Infertility medical therapy
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2]
Overview
Treatment of infertility usually starts with medication. In vitro fertilization (IVF) in addition to various forms and developments of it (ICSI, ZIFT, GIFT) is another solution. They all include that the fertilization takes place outside the body. On the other hand, an insemination can make a fertilization inside the body. Other techniques are e.g. tuboplasty, assisted hatching and PGD.
Medical Therapy
- Treatment depends on the cause of infertility, but may include counselling, fertility treatments, which include in vitro fertilization.
- Treatment methods for infertility may be grouped into medical or complementary and alternative treatments.
- Drugs used for infertility include Clomiphene citrate, Human menopausal gonadotropin, Follicle-stimulating hormone,Human chorionic gonadotropin, Gonadotropin-releasing hormone analogs, Aromatase inhibitor, Metformin[1][1]
Medical Treatments
- Medical treatment of infertility generally involves the use of fertility medication, medical device, surgery, or a combination of those treatments.
- If the sperm are of good quality and the woman's reproductive structures are good (patent fallopian tubes, no adhesions or scarring), physicians usually start by prescribing a course of ovarian stimulating medication.
- The physician may also suggest using a conception cap cervical cap, which the patient can use at home. The conception cap works by placing the sperm inside the cap and putting the conception device on the cervix, or intrauterine insemination (IUI), in which sperm is introduced into the uterus during ovulation, via a catheter.
- In these methods, fertilization occurs inside the body.[2]
- Clomiphene is the drug of choice in women with normal cycles and infrequent ovulation[3]. Clomiphene is also used in PCOS. The administration of drug is started during the follicular phase of cycle[4].
- Clomiphene is a mixed agnoist and antagonist of estrogen receptors, acting differently on the estrogen receptors in the uterus and in the hypothalamus, which is why it is called a selective estrogen receptor modulator. [5]
- Clomiphene binds to the receptors in the hypothalamus and acts as a partial estrogen agnoist. This leads to negative feedback inhibition in the hypothalamus and consequently increases follicle stimulating hormone and luteinizing hormone production.
- Clomiphene is associated with some side effects such as hot flushes, nausea and ovarian hyper stimulation syndrome.
In patients who are infertile due to PCOS, correction of biochemical abnormalities usually results in ovulation. Metformin is the drug of choice to reduce hyperinsulinemia. Metformin and clomiphene in conjunction are found to reduce hyperinsulinemia and hyperandrogenemia[6].
Elevated prolactin level causes ovulatory dysfunction and is treated with bromocriptine or cabergoline. This increases ovarian response to clomiphene which is administered after a course of bromocriptine or cabergoline. In cases of anovulation due to absence of LH surge, human chorionic gonadotropin is administered after clomiphene therapy to aid ovulation. Response to therapy is measured with estradiol level and ultrasound measurement of follicle size.[7]
For any medical therapy targeting ovulation induction, the prerequisite is presence of ovarian reserve. Strongest determinant for ovarian reserve is age. Women who are older have fewer oocytes and may not respond well to ovulation induction therapy.
If conservative medical treatments fail to achieve a full term pregnancy, the physician may suggest the patient undergo in vitro fertilization (IVF)[8]. IVF and related techniques (ICSI, ZIFT, GIFT) are called assisted reproductive technology (ART) techniques.
ART techniques generally start with stimulating the ovaries to increase egg production. After stimulation, the physician surgically extracts one or more eggs from the ovary, and unites them with sperm in a laboratory setting, with the intent of producing one or more embryos. Fertilization takes place outside the body, and the fertilized egg is reinserted into the woman's reproductive tract, in a procedure called embryo transfer.
Other medical techniques are e.g. tuboplasty, assisted hatching, and Preimplantation genetic diagnosis.
Complementary Treatments
At-home Conception Kit
In 2007 the FDA cleared the first at home tier one medical conception device to aid in conception. The key to the kit are cervical caps for conception. This at home [cervical cap] insemination method allows all the semen to be placed up against the cervical os for six hours allowing all available sperm to be placed directly on thecervical os. For low sperm count, low sperm motility, or a tilted cervix using a cervical cap aids conception. This is a prescriptive medical device, but not commonly prescribed by physicians.[9]
At-home Assessment
Prior to expensive fertility procedures, many women and couples turn to online sources to determine their chances of success. A take-home baby assessment can provide a best guess estimate compared with women who have succeeded with in vitro fertilization, based on variables such as maternal age, duration of infertility and number of prior pregnancies.[10]
Fertility Tourism
Fertility tourism is the practice of traveling to another country for fertility treatments.[11] It may be regarded as a form of medical tourism. The main reasons for fertility tourism are legal regulation of the sought procedure in the home country, or lower price. In-vitro fertilization and donor insemination are major procedures involved.
References
- ↑ Szamatowicz M (2016). "Assisted reproductive technology in reproductive medicine - possibilities and limitations". Ginekol Pol. 87 (12): 820–823. doi:10.5603/GP.2016.0095. PMID 28098933.
- ↑ Venturella R, Vaiarelli A, Cimadomo D, Pedri S, Lico D, Mazzilli R; et al. (2019). "State of the art and emerging drug therapies for female infertility". Gynecol Endocrinol. 35 (10): 835–841. doi:10.1080/09513590.2019.1603289. PMID 31032671.
- ↑ Wheeler KM, Sharma D, Kavoussi PK, Smith RP, Costabile R (2019). "Clomiphene Citrate for the Treatment of Hypogonadism". Sex Med Rev. 7 (2): 272–276. doi:10.1016/j.sxmr.2018.10.001. PMID 30522888.
- ↑ Kawamura M, Suzuki A, Kanda R, Kiseki H, Tsukahara Y, Hashimura N (2012). "Modified repeated intracyclic clomiphene citrate therapy after conventional clomiphene therapy". Clin Exp Obstet Gynecol. 39 (3): 317–20. PMID 23157033.
- ↑ Clark JH, Hardin JW, McCormack SA (1979). "Mechanism of action of estrogen agonists and antagonists". J Anim Sci. 49 Suppl 2: 46–65. doi:10.1093/ansci/49.supplement_ii.46. PMID 400777.
- ↑ Practice Committee of the American Society for Reproductive Medicine. Electronic address: ASRM@asrm.org. Practice Committee of the American Society for Reproductive Medicine (2017). "Role of metformin for ovulation induction in infertile patients with polycystic ovary syndrome (PCOS): a guideline". Fertil Steril. 108 (3): 426–441. doi:10.1016/j.fertnstert.2017.06.026. PMID 28865539.
- ↑ Branigan EF, Estes A (2005). "Use of micro-dose human chorionic gonadotropin (hCG) after clomiphene citrate (CC) to complete folliculogenesis in previous CC-resistant anovulation". Am J Obstet Gynecol. 192 (6): 1890–4, discussion 1894-6. doi:10.1016/j.ajog.2005.02.072. PMID 15970844.
- ↑ Legro RS (2015). "Practices in in vitro fertilization". Semin Reprod Med. 33 (2): 61–2. doi:10.1055/s-0035-1546425. PMID 25734342.
- ↑ http://www.newsrx.com/pr_details.php?type=1&id=2904
- ↑ http://www.formyodds.com
- ↑ http://www.wordspy.com/words/fertilitytourism.asp wordspy.com