Female Infertility

How your infertility is treated depends on the cause, your age, how long you've been infertile and personal preferences. Because infertility is a complex disorder, treatment involves significant financial, physical, psychological and time commitments. Although some women need just one or two therapies to restore fertility, it's possible that several different types of treatment may be needed before you're able to conceive.

Treatments can either attempt to restore fertility — by means of medication or surgery — or assist in reproduction with sophisticated techniques.

Fertility restoration: Stimulating ovulation with fertility drugs

Fertility drugs, which regulate or induce ovulation, are the main treatment for women who are infertile due to ovulation disorders. In general, they work like the natural hormones — follicle-stimulating hormone (FSH) and luteinizing hormone (LH) — to trigger ovulation. They are also used in women who ovulate to try to stimulate a better egg or an extra egg or eggs. Fertility drugs may include:

• Clomiphene citrate. Clomiphene citrate (Clomid, Serophene) is taken by mouth and stimulates ovulation by causing the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg.
• Gonadotropins. Instead of stimulating the pituitary gland to release more hormones, these injected treatments stimulate the ovary directly. Gonadotropin medications include human menopausal gonadotropin or hMG (Repronex, Menopur) and FSH (Gonal-F, Follistim AQ, Bravelle). All act to stimulate production of multiple eggs. Another gonadotropin, human chorionic gonadotropin (Ovidrel, Pregnyl), is used to mature the eggs and trigger their release at the time of ovulation.
• Metformin. Metformin (Glucophage, others) is used when insulin resistance is a known or suspected cause of infertility, usually in women with a diagnosis of PCOS. Metformin helps improve insulin resistance, which can make ovulation more likely to occur. Letrozole. Letrozole (Femara) belongs to a class of drugs known as aromatase inhibitors and works in a similar fashion to clomiphene. Letrozole may induce ovulation. However, the effect this medication has on early pregnancy isn't yet known, so it isn't used for ovulation induction as frequently as others.
• Bromocriptine. Bromocriptine (Parlodel, Cycloset) may be used when ovulation problems are caused by excess production of prolactin (hyperprolactinemia) by the pituitary gland.

Risks of fertility drugs

Using fertility drugs carries some risks, such as:

• Pregnancy with multiples. Oral medications carry a fairly low risk of multiples (less than 10 percent) and mostly a risk of twins, but your chances increase to about 15 to 20 percent with injectable medications. Injectable fertility medications also carry the major risk of triplets or more (higher order multiple pregnancy). Generally, the more fetuses you're carrying, the greater the risk of premature labor, low birth weight and later developmental problems. Sometimes adjusting medications can lower the risk of multiples, if too many follicles develop.
• Ovarian hyperstimulation syndrome (OHSS). Use of injectable fertility drugs to induce ovulation can cause OHSS, in which your ovaries become swollen and painful. Signs and symptoms typically last a week and include mild abdominal pain, bloating, nausea, vomiting and diarrhea. If you become pregnant, however, your symptoms might last several weeks. Rarely, it's possible to develop a more severe form of OHSS that can also cause rapid weight gain, enlarged painful ovaries, fluid in the abdomen and shortness of breath.
• Long-term risks of ovarian tumors. Most studies of women using fertility drugs suggest that there are few if any long-term risks. However, some studies suggest that women taking fertility drugs for 12 or more months without a successful pregnancy may have an associated increased risk of borderline ovarian tumors later in life. Women who never have pregnancies have an increased risk of ovarian tumors, so it may be related to the underlying problem rather than the treatment. However, since success rates are typically higher in the first few cycles, re-evaluating medication use every few months and concentrating on the treatments that have the most success appear to be appropriate.

Fertility restoration: Surgery

Several surgical procedures can correct problems or otherwise improve female fertility. However, surgical treatments for fertility are rare these days now that other fertility treatments have high success. They include:

• Laparoscopic or hysteroscopic surgery. These surgeries can remove or correct abnormalities that decrease pregnancy rates. This can include correcting an abnormal uterine shape, removing endometrial polyps and some types of fibroids that misshape the uterine cavity or pelvic or uterine adhesions. This can improve your chances of achieving pregnancy.
• Tubal ligation reversal surgery (microscopic). After a woman has had her tubes tied for permanent contraception (tubal ligation), surgery may be done to reconnect them and restore fertility. Your doctor can determine whether you're a good candidate for this or whether in vitro fertilization (IVF) might be a better choice for you.
• Tubal surgeries. If your fallopian tubes are blocked or filled with fluid (hydrosalpinx), laparoscopic surgery may be performed to remove adhesions, dilate a tube or create a new tubal opening. However, this is rarely done, as pregnancy rates are usually better with IVF. For hydrosalpinx, removal of your tubes (salpingectomy) or blocking the tubes close to the uterus can improve your chances of pregnancy with IVF.

Reproductive assistance

The most commonly used methods of reproductive assistance include:

• Intrauterine insemination (IUI). During IUI, millions of healthy sperm are placed inside the uterus close to the time of ovulation.
• Assisted reproductive technology. These methods involve retrieving mature eggs from a woman, fertilizing them with a man's sperm in a dish in a lab, then transferring the embryos into the uterus after fertilization. IVF is the most effective assisted reproductive technology. An IVF cycle takes several weeks and requires frequent blood tests and daily hormone injections.