Infertility treatment depends on multiple factors such as age, duration of infertility, cause of infertility, and financial burden. Some patients may need only one or two treatment options, while others may need a combination of different treatment options.
- Weight optimization: Women who are either overweight or underweight have greater risk for ovulatory dysfunction and reduced fertility. Weight loss and exercise is recommended as the first-line management for obese women, especially women with polycystic ovarian syndrome (PCOS). Even a 5% to 10% reduction in body weight has been shown to restore ovulation in women with PCOS. On the opposite spectrum, women with low body weight and ovulatory dysfunction are advised to gain weight, modify their diet, and reduce exercise.
- Stress management: Stress has been associated with pregnancy failure. Patients with higher stress levels have lower pregnancy rates when undergoing IVF treatments. Some commonly used stress management strategies include meditation, breathing exercises, therapy, and joining support groups.
Women with ovarian problems are commonly prescribed ovulation induction agents that help stimulate the ovaries. Below are some commonly prescribed medications.
- Clomiphene citrate. This oral drug is often the initial treatment for many infertile women who have irregular menstrual cycles. Clomiphene works by indirectly increasing the reproductive hormones (LH and FSH) levels, which in turn, stimulate more eggs to develop.
- Letrozole. This oral drugs works by decreasing estrogen levels and was originally developed for breast cancer treatment. Letrozole is commonly used in women with PCOS. Recent studies show letrozole may work better than clomiphene in women with PCOS to induce ovulation and become pregnant.
- Metformin. This oral drug is a common diabetic drug used to control high blood sugar levels. Metformin is commonly prescribed to women with PCOS. Women with PCOS have higher insulin resistance and this negatively affects ovulation. Metformin can help reduce the insulin resistance and thereby increase the likelihood of ovulation.
- Gonadotropins. Although clomiphene citrate is easy to use and its use leads to ovulation in most patients, the pregnancy success rates are low. Patients who cannot get pregnant using clomiphene citrate are often classified as “clomiphene citrate resistant.” The next step in these patients can be the administration of gonadotropins (reproductive hormones) injections. These medications stimulate the ovaries directly to produce more eggs. Gonadotropin medications include FSH and human chorionic gonadotropin (hCG), which contains both LH and FSH. Gonadotropin injections carry the risks of excessive ovarian response, need close medical monitoring, and are typically expensive to purchase.
Corrective surgery can be an option for some anatomic abnormalities of the female reproductive tract that is causing infertility.
- Fallopian tubes abnormalities. If the fallopian tubes are blocked or if there are adhesions, laparoscopic surgery may be performed to re-open the tube or create a new tubal opening to allow the sperm and the fertilized egg to travel through the fallopian tube unobstructed.
- Uterine abnormalities. Doctors may suggest laparoscopic or hysteroscopic surgery to correct uterine abnormalities. Some examples are removing fibroids in patients with leiomyomas, restoring the normal uterine cavity size in patients with intrauterine adhesions, and restoring the pelvic anatomy in patients with pelvic adhesions.
Assisted reproductive technology (ART)
Assisted reproductive technology is used to achieve pregnancy in infertile couples for whom the underlying cause of infertility cannot be effectively treated or is unknown.
- Intrauterine insemination (IUI). IUI is typically the first step in the treatment of young couples with no evidence of tubal damage or severe male factor infertility. This procedure involves injecting previously collected sperm into the uterus by a catheter placed inside the uterine cavity through the vagina.
- Intracytoplasmic Sperm Injection (ICSI): ICSI is used to assist the fertilization process when a male’s sperm is abnormal. This technique involves using specialized equipment to select and pick up one sperm that is then directly injected into the inner part of the egg held with a specialized pipette.
- In vitro fertilization (IVF): IVF is a medical and surgical procedure that involves fertilizing the egg outside the woman’s body and transferring the resulting embryo back into the woman’s body. The procedure is a multistep process over 4 to 6 weeks that requires medications to stimulate egg production in the ovaries, minor surgical procedures to retrieve the eggs and implant the embryo, and clinical monitoring by the doctor throughout the process.
Crosignani PG, Colombo M, Vegetti W, et al. Overweight and obese anovulatory patients with polycystic ovaries: parallel improvements in anthropometric indices, ovarian physiology and Fertility rate induced by diet. Hum Reprod. 2003;18(9):1928-32.
Thiering P, Beaurepaire J, Jones M, et al. Mood state as a predictor of treatment outcome after in vitro fertilization/embryo transfer technology (IVF/ET). J Psychosom Res. 1993;37(481):481-91.
Legro RS, Brzyski RG, Diamond MP, et al. Letrozole versus clomiphene for infertility in the polycystic ovary syndrome. N Engl J Med. 2014;371:119.