Once your initial evaluation has been completed, we will discuss the findings and make individual recommendations for your treatment. Since there is tremendous variability in the exact treatment that individuals receive, this section will be divided into generalized treatment categories. Below is a brief description of the different types of treatment. Click on the title to go to the page of interest where you will find more specific information.
Some couples complete their testing without any abnormalities identified. While this may be frustrating to be diagnosed as unexplained infertility, all hope is not lost. This simply means you have reached a point in your evaluation that the more common causes of infertility have been ruled out and the best course of action is to begin a coordinated attempt at pregnancy rather than continue to look for reasons why you are not pregnant. There are many natural hurdles to pregnancy such as the passage of sperm across the cervix, interaction with the sperm and the female reproductive tract, fertilization of the egg, transport of the embryo through the fallopian tube to the uterus, and implantation into the uterus. One of the biggest hurdles to pregnancy is genetic mistakes that occur naturally within embryos. These mistakes become worse with age. In cases of unexplained infertility, many patients simply haven’t overcome the natural barriers to pregnancy. Without identified abnormalities during your evaluation you will likely have a very good chance of becoming pregnant.
Ovulation induction refers to the process of using medications to produce an egg or multiple eggs for the purpose of increasing a woman’s chances of becoming pregnant. There are several techniques for stimulating the production of eggs. The main approaches to growing follicles include Clomiphene citrate (Clomid), letrozole (Femara), and injectable medications, or gonadotropins. Once the eggs are ready, there are several options for helping the sperm and egg get together. These options include intercourse, intrauterine insemination (IUI), and in vitro fertilization (IVF).
Clomid is an oral medication taken for 5 days that indirectly stimulates follicular development. This treatment requires the fallopian tubes that are open as well as relatively good sperm parameters. This type of ovarian stimulation can be combined with home intercourse, or intrauterine insemination. Donor sperm may be used when needed. Ovulation is usually triggered with HCG based on ultrasound monitoring. Some patients are given Clomid by their doctor without monitoring. This can be useful in many cases when a woman doesn’t ovulate. A progesterone level may be drawn on cycle day 21 (or 7 days after suspected ovulation) as an indicator of ovulation if monitoring is not done. Our physicians use ultrasound monitoring in all cases to evaluate for the response to medication and to time fertilization with intercourse or IUI.
Letrozole is a type of medication called an aromatase inhibitor. It is used to remove some of the inhibitory factors that normally suppress egg growth. This works slightly different than Clomid, but in many cases can be as effective or better. It is administered the same way as clomid for 5 days in the beginning of the cycle starting on day 3, 4, or 5 of menses. In some cases, a bolus dose of Letrozole is used. In this case the patient takes a larger amount of the medication to help jump start follicle development. Individual dosing should be discussed with the physician prescribing the medications.
Controlled Ovarian Hyperstimulation (COH)
Technically Clomiphene citrate is a form of COH, however, the term COH is commonly used to mean ovarian stimulation with gonadotropins combined with ultrasound monitoring of the ovarian response. Gonadotropins are hormones that directly stimulate egg production. There are several brand names of gonadotropins commonly used. Gonal F, Follistim, and Menopur are among the most common injectable fertility medications. COH also involves the timed release of the oocytes based on ultrasound parameters. Since the oocytes are not retrieved in a COH cycle the fallopian tubes need to be open and the sperm parameters need to be adequate. Problems encounterd with COH cycles include the high cost of medication, high numbers of eggs resulting in higher risks of multiples, and only a marginal improvement in success rates. In many cases, COH is not a good option when the cost-benefit or risk-benefit is considered. With the current high rates of IVF success and the potential to store embryos for the future, many patients should consider IVF instead of COH. COH can be combined with home intercourse, donor sperm insemination, or intrauterine insemination. [COH IUI – Gonadotropins]
After the preparation of the eggs, sperm must be introduced by one of several means. Intercourse offers the most natural way of fertilizing eggs, but is usually associated with the lowest chance of a pregnancy. In most cases, patients presenting to the fertility clinic have already been attempting intercourse for an extended period of time. Intrauterine insemination, sometimes called artificial insemination, would be the next most effective treatment followed by in vitro fertilization. Additional information on each treatment can be found by clicking the bold title below.
Intrauterine Insemination (IUI)
IUI involves the preparation of the sperm for injection directly into the uterus. This allows the sperm to be concentrated to allow more sperm to enter the uterine cavity than with normal intercourse. The sperm preparation process, or sperm washing, is designed to remove any debris or chemicals that would not normally enter the uterus. An IUI would also bypass any problems with abnormal cervical mucous, vaginal pH, or cervical stenosis (closed cervix). There is much concern about the environment of a woman’s vagina killing the sperm though there is not a lot of evidence to support these concerns. Inseminations would bypass any of these factors if they were present. An IUI is considered a conservative treatment. When timed with ultrasound monitoring, IUI is helping to improve the pregnancy rates by getting more sperm into the uterus and hopefully more sperm to the egg. IUI treatments are usually used for 3 to 6 tries depending on the patient’s circumstances. A young couple with unexplained infertility trying IUI for 6 cycles would have a cumulative rate of success around 40-50%. [Intrauterine Insemination – IUI]
In vitro Fertilization (IVF) and Intracytoplasmic Sperm Injection (ICSI)
IVF involves the stimulation of follicles with gonadotropins (injectable fertility medications) combined with ultrasound monitoring. The eggs develop over 9 to 14 days in most cases. Once the eggs are ready, medications (HCG or Lupron) is used to prepare the oocytes for retrieval. The egg retrieval is performed under intravenous sedation with a transvaginal needle under ultrasound guidance. The oocytes are then combined with the sperm so that fertilization may occur. Techniques such as ICSI and assisted hatching require IVF since the eggs and embryos must be outside of the body for these procedures. Patients with tubal factor infertility or male factor infertility will need IVF if the abnormalities are severe enough to preclude insemination procedures – IUI. Also, patients that have failed other therapies such as IUI may be candidates for IVF. Because IVF pregnancy rates have improved substantially over the last few years, many patients are considering IVF as a first line of treatment. Many patients under the age of 40 can realize up to a 70 to 80% rate of success on the first attempt depending on which technique is used. This is not counting the success or benefits achieved with having embryos frozen. Frozen embryos do not age as a couple ages and can be a very effective way to preserve fertility.
- In vitro Fertilization (IVF)
- Intracytoplasmic sperm injection (ICSI)
- Pre-implantation genetic screening of embryos (PGS)
- Frozen Embryo Transfer (FET)
Fertility Preservation and Egg Freezing
Advances in the technology used to freeze eggs and embryos has opened new doors for fertility preservation. Oocyte cryopreservation is the process of freezing eggs to store them for future use. As women age, the health and quality of the eggs will decline. By freezing eggs, a woman is able to work with her own eggs years later and retain the chances of success associated with her age at the time of egg freezing. The initial process is similar to IVF except the eggs are not fertilized. When the eggs are thawed for use at a later time, they can be fertilized to form embryos. The embryos are grown to the stage where they are transferred in a procedure called embryo transfer procedure. Fertility preservation through egg freezing offers career minded women a means to delay child bearing, women who haven’t yet the right reproductive partner, or women facing medical treatments that may affect their fertility can benefit from oocyte cryopreservation. When patients have a reproductive partner or intend to use donor sperm, they may freeze embryos as a means to preserve fertility. Couples starting their families later in life may also desire to store embryos to avoid the decreased rates of success that may affect their chances of pregnancy with a second or third child in the future. We offer both egg and embryo preservation services.
Donor Oocytes (eggs)
The donor oocyte program offers and alternative for patients who are unable to use their own oocytes to achieve pregnancy. This process requires IVF as described above. The egg donor must undergo stimulation of egg development and the egg collection procedure to have her eggs made available for fertilization. Oocyte donors receive compensation for their time and the procedures. Success from the donor egg program is based on the age of the donor and not the age of the recipient. California IVF works with our own in house pool of egg donors in their 20’s. The rate of success when two embryos are transferred into a normal uterus can be as high as 75% per try. Subsequent tries with frozen embryos are much less expensive than the initial egg collection and development of the embryos to a stage where they can be transferred. More detailed information is provided for both oocyte donors and oocyte recipients.
Donor sperm is obtained from a sperm bank and used with IUI or IVF as described above. Directed sperm donation from a friend can be used but adds additional layers of complexity with donor regulations and screening requirements. We can help you understand the process of finding a sperm bank and selecting a sperm donor during your initial visit. Donor sperm is an excellent option for single women or lesbian couples as well as couples where the man was found to not have any sperm. Men that have abnormal sperm counts, motility or morphology (shape of the sperm) are still candidates for ICSI – sperm injection into the egg. [Donor Sperm]
California IVF offers a unique program called the California Conceptions Donor Embryo Program. This program uses donor sperm and donor eggs to form donor embryos. Since the embryos are formed from donor gametes, the rate of success is generally very high. This program is very suitable for patients with both male and female infertility, patients with multiple failed IVF treatments, women with advanced reproductive age including lesbian couples, and many other patients who would otherwise consider adoption.
When there are problems with a woman’s uterus or reasons why a woman shouldn’t be pregnant, a gestational carrier can be used to carry a pregnancy. The eggs can come from the intended mother or from an egg donor. Gestational carriers are not needed as frequently as most people think. California IVF can help guide patients through the process of using a gestational carrier and help patients connect with the necessary legal resources and appropriate agencies.
Fertility treatments are not always successful. As one of the alternatives to becoming pregnant, adoption can be very rewarding. There are many options available, including embryo adoption. Here you will find several links to resources on the internet. Please send your links to sites you have found useful and informative. [Adoption information and resources for California Patients including embryo adoption]
Child Free Living
If you have been unable to become pregnant and do not feel adoption is the alternative for you, there are many others like you that have found happiness. There are many organizations on the internet that can provide information about this option as well as helping you locate support groups. Be certain to fully understand your options for fertility treatments and adoption. Choosing child free living should be an active decision.
Selecting a Treatment You will need an evaluation into the possible causes of infertility as well as an individualized assessment by an experienced infertility specialist. Our doctors will review your history and available treatment options in detail. Often there will be more than one option available. You will need to take into account the success of the infertility treatment, length of time it may take to achieve a pregnancy, and the estimated cost of the treatment. You can find out more about the costs associated with infertility treatments as well as insurance options here.