This description is not intended to be a complete guide to every form of available therapy. Should any doubt exist, you should ask your doctor for advice.
The object of treatment is the release of a fertile egg(s)
Obesity – not only is being overweight a possible cause of failure of ovulation, and possibly other causes of infertility, but also has detrimental effects on pregnancy, health and increases the risks of surgery. Controlled weight loss can aid ovulation. Certain patients with obesity may have PCOS. Patients with both obesity and who are underweight will have lower pregnancy rates with ART.
While body weight is important there is a better method of correlating weight and disease and this is the BMI. BMI stands for “Body Mass Index,” a ratio between Weight and Height. It is a mathematical formula that correlates with body fat.
If you want to compare your weight status to others, BMI is a great method of analysis.
Fat predominantly distributed around the waist is also a risk factor for health complications such as cardiovascular disease and type II diabetes. Fat predominantly deposited around the hips and buttocks doesn’t have this same risk.
It is worthwhile to try and get your BMI into the healthy range!
Underweight – if your weight falls below a certain level it too can interfere with ovulation and again one must discuss this with your doctor, as controlled weight gain can aid ovulation. Being underweight often occurs in people who exercise excessively or may have eating disorders. Medical advice in these circumstances is essential.
Patients often feel that one form of medication is stronger than another. This is not true. For each ovulation problem there is usually a specific form of treatment. Remember that once ovulation occurs, it only continues with the repeated monthly use of the medication. There is rarely any permanent cure. Also, once ovulation occurs, the monthly chance of conception is provided, so the patient should not necessarily expect pregnancy to occur during the first month (even though these drugs are called “fertility drugs”, in reality they are ovulatory drugs).
There are basically two broad groups of drugs available, those acting directly on the pituitary gland and ovary, and those acting indirectly:
By virtue of their action, both clomiphene citrate, HMG and recombinant agents are associated with increased risk of multiple pregnancy. However, when used and monitored correctly, the likelihood of multiple pregnancies is reduced.
Elevated levels of prolactin either prevent or reduce the quality of ovulation. Bromergocriptine or Cabergoline is given to return the prolactin levels to normal. Stopping treatment even for a few days allows prolactin levels to increase, and the medication should therefore be taken continuously unless otherwise advised by the doctor.
Dangerous side effects of these agents are extremely rare and there is no specific evidence to show that they lead to birth defects in children. However, bromocriptine may have some initial unpleasant side effects on some patients, e.g. headaches, dizziness associated with low blood pressure, “stuffy” nose, or nausea. These side effects are overcome by gradual increase to the prescribed dose, and taking of the medication in the middle of meals. Cabergoline tends to have far fewer side effects and is replacing bromocriptine as the drug of choice especially as it is taken once a week.
In patients with polycystic ovarian syndrome, laparoscopic ovarian drilling has been shown to induce ovulation. Ovarian Drilling is performed by making 4 or 5 small holes in each ovary with a diathermy probe. Obviously this is a destructive procedure and should only be performed by a suitably trained fertility specialists once you complete infertility investigation. Excessive diathermy can lead to ovarian damage.
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This is a condition in which tissue resembling the normal lining of the uterus (endometrium) is found outside the cavity of the uterus. It may occur on the ovaries, tubes, outside of the uterus or anywhere in the pelvic cavity, rarely elsewhere. Its presence can lead to local inflammation, scarring and pain.
The incidence of endometriosis varies but is thought to affect ± 21% of infertile women. It is best diagnosed with laparoscopy but ultrasound does help in diagnosing ovarian endometriotic cysts (endometrioma).
When present in minor amounts, just a few spots and without causing any other complaints, it can lead to infertility and its removal usually laparoscopically leads to an improved chance of pregnancy in about 35% of cases. This result is further increased if surgery is followed by induction of ovulation and intra uterine insemination. In other words removal of endometriosis creates a “window of opportunity” for fertility and this is magnified by including other fertility treatment options.
When present in moderate or severe forms it may add a secondary mechanical cause of infertility, affecting the tubes alibility to collect eggs due to scarring and adhesions. Although a poorly understood condition, it is associated with an increased risk of infertility. Drugs, surgery or assisted reproductive techniques may be used in treatment, and your doctor will decide what form of therapy is appropriate. At present there is no cure, but control is possible.
Basically drugs are used to treat the symptoms of endometriosis, such as pelvic pain, progressive dysmenorrhoea and pain on intercourse, but do not increase the chances of pregnancy whereas surgery increases the pregnancy rate as well as treating symptoms. Surgery can also lead to healing by scar tissue which itself can aggravate infertility, so this type of treatment should be carefully discussed with your infertility expert. Once a woman is pregnant endometriosis has no effect on the pregnancy. Endometriosis does not affect IVF outcome. Pregnancy on the other hand leads to an improvement or cure of the endometriosis, a wonderful bonus for the sufferer. The aim of therapy is to reduce the amount or effect of endometriosis and so maximise the chance of conceiving.
Drugs used to treat endometriosis include:
These two drugs are derived from synthetic male hormones and may have mild side effects as a result. These side effects may include development of oily skin or hair, some acne, or weight gain. These effects are usually mild and reversible. Treatment using these two drugs often lasts up to six months. While on treatment your menstruation will diminish and usually stop altogether. This is quite normal. Provided the drugs are taken correctly, conception cannot take place during this form of treatment as it stops all ovarian activity. These drugs are usually used to control symptoms but do not appear to improve fertility.
This type of medication is prescribed to minimise the effects and amount of endometriosis prior to surgery. Occasionally oestrogen and progesterone must be added in small amounts to prevent osteoporosis (weakness and brittleness of bones) and this is referred to as “add back therapy”.
These drugs are currently undergoing trials prior to release and we await information regarding their potential role in the treatment of endometriosis.
Letrozole is one example. Its action is to block oestrogen synthesis on the basis that the development of endometriosis is oestrogen dependent. Research with this type of drug is ongoing.
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If you suffer from stomach acidity or stomach or duodenal ulcers, this has nothing to do with your cervix. Thus diet does not affect the state of your cervical mucus.
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Although developmental abnormalities of the uterus do not usually prevent conception, they may have effects later in a pregnancy and may require correction prior to attempting conception. This subject is complicated and needs to be discussed with your infertility specialist.
Similarly, if smooth muscle tumours of the uterus, i.e. fibroids (fibromyomata), are close to or project into the uterine cavity they must be surgically removed (myomectomy). Instead of open abdominal surgery i.e. laparotomy, today surgery often can be performed hysteroscopically or laparoscopically by suitably skilled endoscopic surgeons. This newer approach to surgery dramatically reduces hospitalisation and recovery time. In addition a newer but still experimental approach for infertile patients, involves blocking the blood vessels supplying the fibroids i.e. “Embolisation”.
In select cases a myomectomy could lead to some improvement in ART success rates.
Tubes & Ovaries
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Surgery is recommended to correct certain types of problems affecting tubes and ovaries. The decision to undertake this form of therapy is not easy, and your doctor will advise you. The delicate type of surgery undertaken on tubes and ovaries is called microsurgery and fertility experts require specific training in this specialised field. Only trained microsurgeons should therefor correct these problems and the patient should confirm this prior to undergoing corrective surgery! Often the potential success of surgery must be weighed up against the success of ART and today most ART units have success rates so much better than those resulting from surgery, that surgery is seldom undertaken. However if ART is not available then surgery may be a good alternative. Certain types of microsurgery can be performed via the laparoscope however you may have to be referred to a specialist unit for this.
Tubal ligation and approach to restoring fertility
Patients may request the reversal of a tubal ligation. Tubal ligation is a general term describing many different types of surgical procedures to block a woman’s Fallopian tubes in order to sterilise them. Surgical reversal of this type of operation once again depends upon a number of factors including the woman’s age, the type of sterilisation procedure performed, the overall fertility of the couple and the fertility expert’s skill at microsurgery to mention a few. The IVF option does not require functional Fallopian tubes. Further information should be obtained from your fertility specialist.
At present rather than undertaking open surgery (laparotomy) in the form of microsugery, when required it can be undertaken by laparoscopy, which is far less invasive than open surgery, and equally as effective.
Removal of Blocked tubes for IVF
One cause of infertility is blocked Fallopian tubes filled with fluid called hydrosalpinges. This problem is treated by IVF. It has been found that removal or blocking off these tubes can increase IVF success rates by up to 40%. These procedures should be discussed with your fertility specialist specially if IVF has not been successful and you suffer from this problem.
Finally, other forms of surgery, such as wedge resections of ovaries (cutting a piece out, laser, ventrisuspension and ventrifixation changing the position of the uterus) should rarely, if ever, be performed, as complications of these operations usually outweigh any potential benefits.