Pregnancy Info

If a woman is not ovulating, her ovaries can nearly always be encouraged to produce good-quality eggs by using fertility drugs. These drug treatments used to produce a large number of multiple pregnancies, but much more is now known about the correct dosage, and treatment is very carefully controlled and monitored.

Drug Treatments

Clomiphene -This is the most common fertility drug and is taken for five days at the start of each menstrual cycle. Clomiphene stimulates the release of follicle-stimulating hormone (FSH) by the pituitary gland. This acts on the ovaries and often triggers the ripening of a follicle and then ovulation, usually five to 10 days after the last tablet is taken. Clomiphene’s advantages are that it has no major side effects and has a low multiple pregnancy rate­only five to 10 percent. There’s a possible association with ovarian cancer after 12 cycles, so if conception isn’t achieved after about six cycles, you may be advised to try ART.

Clomiphene-resistant PCOS - If you’re suffering from polycystic ovarian syndrome (PCOS) but you’ve failed to ovulate or conceive after six months’ treatment with clomiphene, your doctors may suggest you have surgery such as ovarian drilling. In this operation, holes are drilled in the surface of your ovary with diathermy laser in order to stimulate ovulation. If ovulation has not been achieved in three cycles of clomiphene, metformin may be added to reduce insulin levels. This has been found to work best in women who were obese and lost weight during treatment. This drug should be stopped if you become ill, and should not be taken at all if you have renal abnormalities.

Alternatively, you could be given a course of follicle­stimulating hormone (FSH) by injection. The success rates of this treatment are quite high-there’s an ovulation rate of about 95 percent per cycle and pregnancy rates of up to 25 percent after three cycles.

Dexamethasone - For women with adrenal overactivity as shown by excess hair growth and rising DHEAS levels, dexamethasone may be given to suppress the adrenal gland. It is given in conjunction with clomiphene and has an increased success rate in these women.

Pulsatile GnRH - Hypothalamic infertility with amenorrhea is caused by the absence of a hormone called gonadotrophin releasing factor, (GnRH), which is made in the part of the brain called the hypothalamus. The role played by GnRH in fertility is to force another part of the brain, the pituitary gland, to release FSH and LH, which in turn stimulate the ovary to ovulate. Women who are deficient in GnRH can be treated with hormone replacements. These are usually given in intravenous “pulses” to mimic normal secretions at 60,90, and 120 minutes, in an increasing dose per pulse. Ovulation rates as high as 75 percent and pregnancy rates up to 15 percent per cycle can be achieved after GnRH replacement treatment.

Bromocriptine - If a woman has high levels of the hormone prolactin in her blood, normal GnRH pulses may be suppressed, so she does not ovulate and cannot conceive. Bromocriptine is the best treatment for this condition-it suppresses prolactin production so the ovaries work properly again, and ovulation rates can be as high as 75 percent. If a woman does get pregnant, bromocriptine treatment should be stopped, but there are no known cases of miscarriage, prematurity, fetal abnormalities, or multiple pregnancies as a result of taking this drug.

Surgical Procedures

Microsurgical techniques, involving laparoscopy, have greatly improved doctors’ ability to repair damaged fallopian tubes.

Tuboplasty - Scarred and narrowed fallopian tubes can be unblocked by an operation known as tuboplasty. A small balloon-tipped catheter is inserted into the blocked fallopian tube. The balloon is then inflated to open the damaged tube and create a passage for fertilized or unfertilized eggs to pass through to reach the uterus. The balloon is then deflated and removed.

Fimbrioplasty - Sometimes the frondlike ends of the fallopian tube (known as the fimbriae) fuse together, blocking the opening of the tube and preventing eggs from entering from the ovary. Microsurgical techniques allow the blocked end of the tube to be opened, giving free access for eggs once again.

Reversal of sterilization - Reversal of female sterilization is an increasing part of the treatment of infertility. Around three out of every 100 women who are sterilized regret it later and ask for the operation to be reversed, often because they’ve begun a new relationship and want to have children with their new partner.

If the severed ends of the fallopian tubes are rejoined, the woman has a good chance of achieving a normal pregnancy ­rates are as high as 92 percent-but this does depend on the expertise of the surgeons at your particular clinic. Unfortunately, 10 some clinics, success rates may be less than 50 percent, so it is worth checking this.

Sterilization in which the tubes have been clamped with clips has the highest chance of being successfully reversed. However, IVF may be the treatment of choice for sterilized women, the pregnancy rate being about one in six.

Fertilization happens when a sperm meets and penetrates an egg. Most human cells contain 46 chromosomes-threadlike structures that carry their genetic information. But sperm cells and egg cells each have only 23 chromosomes. When a sperm and an egg meet and fuse, the resulting fertilized cell has the full 46 chromosomes.

The new cell, which is called a zygote, splits first into two identical cells, each with 46 chromosomes. It continues to divide slowly as it travels down the fallopian tube, until it reaches the uterus. By the time it reaches the uterus it is a hollow clump of about 100 cells called a blastocyst or blastula.

Implantation - A week after fertilization has taken place, the blastocyst produces a hormone that helps it to burrow its way into the endometrium. Implantation is usually in the upper one-third of the uterus. The pregnancy is now established and the placenta will start to form.

Twins - When a woman releases more than one egg at a time, nonidentical (fraternal) twins may develop from two separate eggs, fertilized by two separate sperm. Each embryo then has its own placenta inside the mother’s uterus. Identical twins come from a single egg, fertilized by a single sperm. This egg divides into two, and each develops independently into a genetically identical twin sharing a single placenta. Other multiple pregnancies, such as triplets, start in the same ways as twins and, similarly, the siblings may be identical or fraternal.

First of all, see your family doctor so you can talk about your worries and ask questions. For many couples, the woman seeks advice first, but it’s really important for you both to accept that whatever the reasons for your problems, you’re both going to need investigation. So try to get off to a good start and make the first visit a joint one. If you’re worried that your doctor won’t have time for the kind of detailed, relaxed conversation you need, ask for a longer appointment, perhaps at a time of day when things are less rushed. Or you could try going to the sexual health clinic in your local hospital or a family planning clinic. You don’t need a referral from your doctor for either of these, and you should find a team of sympathetic experts able to discuss your problems.

How Your Treatment Will be Managed

When you first see your doctor, ask how any treatment is likely to be managed. Each stage in the investigation and treatment of infertility should be fully explained to you in a way you can understand, and you’ll be given lists of self-help organizations to get in touch with.

Your family doctor may do the initial tests or refer you from the outset. Either way, you’ll be referred for all secondary tests and for further treatment to a specialist infertility clinic run by a professional, multiskilled team. Call your insurance company first to find out if your policy covers infertility treatment; many plans do not, and it can be very expensive.

Any infertility treatment is a stressful business, so it’s important that the doctors caring for you are relaxed and friendly. The atmosphere of the clinic should be sympathetic so you feel that you’ll be listened to properly. The clinic should also provide information on what will be involved, including the pros and cons of any alternative treatments that are relevant.

With this kind of treatment, you have a right to expect that your feelings and preferences are considered by the professionals and that any disagreements will be negotiated between you both. Your doctor and the fertility clinic to which you’re referred will want to provide the best possible outcome for you both-that is, for you to conceive and give birth to a healthy baby-but the route to this goal could be rocky, and it’s best to be prepared from the outset.

Primart Tests

Primary tests can be done by your family doctor, although many doctors prefer to refer you. It’s important for your partner to be involved, since 30 to 40 percent of infertility is linked to the man’s reproductive system. Your doctor will ask about your fertility history as a couple, including your ages, how long you’ve been trying to conceive, past illnesses or surgery, and any drugs you’ve been taking that might affect fertility. The woman will also be asked about her menstrual cycle, how regular it is, how long her periods last, and whether or not they’re painful. You’ll also be asked about your job in case either of you could be exposed to dangers at work that may affect fertility. The doctor will also ask about any past sexually transmitted disease in either partner, including chlamydia, and will look at past smear test results.

Primary tests for the woman:

• smear test (if not done recently)
• test for chlamydia, which will be treated if found
• physical examination, including an internal examination
• fasting blood glucose and TSH (thyroid stimulating hormone) levels
• a simple blood test for progesterone levels in the second half of the cycle to confirm whether ovulation is taking place.

Primary tests for the man:

• physical examination of the man’s penis and testes
• two semen samples to be analyzed by the lab at the clinic where further investigations and secondary tests will be done.

Rapid referral for secondary tests In some circumstances couples are referred as quickly as possible for secondary investigations at a specialist clinic. These include:

• if either partner is over 35 years of age
• if the woman has a history of amenorrhea (absence of periods), or oligomenorrhea (sparse or infrequent periods)
• abnormal anatomy on internal examination of the woman or a varicocele of the scrotum in the man.