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Patient information from the BMJ Group
Fertility problems: what treatments work?
If you and your partner have been diagnosed as having fertility problems, it means
you've been trying for a baby for at least a year without success. It doesn't mean
you'll never be able to have a baby. Fertility problems are common and there are
treatments that can help.
We’ve looked at the best and most up-to-date research to produce this information.
You can use it to talk to your doctor and decide which treatments are right for you.
What happens in fertility problems?
The most common reasons for fertility problems are: The woman is not releasing eggs (ovulating) regularly The eggs are being released, but cannot get from the ovaries to the womb, becausethe fallopian tubes that connect them are blocked The sperm are misshapen and can’t fertilise the eggs You will have a range of tests to find out what is the most likely problem. The types oftreatment you will be offered may depend on your test results. But some couples neverfind out what is causing their infertility. In that case, doctors offer treatment that may help,without being completely sure of the cause.
What treatments work?
Treatments for infertility include medicines, surgery and "high-tech" treatments such asin vitro fertilization (IVF).
It's worth weighing up the strain of some fertility treatments and the risk of possible sideeffects against the chances of success. Not everyone who has fertility treatment getspregnant. It might help to talk to an infertility counsellor.
Bear in mind that if you get pregnant you may still miscarry. As many as 1 in 5 coupleswho get pregnant have a miscarriage. Treatment for infertility doesn't make a miscarriageless likely. The older the woman, the greater the chance of miscarriage.
Medicines
Clomifene (Clomid) is the first treatment you’re likely to be offered if you are a woman
who has problems ovulating or you have unexplained fertility problems.
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Fertility problems: what treatments work?
Clomifene is a pill that helps you ovulate. After two, three or four cycles of treatment withclomifene, about 6 in 10 women with ovulation problems ovulate and about 1 in 10 getpregnant. That’s three times as many women getting pregnant as would have donewithout treatment.
If you have polycystic ovary syndrome, you may be offered a medicine called metformin,
as well as clomifene. It’s normally used to treat diabetes. But it may also help you ovulate,
if clomifene alone hasn't helped. Over six months, you have about a 1 in 3 chance of
getting pregnant taking the combination, compared to about a 1 in 10 chance if you just
take clomifene.
Clomifene has some side effects, but they're usually not serious and don't need treatment.
They include feeling bloated, puffy, or uncomfortable, hot flushes and putting on weight.
If you take clomifene and you get pregnant, you're more likely to have twins or tripletsthan women who don't take clomifene. You may even have more than three babies,although this is less common. This happens because clomifene can make your ovariesrelease more than one egg at a time. As many as 1 in 10 women who get pregnant withclomifene have more than one baby.
If clomifene and metformin have not worked, or if you have a condition where you are
not making sufficient hormones (hypogonadotrophic hypogonadism), your doctor may
suggest you try hormone injections. You take these injections once a day for 12 days,
from the start of your menstrual period. Your doctor will check on how your eggs are
growing, using ultrasound.
Hormone injections contain one or both of follicle-stimulating hormone (FSH) andluteinising hormone (LH). They help you to ovulate. If you have polycystic ovary syndrome(PCOS) and are treated with hormone injections, you have between a 1 in 10 and 1 in3 chance that you will get pregnant each cycle.
Hormone injections have more side effects than clomifene. One side effect of hormoneinjections is called ovarian hyperstimulation syndrome (OHSS). Mild symptoms includeswelling in your legs or arms, putting on weight and feeling bloated. About 1 in 10 womenget more serious side effects, such as feeling sick or vomiting, being out of breath andproblems with their kidneys or liver.
Like clomifene, taking hormone injections may make you more likely to have twins ortriplets.
Hormone injections are sometimes combined with a treatment to put sperm directly into
the womb. It’s called insemination. Putting sperm directly into the womb may increase
your chances of getting pregnant, compared to trying to get pregnant by having sex.
Putting sperm directly into the womb may help if the man has problems with sperm, for
example a low sperm count or sperm that don’t swim well.
There have been some reports that clomifene and hormone injections may make youmore likely to have cancer of the ovaries. But there is not enough research about this tobe sure. The risk seems to be very small.
BMJ Publishing Group Limited 2011. All rights reserved.
Fertility problems: what treatments work?
There are different types of surgery available to help couples who are trying to have ababy. The type you are offered will depend on the cause of your fertility problems.
If you have polycystic ovary syndrome, surgery called laparoscopic drilling may help
you get pregnant. But there isn't enough evidence to say for sure that it works.
A surgeon makes a series of small holes in your ovaries. This helps your ovaries releasethe eggs. If you're having a test called a laparoscopy to check your ovaries, your surgeonmay be able to give you this treatment at the same time.You'll need a general anaesthetic.
If you have polycystic ovary syndrome and clomifene hasn't worked, laparoscopic drillinggives you a 3 to 6 in 10 chance of getting pregnant after six months to 12 months. Thisis about the same chance as if you have hormone injections or take metformin.
For women with blocked or damaged tubes, surgery to repair or remove the tube is also
an option. If the scarring is very small, surgery can work as well as IVF. But for most
women with blocked or damaged tubes, IVF is a better treatment. However, if your
fallopian tubes are swollen and full of fluid, having surgery to repair damaged tubes
before having IVF can double your chance of having a baby.
If you have endometriosis, surgery to remove damaged tissue around your ovaries and
womb may help you get pregnant. In endometriosis, cells from the lining of the womb
(the endometrium) grow outside your womb. This can cause scarring and damage. If
you have surgery for endometriosis, the surgeon will take away any damaged tissue
that may be preventing you from getting pregnant.
About 1 in 4 women who have surgery for endometriosis go on to have a baby. Thiscompares to about 1 in 5 women who don’t have their endometriosis removed.
All surgery has risks, for example, of having a reaction to the anaesthetic or getting aninfection. But these operations are all quite low risk.
High-tech treatments
In-vitro fertilisation (IVF) is the most common form of high-tech fertility treatment. It’s
a very demanding treatment and can have major side effects, especially for the woman.
You need to think carefully before you go ahead. It may help to talk to a counsellor first.
Doctors normally suggest IVF when other treatments haven't worked. IVF can helpcouples with fertility problems caused by lots of things, including problems ovulating,blocked tubes, endometriosis and some sperm problems. There’s not enough researchto show whether or not it works for couples with unexplained fertility problems, althoughit is sometimes tried.
In IVF, scientists mix the man's sperm with the woman's eggs in a laboratory. The spermare allowed to join with the eggs. Doctors then put back the fertilised eggs (now calledembryos) into the woman's womb so that they can grow.
BMJ Publishing Group Limited 2011. All rights reserved.
Fertility problems: what treatments work?
National figures show that infertile couples who have IVF have about a 1 in 5 chance ofhaving a baby after one attempt. But we don't know how many of these women mighthave had a baby without IVF. Remember that this figure is an average and your individualchances will depend on the clinic where you are having treatment. The chances of itworking are much better if the woman is aged under 35. Ask your doctor how well IVFworks for couples with your particular fertility problem, in your age group, at this clinic.
There are some variations on IVF. ICSI (intracytoplasmic sperm injection) is a treatment
where doctors choose a healthy sperm from the man and inject it directly into the woman’s
egg to fertilise it. Then the fertilised egg is put back into the woman’s womb, as with IVF.
ICSI sometimes works when IVF has been tried and has not worked.
GIFT stands for gamete intrafallopian transfer. Doctors put the egg and sperm mix into
one of the woman's fallopian tubes, instead of waiting for them to fertilise in the laboratory.
They do this by making a small cut in her abdomen, using a special camera called a
laparoscope. The sperm fertilises the egg naturally in the woman's fallopian tube.
Before having these treatments, the woman will need to take hormone injections to controlher ovulation. So she may get the side effects listed above. About 1 in 50 women whohave IVF have serious problems that can affect their heart and circulation, lungs, liver,or kidneys. Sometimes this is dangerous and you may need to go to the hospital.
If you get pregnant, you may have more than one baby after IVF, because clinics oftenput more than one embryo into the womb, to give a bigger chance of success. Talk toyour doctor about how many embryos will be put into your womb.
Children born after IVF are more likely to be born premature and to weigh less at birth.
But this is probably due to the greater number of multiple pregnancies and the older ageof women having IVF, rather than due to the IVF itself. There is no evidence that babiesborn after IVF are more likely than average to be born with birth defects.
If you're thinking about trying ICSI, you should talk to your doctor about the possible risksto your baby. These risks are not certain. But there is some evidence that children bornas a result of ICSI are more likely to have serious physical and mental problems.
What will happen?
What you decide to do about your fertility problems is a very personal matter. It willdepend on how important it is for you to have a child using your own eggs and sperm.
Some couples are prepared to have far more tests and treatment than others.
Even without treatment, some couples go on to conceive. Every month, about 1 or 2 inevery 100 couples with fertility problems become pregnant without any medical treatment.
If you have treatment, your chances of success will depend on several things: BMJ Publishing Group Limited 2011. All rights reserved.
Fertility problems: what treatments work?
Before you make decisions, it’s useful to think what sorts of treatment you would beprepared to try, if the first one doesn’t work. How long will you try for? You and your partner may want to consider other options if treatments don’t work, suchas donor eggs or donor sperm, or adoption. Discussing how you feel about these optionswith your partner will help you prepare for whatever happens in the months to come.
Your fertility clinic should be able to give you more information about these options. Bearin mind that tests and treatments for infertility can be a strain, physically, emotionally,and sometimes financially.
Where to get more help
The National Institute for Health and Clinical Excellence (NICE) has produced informationabout the types of fertility treatment couples can expect to be offered, which is availableon its website (http://guidance.nice.org.uk/CG11/publicinfo/pdf/English).
This information is aimed at a UK patient audience. This information however does not replace medical advice.
If you have a medical problem please see your doctor. for this content.
BMJ Publishing Group Limited 2011. All rights reserved.
Last published: Aug 17, 2011

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