TREATMENT OVERVIEW

We favor treatment plans that are time efficient and cost effective. Depending on the cause of infertility, treatment can begin with the most basic or the most advanced. For practical purpose treatment can be divided into three levels: 

1. Ovulation Induction using Oral Medications such as clomiphene (Clomid, Serophene) or letrozole (Femara) with or without intrauterine insemination (IUI).

2. Super Ovulation Induction using Injectable Medications such as FSH (Bravelle, Follistim, Gonal-f) or HMG (Pergonal, Repronex) usually in combination with IUI.

3. Advanced Reproductive Technologies such as IVF and ICSI using autologous eggs or donor eggs.

For couples who have severe male factor, stage 3 or 4 endometriosis, or tubal damage as the causes of their infertility, IVF is the treatment of choice. Surgery to repair male factor (varicocele repair) or to open diseased tubes (tuboplasty) has limited value. In our experience IVF option in these instances yields a higher rate of pregnancy and is more cost effective.

Operative laparoscopy is helpful in case of suspected endometriosis. Endometriosis implants have been shown to secrete substances that can impair the fertilization process by damaging the integrity of the egg and sperm and by impairing the ability of the tubes to capture the egg. Removal of these implants has been shown to increase the pregnancy rate during the first 6 to 8 months after surgery. In addition, patients with large endometriotic lesions on the ovaries (endometrioma) should have these lesions removed before proceeding to IVF to allow more room on the ovaries for new follicles to develop. In addition, in cases of hydrosalpinx (fluid-filled tubes), operative laparoscopy should be performed before IVF to remove the damaged tubes in order to prevent the tubal fluid from flowing into the uterus.

At ARCC the diagnostic and treatment algorithm is as followed:

Diagnostic Cycle

Laparoscopy

Clomiphene ± IUI 3 - 5 cycles

Superovulation+IUI 3 cycles

HSG normal?

Tubes normal?

Semen normal?

IVF ± ICSI

NO

YES

YES

YES

NO

NO

Mildly abnl?

YES

NO

Note: Laparoscopy can be performed even in presence of normal findings on the HSG to rule out endometriosis and pelvic adhesions after unsuccessful ovulation induction cycles. Patients with tubal abnormality on the HSG can proceed directly to IVF without laparoscopy to avoid the risks of surgery.