions by either burning them using a fine metal electrode or laser them. This usually improves the fertility in the subfertile women with mild/minimal endometriosis (NICE Fertility Guidelines, UK, 2004). In women with large ovarian endometriotic cysts. Surgery may improve access for egg collection and the chance of pregnancy if IVF is considered. The procedure is done under a general anesthetic and can be done by laparoscopy and in certain cases by laparotomy. The procedure involves the endometriosis being cut away or burned, the adhesions divided. Chocolate cysts are removed or opened and drained and their lining destroyed to prevent the cyst from reforming.

Post-operative medical treatment does not improve pregnancy rates in women with moderate to severe endometriosis and so is not usually recommended (NICE Fertility Guidelines, UK, 2004).

Unlike drug treatment, the patient can try for a baby within two to three weeks of the operation and thus it is usually a better option for older women.

IUI

The technique intrauterine insemination with ovulation induction is effective treatment but only suitable for young women with healthy Fallopian tubes who ovulate regularly, have a minimal or mild endometriosis and where there is no severe male factor infertility. Up to 6 cycles of intrauterine insemination should be offered because this increases the chance of pregnancy (NICE Fertility Guidelines, UK, 2004).

IVF

The technique IVF is an effective treatment in all stages of endometriosis and is the treatment of choice in women with severe or moderate endometriosis.

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Tubal damage

There are several possible treatment options available to patients suffering from tubal damage. These may include one of the following techniques: tubal surgery, selective salpingography and IVF.   

Tubal surgery

Tubal surgery is performed under a general anesthetic and can be performed by laparoscopy (a keyhole operation) following the surgery. The patient may be able to return home the same day or the following day, returning to full activities in three to seven days. Laparoscopic surgery can be performed using lasers or special instruments. Not all procedures can be performed with this technique. Tubal surgery can be performed by laparotomy, through a cut across the lower abdomen, known as a "bikini incision". Following laparotomy the patient will usually stay in the hospital for about 3-4 days. When tubal surgery is done by microsurgery (surgery with the aid a special microscope) the results are better.

Your doctor should be able to discuss with you the pros and cons of performing operative laparoscopy versus a laparotomy.

Some women ask how soon after surgery can they have sex; the answer is as soon as they feel comfortable. Tubal surgery may be appropriate in selected cases where the tubes are not badly damaged. The following are examples of where tubal surgery might be appropriate:

Reversal of sterilization

A small number of women who have been sterilized come forward to request a reversal procedure because of changes in family circumstances. The method used to reverse sterilization will depend on how the operation was initially performed and the extent of damage to the tubes e.g. ligation, clips, rings and diathermy (electrical cautery) etc. The doctor may need to do a laparoscopy and a HSG to assess the status of the tubes before deciding on the operation. Sterilization can sometimes be reversed, however, if the tubes are totally removed or are badly damaged this will not be feasible and your only chance will be IVF. The operation involves the removal of the scarred tissues and rejoining the ends of tubes. The success of such operations is good; but better results are achieved if the operation is performed using microsurgery techniques. The chance that the tubes remain open after surgery is about 80%, and pregnancy rates are about 60%.

Adheisolysis

This involves the division of scar tissues (adhesions) around the tubes. These scars usually glue the tubes to other internal organs causing them to stick together, thus reducing the mobility of the tubes. These adhesions could be due to previous infections or endometriosis. The adhesions are broken down using a special pair of scissors known as microscissors.

Salpingostomy

This is used to treat a blockage at the fimbrial end of the tube. Any scar tissue that covers the end of the tube is removed; the tube is then opened and turned back on itself so that it will remain open.

The success rate following tubal surgery depends primarily on the extent and site of tubal damage. Other factors that may affect the outcome include: the technique used, women's age, etc. The tube can be opened successfully in 80% of cases, but only about 20% of these women will achieve a pregnancy. This is because when the tube is blocked, much if not all their lining tends to be destroyed, and even if they can be opened by surgery they remain functionless. Furthermore, the scar tissue may return and reblock the tube.

Patients expect tubal surgery to work immediately; this is hardly ever the case. However, if pregnancy has not occurred within 12 months of the surgery, IVF should be considered.

Tubal surgery has the best chance of being successful at the first attempt, repeat tubal surgery is rarely successful and should only be undertaken when other alternatives are not available or unacceptable to the patients. The removal of damaged tubes e.g. Hydrosalpinx prior to IVF treatment has been shown to improve the chance of a live birth.

Side effects and complications of tubal surgery

In addition to the general complications associated with any surgery such as: anesthetic complications, infection, bleeding and injury to other organs such as bowels, there are specific complications related to tubal surgery. These include: adhesion formation, reformation of the blockage and ectopic pregnancy. Ectopic pregnancy has been reported to occur in up to 40% of subsequent pregnancies.

Selective salpingography

A procedure used to open the proximal tubal blockage (the end of the tube close to the uterus) when the rest of the Fallopian tube is healthy. The procedure is performed under X-ray control and takes approximately 15-20 minutes. An X-ray dye is injected through the cervix so that the outline of the womb cavity can be seen on the X-ray screen. A special curved catheter is then guided up towards the opening of the tubes and further dye is injected to confirm that the tube is blocked. If the tube is blocked, the dye is injected with a little more pressure in order to remove the obstruction. If this fails, a very fine flexible wire is guided up through the catheter to the opening and gently pushed through. The procedure is not pain free and the patient may feel some discomfort. Selective salpingography has an acceptable success rate. It is claimed that the tubes can be opened in 90% of the cases and 50% of the women undergoing the treatment are expected to be pregnant within the next 12 months.

Complications of the procedure are minimal and include: perforation of the tube, infection and an increased risk of ectopic pregnancy.

IVF

The technique IVF is an effective treatment for all forms of ubal damage and pelvic adhesions and should be considered as the first line of treatment for moderate or severe tubal disease. The aim here is to bypass the tubes altogether.

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Uterine problems

There are a number of treatment options available for patients with uterine problems. Treatment options may include one of the following techniques: myomectomy, polypectomy, adhesiolysis, metroplasty and septoplasty.

Myomectomy (removal of fibroids)

This may be recommended if the doctor thinks that fibroids are affecting the patients fertility (significantly distorting the uterine cavity). This can be performed by laparoscopy, laparotomy and in selected cases by hysteroscopy. The procedure is done under a general anesthetic. Some doctors gives an injection of GnRH agonist prior to surgery in order to shrink the fibroid and make surgery technically easier with less blood loss.

Polypectomy  (removing the polyp)

This is usually a simple procedure done with the aid of a hysteroscope or by a D & C.

Adhesiolysis (division of adhesions)

This is a minor procedure, usually done using a hysteroscope. Antibiotics may be prescribed to diminish the chances of infection.

Metroplasty (plastic reconstruction of the uterus)

Septoplasty (plastic operation to remove the septum)

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Cervical mucus hostility

There are a number of treatment options available to a patient with cervical mucus hostility. Treatment options may include one of the following techniques: antibiotics, estrogen tablets, IUI and IVF. 

Antibiotics

Antibiotics if there is an infection.

Estrogen tablets

Estrogen tablets to make the cervical mucus watery.

IUI and IVF

Intrauterine insemination and IVF if there are antisperm antibodies present. Some specialists may recommend a course of steroids to stop the antibodies from developing. To be effective they have to be given in a high dose and over a long period of time. It should be noted that steroids do not always work and are associated with significant side-effects.

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Immunological infertility

There are several treatment options available to patients with immunological infertility. Treatment options may include one of the following techniques: antibiotics, intrauterine insemination, drugs, IVF. 

Antibiotics

Antibodies are sometimes produced by men with an infection of the prostate. Long term administration of antibiotics can sometimes result in a significant reduction of antibodies and some pregnancies have been achieved following treatment.

Intrauterine insemination

The intrauterine insemination technique involves washing the sperm free of antibodies and then introducing them into the uterus.

Drugs

Men may be given steroids to suppress the production of antisperm antibodies; they will need to take them for a few months and in high doses. There is a one in three chance of a natural conception. Most pregnancies occur 6-9 months after the treatment. The outcome of the treatment with steroids is unpredictable, as some men may not benefit from it. Treatment with steroids is associated with significant side effects.

IVF

The IVF technique involves washing the sperm and eggs prior to them  mixed together.

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Unexplained infertility

There are several treatment options available to couples with unexplained infertility. Treatment options may include one of the following techniques: the wait and see approach, intrauterine insemination, GIFT, IVF and ZIFT.

The wait and see approach

Without treatment about 50% of the infertile couples will conceive within 3 years, this will depend on many factors such as: the women's age, duration of infertility, previous pregnancy, etc.

Ovarian stimulation with Clomiphene Citrate

Women with unexplained infertility may have higher pregnancy rates if they take Clomiphene tablets.

Intrauterine insemination with or without ovarian stimulation

This may be as effective as IVF, less invasive, and less costly.

GIFT

IVF

IVF is preferred to GIFT because it provides information about fertilization. In addition, it avoids laparoscopy with its associated risks and may be performed under a local anesthetic and thus avoiding a general anesthetic.

ZIFT

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