Medical fertility treatments

Serial ultrasound scans to monitor egg development in the ovary and to assess how the womb lining thickens during one typical month of a womans’ cycle, can be very useful in identifying potential problems, and in pinpointing exactly when ovulation occurs. The 2 to 3 ultrasound scans are often combined with blood tests, mucus assessment and urine ovulation test sticks to provide a complete picture.

Tablets or injections may be recommended to regulate or boost ovulation and improve the chance of pregnancy. These treatments are only useful if the fallopian tubes are open and the sperm test is normal. These treatments may be combined with other techniques including intrauterine insemination (IUI), which boost chances further. I always recommend IUI when injections are used.

Clomiphene has been used for many years to induce ovulation in women who do not naturally produce an egg once a month. It is routinely given from the second full day of the period for 5 days, and the dose may vary from 25-150mg per day. Some women are resistant to the action of the drug and require larger doses, but most women start on 50mg daily. A different means of treatment is used if no ovulation occurs after increasing the dose over several months, or if no pregnancy results after 6-9 months when ovulation is happening monthly. The drug should not be used continually for over 12 months as there is some evidence that prolonged use may increase the risk of ovarian cancer. A shorter duration of use is not associated with any risk. Like all fertility drugs, Clomiphene can be associated with the possibility of multiple egg development. It is for this reason that all women on the medication should have an ultrasound scan during at least one of their treatment cycles, to ensure that the treatment is working, and that too many eggs are not developing in any one month, which would in turn increase the risk of conceiving twins, triplets or even more babies at the same time.

Some women experience headaches or hot flushes whilst taking the tablets, and they can be associated with feeling a little depressed, but most patients have no side effects at all. Rare side effects include alopecia and blurred vision. The medication should be stopped immediately if these symptoms occur.

There is no increased risk of miscarriage or birth defects after taking Clomiphene.

Tamoxifen is similar to Clomiphene in the effects on the ovary, but it tends to cause less side effects. Most people recognise it as the drug routinely used in women with breast cancer but it works very well when it comes to promoting egg growth. It is given the same way as Clomiphene. I advise patients to take between 20-60mg daily for five days, starting on the second full day of the period. A scan is performed between day 10 and 12 to monitor egg growth and to predict when ovulation will occur.

Injections are often used when Clomiphene or Tamoxifen have not worked, or in some women who ovulate normally but need ‘superovulation’ to help conception. It is my routine practice to combine the use of these injections with intra-uterine insemination each month. The injections themselves start between day 2 and 3 of the period, and are usually recommended daily, or less commonly on alternate days. They sound frightening I know, but they are easy to do! The needle used is very small and the medicine kept in an injector pen that you will be taught to use yourself. It is unusual for my patients not to feel confident to do the injections themselves, once the easy technique has been taught, and they really don’t hurt I promise, but when squeamishness takes over, a friend or your partner can usually be taught to do them for you. A total of 10 to 12 daily injections are normally needed to ‘grow’ one or two eggs every month. A scan will confirm when the egg(s) is ripe. At this stage a different injection will be given to help the egg(s) release (Ovitrelle or Pregnyl), and the IUI treatment arranged 24 hours later.

Pregnancy should result within 6 months when the injections are used during each cycle. In vitro fertilisation is the next step if there is no news at that stage, and may be recommended earlier if the response to the treatment is not optimal.

Very rarely, low hormone production from a gland in the brain called the hypothalamus is the reason why a woman fails to ovulate monthly. In these cases, a pump that delivers the deficient hormone (LHrh, Lutrelef) in pulses every 90 minutes is used to simulate normal hormone production. The ovary responds very well in these cases, and once the correct dose is established, scans will confirm that an egg is developing, and when ovulation occurs. The pump is just bigger than a matchbox, and is strapped to the upper arm or kept inside a bra. A tiny needle is secured under the skin of the upper arm, and is kept there constantly throughout the month (although the needle is changed regularly). When pregnancy results, I keep the pump going for at least another month until it has been confirmed that the pregnancy is growing well.

The use of the pump is not associated with any increase in miscarriage or fetal abnormalities.

This is a common technique used to assist conception where a sperm sample is produced by masturbation, and then handed to the laboratory staff to enable them to select the best looking and best swimming sperm in the sample. This ‘olympic team’ are then inserted into the womb cavity just before ovulation is expected to occur, using a tiny catheter, in a procedure a bit like having a cervical smear test done.

This treatment may be offered to improve the chance of conception if sperm quality is normal or slightly low only. It is not appropriate for couples when sperm quality is poor. The procedure is not recommended when the fallopian tubes are damaged. The insemination is performed in a natural cycle if female ovulation is predictable and regular, but it is often combined with treatment to stimulate ovulation (tablets or injections) to further improve the chance of pregnancy.

Pregnancy should result within 6 cycles of treatment where ovulation is confirmed and the sperm preparation used for the insemination is good. In vitro fertilisation would be recommended at that stage if conception has not occurred, or sometimes earlier in older couples, or when the cycle response has not been good.

Some couples have difficulty having sex, and although many have an otherwise close relationship, the issue creates a major problem when the couple wish to start a family. Psychosexual therapy can deal with many of the issues, but it is often a very time consuming and slow process. Women in their mid to late 30s and above may have significantly reduced fertility by the time a satisfactory sex life sufficient to optimise the chance of conception is achieved. Self insemination, ovulation induction with intrauterine insemination, and in some cases IVF may be recommended when sexual problems coincide with the desire to have children.