Infertility - a Summary of Treatments

What are the main treatments used for infertility?

Fertility treatments can be grouped into three categories:

• Medicines to improve fertility - sometimes used alone, but are also used in addition to assisted conception.
• Surgical treatments - which may be used when a cause of the infertility is found that may be helped by an operation.
• Assisted conception - which includes several techniques such as intrauterine insemination (IUI), in vitro fertilisation (IVF), gamete intrafallopian transfer (GIFT), and intracytoplasmic sperm injection (ICSI).

Each of these is briefly discussed below.

Medicines (drugs) that may improve fertility

Medicines are mainly used to help with ovulation. Ovulation is when the ovary makes and releases an egg (ovum). Ovulation should occur about once a month in women up until the menopause. For various reasons, ovulation may not occur at all, or it may occur less often than normal.

Ovulation is partly controlled by hormones called gonadotrophins. These are made in the pituitary gland (a gland just under the brain). A gonadotrophin is a hormone that stimulates the activity of the gonads. (The gonads are the ovaries in women, and the testes in men.) The main gonadotrophins made by the pituitary gland are called follicle-stimulating hormone (FSH) and luteinising hormone (LH). These pass into the bloodstream and travel to the ovaries.

• Clomifene is a medicine that has been used to help with fertility for many years. It is taken as a tablet. It works by blocking a 'feedback' mechanism to the pituitary gland. This results in the pituitary making and releasing more gonadotrophin hormones than normal. The extra amount of gonadotrophin hormones released into the bloodstream stimulate the ovary which may result in ovulation.
• Medicines that contain gonadotrophins are another type of treatment. These need to be injected and tend to be used when clomifene does not work, or prior to IUI and IVF to cause ovulation. Gonadotrophin medicines may also improve fertility in men with certain types of testes problems.
• Medicines that contain gonadotrophin-releasing hormone are sometimes used. These stimulate the pituitary to releases gonadotrophins (which in turn stimulate the ovaries).
• Metformin may be offered to women with polycystic ovary syndrome who have infertility and who have not responded to clomifene. Metformin is a medicine that is commonly used to treat some people with diabetes. It has recently been shown to help in some cases of polycystic ovary syndrome.

Make sure you have a full discussion with your doctor before taking any medicine for infertility. This is so that you are aware of success rates, and any potential side-effects or risks. For example, there is an increased chance of having multiple births (twins, triplets, etc) after taking some medicines used to treat fertility.

Surgical treatments

The situations where surgery may be an option include:

• Surgery to the fallopian tubes may help some women with infertility caused by fallopian tube problems. For example, if your fallopian tubes have been blocked or scarred from a previous disease, infection, or other problem. Some women who have had a 'tubal tie' in the past for contraception can have their fertility restored by tubal surgery. These days, most surgery to the fallopian tubes is done by 'keyhole' surgery.
• Surgery may help to improve fertility in women with endometriosis.
• For women with fibroids, surgery to remove the fibroid may be considered if there is no other explanation for the infertility.
• One type of male infertility is caused by sperm being blocked by an abnormality in the epididymus in the testis. This may be treated with surgery.

An operation used to be thought to help men who had a varicocele (like 'varicose veins of the testes') and who were infertile. However, a recent study has concluded that surgery is not likely to help in this situation. See separate leaflet called 'Varicocele'.

Assisted conception

Current techniques are briefly described below. Your specialist will advise on which techniques are options for your particular cause of infertility, and the chance of success.

Intrauterine insemination (IUI)
This is the process by which sperm is placed in the woman's uterus. It is done by using a fine plastic tube which is passed through the cervix into the uterus. Sperm are passed through the tube. It is a relatively straightforward procedure. It is timed to coincide with ovulation (about half way through a monthly cycle). Fertility medicines are commonly given beforehand, to maximize the chance of ovulation occuring. Women who have this procedure need to have healthy fallopian tubes to allow the egg to travel from the ovary into the uterus. If successful, fertilisation takes place within the uterus.

The sperm used can be either from the male partner, or from a donor.

• The male partner's sperm can be used when the cause of the infertility is unexplained and the sperm seems fine, or for cases where the female cervical mucus seems to block or kill the sperm. Sperm is obtained by masturbation just prior to the IUI procedure.
• Donor sperm is obtained from a 'sperm bank' of frozen sperm provided by donors. It may be considered as an option when: the male partner has no or very few sperm; has had a vasectomy, and reversal has failed or not been tried; has an infectious disease such as HIV; where there is a high risk of transmitting a genetic disorder to a baby.

If IUI does not work, couples tend to move on to try other methods described below.

In vitro fertilisation (IVF)
In vitro fertilisation means fertilisation outside of the body. In vitro literally means 'in glass ' (that is, in a laboratory dish or test tube). IVF is mainly used for cases of infertility caused by blocked fallopian tubes, or unexplained infertility.

IVF involves taking fertility medicines to stimulate the ovaries to make more eggs than usual. When the eggs have formed, a small operation is needed to get them ('egg retrieval'). The eggs(s) are mixed with sperm which is obtained in the same way as for IUI (described above). The egg/sperm mixture is left for 2-3 days in a laboratory dish (often referred to as a 'test tube'). The aim is for sperm to fertilise the eggs to form embryos.

One or two embryos which have formed are then placed in the woman's uterus using a fine plastic tube passed through the cervix. Any other embryos which have formed in the dish are either discarded or, if you wish, frozen for further attempts at IVF at a later date if the initial attempt fails to result in pregnancy. You may also be asked to consider donating any spare embryos to be used for research, or to be donated to other infertile couples.

Gamete intrafallopian transfer (GIFT)
A gamete is an egg or sperm. Eggs and sperm are collected in the same way as for IVF. The eggs are mixed with sperm. The mixture of eggs and sperm are then placed into a fallopian tube. Therefore, unlike IVF, the sperm fertilises the egg 'naturally' inside the woman's fallopian tube or uterus, and not outside the body in a laboratory dish. For this to work, the woman's fallopian tube needs to be healthy. GIFT tends mainly to be used in cases of 'unexplained fertility'.

Intracytoplasmic sperm injection (ICSI)
This technique involves an individual sperm being injected directly into an egg. (It is injected into the cytoplasm - the outer part of the egg.) This method bypasses any natural barriers that may have been preventing fertilisation. For example, some cases of infertility are due to the sperm of a male partner not being able to 'penetrate' the outer part of the egg to fertilise the egg. ICSI can also be used when a male partner has a low sperm count as only one sperm is needed.

If needed, a sperm can also be obtained by a small operation to the testis. This may be done when sperm cannot be produced in the usual way (for example, if the male partner has a blocked vas, or has had a vasectomy).

The egg containing the sperm is then placed in the uterus in the same way as with IVF. ICSI is used for couples who have failed to achieve fertilisation through IVF, or where the quality or number of sperm is too low for normal IVF to be likely to succeed.

Egg donation
This involves stimulating the ovaries of a female donor with fertility medicines, and collecting the eggs which form. The eggs are mixed with and fertilised by sperm of the recipient's partner (similar to IVF). After 2-3 days embryos are placed in the uterus of the recipient via the cervix.

This method is an option for: women who have ovarian failure and cannot produce eggs (for example, after radiotherapy); who have had their ovaries removed; who have conditions where the ovaries do not work (for example, Turner's syndrome); where there is a high risk of transmitting a genetic disorder to the baby. It is also used in certain cases of IVF failure.

Embryo donation
Couples who have had successful IVF treatment may decide to donate any spare embryos to help other infertile couples.

Ethical issues

Some types of assisted conception are controversial and unacceptable to some people. This is mainly because of the wastage of embryos after conception. For example, in IVF, embryos that are not used for implantation are discarded (or frozen for future use, donation or research).

Further information

This leaflet is a very basic overview of the treatments involved in infertility. Further sources of more detailed information include:

Infertility Network UK (I N UK)
Charter House, 43 St Leonards Road, Bexhill on Sea, East Sussex, TN40 1JA
Tel: 08701 188088    Web: www.infertilitynetworkuk.com
Provides advice and information for members of the public and for professionals on all aspects of infertility.

Human Fertilisation & Embryology Authority - HFEA
21 Bloomsbury Street London WC1B 3HF
Tel: 020 7291 8200    Web: www.hfea.gov.uk
The HFEA produces a wide range of information on a range of different infertility treatments, as well as on legal issues, consent procedures, success rates of treatments, what you should expect from fertility treatment centres, how to make a complaint, etc. Their "Guide to Infertility and Directory of Clinics" is a comprehensive guide to infertility treatments and clinics in the UK and can be downloaded from their website.

Patient UK
The infertility section - www.patient.co.uk/showdoc/380/ - provides a large set of links to organisations and patient groups concerned with infertility and it's treatment.

© EMIS and PIP 2005   Updated: June 2005