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Introduction to Fertility Treatments
Some couples experience infertility due to a major factor like lack of ovulation unresponsive to fertility tablets (clomiphene citrate), bilateral tubal blockage or a very significant decrease in sperm numbers (sever male factor). Some of the fertility treatments described below are not appropriate for these situations. We will have explained to you what your options are in those circumstances (for example a complete tubal blockage can only respond to surgery or IVF).
The treatments described below apply to couples who want to increase their chances to become pregnant in the next year and in whom we have not identified a major tubal factor (the tubes have to be open and able to pick up the eggs so that the fertilization process can occur naturally in the Fallopian tubes) or a severe male factor where the amount of normal motile sperm is so reduced that we do not anticipate sufficient sperm will be able to ascend in the Fallopian tube to fertilize the egg.
As an example the diagnosis for which these treatments might benefit the couple are: irregular ovulation, mild-moderate endometriosis, mild to moderate male factor and unexplained infertility or any combination of the above mentioned factors.
Since some of the fertility treatments can lead to side effects for the woman and multiple pregnancies (twins or triples), you may choose to try naturally for a least two years before undertaking them, especially if you are young. For example, we know that after three years of unexplained infertility a couple has a 1-2% chance of becoming pregnant per cycle. This is reduced if the woman is in her late 30s. This would be a reasonable time to consider doing a fertility treatment.
Every couple undergoing the devastating experience of unwanted childlessness, needs to very carefully discuss and consider what treatment or if any at all will suit their needs. It is very important that you give yourselves sufficient time together to make these important decisions as a couple. If you need help, our clinic counselor can be helpful. You can find her number through our clinic by phoning 875-2445. Her sessions are not covered by the medical plan.
Clomiphene is a drug that increases the woman’s FSH (follicle stimulating hormone) at the beginning of the cycle with hopes of ovulating 2 follicles (eggs) and to improve follicular hormonal production. It unfortunately has an antiestrogenic effect and causes thin endometrium (uterine lining) and poor dry cervical mucus (both antifertility effects). The maximal pregnancy rate per cycle is 4-5%. Intrauterine insemination (IUI) can be added to it at the time of ovulation. This might increase the pregnancy rate especially in cases of mild male factor.
Since there are some reports of increased risk of ovarian cancer after 12 cycles of clomiphene treatment, its use should be restricted to 3-4 cycles. It rarely works after 3 cycles of use.
If you decide to do this treatment, you will take Clomiphene tables for five days from day 3 of you period to day 7. Your fertile time is anytime from day 11-16. If you decide to add IUI you will have to monitor your ovulation with a predictor kit, call the nurse at the clinic when it becomes positive and come together to provide the sperm sample and undergo the insemination the next day. The clinic is open 7 days a week except for the week between Christmas and New Years.
The cost for clomiphene+IUI cycle is between $200-300 and the pregnancy rate is approximately 5% per cycle.
If you choose this treatment you should know that 10% of pregnancies are twins, triplets are exceedingly rare and the side effects are minimal and always reversible.
The next choice available to you is to do a cycle in which ovarian stimulation is performed with FSH from day 3 of your menstrual period.
FSH is administered as a daily subcutaneous injection (like an insulin injection) by yourself or your partner from day 3 of your cycle until ovulation. The purpose is to override the natural one egg selection of the ovary and mature 2-4 eggs. The cycle needs to be carefully monitored in the clinic to make sure that sufficient but not excessive stimulation is provided. This is accomplished by 6-10 visits to the clinic between 8-10 am to have blood tests for estradiol (estrogen) levels and periodically an ultrasound to monitor follicle development. Once the follicles are deemed to be ready you will inject HCG (human chorionic gonadotropin) to ovulate the eggs and will have an intrauterine insemination in the clinic the next day.
Complications include multiple pregnancies (20% twins, 5% triplets and rarely more) and ovarian hyperstimulation (<1% of cases).
The success of the treatment is 10-12% pregnancy rate/cycle. The costs are much larger since the drugs cost an average of $1500-2500, unless you have a private insurance plan that will cover them. The clinic will charge you approximately $350.00 for the monitoring, counseling and insemination.
We advise 3-4 cycles of superovulation+IUI with a maximum of 6. If a couple does not conceive within a reasonable period of time, I will advise you to consider to move on to a much more complex procedure like In Vitro Fertilization.
IVF is considered by many to be the most effective fertility treatment of all. Pregnancy rates vary between 25-44% per cycle depending on the woman’s age, ovarian response and cause of infertility.
Unfortunately, IVF is not covered at all by the medical plan; the costs are approximately $5,000 - $7,000 plus medication (see superovulation).
The procedure involves starting a nasal spray on day 21 of your cycle, returning to the clinic two weeks later to have a baseline ultrasound and blood test. Then you will proceed with a very similar ovarian stimulation with injectable FSH (see superovulation).
After the HCG is given, the woman will undergo a procedure call Egg Retrieval done under local anesthesia and conscious sedation (intravenous painkillers) where the eggs are removed with a needle attached to a vaginal ultrasound. Most women tolerate the procedure with mild discomfort only.
The eggs are allowed to incubate in the laboratory for 24 hours with the male partner’s sperm. The following day the number of fertilized eggs (usually 50-75%) is incubated for an extra 48 hours and the best 3-4 embryos are transferred to the uterus by a small catheter (this is usually a painless procedure). You will know if you have become pregnant 2 weeks later.
The complication rate is very small, but multiple pregnancy and hyperstimulation rates are similar to the superovulation procedure. We will not advise more than 6 cycles.
We hope this helps you to understand the difference choices available for you to have a child. This is a very brief overview. We will give you a lot more information about the specific procedures, please bring your questions along to the appointments. The final decision is always yours, please take your time and think carefully. “Does this treatment feel RIGHT for us NOW? Our clinic philosophy is to respect your choices and help you with them.
4. INTRACYTOPLASMIC SPERM INJECTION (ICSI)
The standard insemination procedure of in vitro fertilization (IVF) is to place the egg and sperm in a laboratory dish; however historically, this method to treat couples with male factor infertility has had relatively disappointing results. This has led to the application of intracytoplasmic sperm injection (ICSI), a technique allowing the microinjection of a single sperm into the cytoplasm of a mature egg (oocyte).
Male factor infertility is associated with abnormal sperm parameters. These include absence of sperm in the ejaculated semen sample (azoospermia), low sperm count (oligozoospermia), poor motility (asthenozoospermia) and increased abnormal morphology (teratozoospermia). Any on of these abnormalities in the sperm can lead to failure of fertilization or low fertilization rates from a standard IVF procedure.
ICSI can overcome these problems. A single sperm, independent of motility, morphology and developmental stage (sperm can be retrieved from testis and epididymis) can be used to fertilize an egg with high fertilization and pregnancy rates.
ICSI is a major advancement in the treatment of severe male factor infertility. It has increased choices for couples with severe male infertility that in the past may have used donor insemination. So far there is no evidence to suggest that ICSI increases pregnancy loss or birth defects. Like other centres, our centre uses the ICSI technique as the primary method of assisted fertilization.