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Dx Fertility Treatments:

Treatment of Infertility

The Merck Manual Home Edition
"Infertility is the inability of a couple to achieve a pregnancy after repeated intercourse without contraception for 1 year.

Frequent intercourse without birth control usually results in pregnancy:
*For 50% of couples within 3 months
*For 75% within 6 months
*For 90% within 1 year

To maximize the chance of pregnancy, couples should have frequent intercourse for the few days when egg release (ovulation) is most likely—the time when women are most likely to become pregnant. Ovulation usually occurs in the middle of the menstrual cycle, which is about halfway between the first day of two periods. There are two methods women can use to estimate when ovulation occurs:
*Measurement of body temperature at rest (basal body temperature)
*Home ovulation predictor kits

If women have regular periods, they can estimate when ovulation occurs by measuring their temperature each day before they get out of bed. A decrease suggests that ovulation is about to occur. An increase of 0.9° F (0.5° C) or more suggests ovulation has just occurred. However, this method is inconvenient for many women and is not reliable or precise. At best, it predicts ovulation only within 2 days.

Home ovulation prediction kits are more accurate. These kits are used to detect an increase in luteinizing hormone in the urine. (This hormone stimulates the ovaries to trigger ovulation.) Usually, this increase occurs 24 to 36 hours before ovulation. Women usually need to repeat the test for several consecutive days, so kits typically include five to seven sticks. The sticks can be held under a stream of urine or dipped into urine that is collected in a sterile container...

About one in five couples in the United States do not conceive for at least a year and are thus considered infertile.The cause of infertility may be due to problems in the man, the woman, or both:
*Problems with sperm (in 35% or more of couples)
*Problems with ovulation (in 20%)
*Problems with the fallopian tubes in the pelvis (in 30%)
*Problems with mucus in the cervix (in 5% or fewer)
*Unidentified factors (in 10%)

Thus, the diagnosis of infertility problems requires a thorough assessment of both partners. Usually, the assessment is done after at least 1 year of trying to achieve a pregnancy. However, it is done sooner if:
*The woman is over 35
*The woman's menstrual periods occur infrequently
*The woman has an abnormality of the uterus, fallopian tubes, or ovaries
*Doctors have identified or suspect problems with sperm in the man.

Age is a factor, especially for women. As women age, becoming pregnant becomes more difficult, and the risk of complications during pregnancy increases. Also, women, particularly after age 35, have a limited time to resolve infertility problems before menopause.
Of the couples who have not conceived after a year of trying, more than 60% conceive eventually, with or without treatment. The goals of treatment are to treat the cause of infertility if possible, to make conception more likely, and to reduce the time needed to conceive.

Even when no cause of infertility can be identified, the couple may still be treated. In such cases, the woman may be given drugs that stimulate several eggs to mature and be released—so-called fertility drugs. Examples are clomiphene and human gonadotropins. A woman's chances of becoming pregnant are about 10 to 15% with each month of such treatment. Alternatively, an artificial insemination technique that selects only the most active sperm may be tried."

Medications Used in Treatment:
1. Gonadotropins: Menopur®/menotropins, Follistim®AQ/follitropin beta, Gonal®F Gonal®F-RFF/ follitropin alfa, Novarel® Pregnyl®/human chorionic gonadoptropin, Ganirelix®, Bravelee®/urofollitropin, Cetrotide®/cetrorelix
2. Progesterones: Endometrin®/progesterone in sesame oil, progesterone in oil, Prochieve® Crinone®/progesterone
3. Gonadotropin Releasing Hormone Antagonists: Ovidrel®/human chorionic gonadotropin
4. Estrogen Agonist/Antagonists: Clomid® Serophene®/clomiphene

*[Editor] The most common cause of infertility in the woman is endometriosis. The diagnosis becomes the primary focus when 1) she has proven to ovulate (progesterone serum level greater than 15 on day 23 (with or without treatment with clomiphene), 2) when her fallopian tubes are open (hysterosalphingogram) and 3) his sperm count is adequate. The presence of pain or heavy menstrual flow increases the probability of endometriosis. If the fertility expert resorts to laparoscopy and confirm endometriosis or the couple is at 'wit's end' the novel treatment for endometriosis with anabolic steroids as described by the Editor and published through the American College of OB-Gyn should be considered.

*[Editor] As a gynecologist, three simple tests can be done and most causes of infertility can be diagnosed quickly: *laboratory blood test on day 23 of a 28 day cycle for progesterone, FSH, LH and estradiol. If the progesterone level is 15ng/ml, she is ovulating. If her FSH and LH are greater than 20miu/ml and her estradiol is less than 50ng/dl, then the same tests are repeated two (2) weeks later. If the results match, she is experiencing premature ovarian failure: she is nearing menopause.
*X-ray of the uterus and fallopian tubes is called a hysterosalpingogram. If the uterus is normal and the tubes are open, this will be noted. Many women have gotten pregnant after the test as if the dye "flushed out and straightened the tubes."
*Sperm count from the male after 3 days without ejaculation. Sperm counts need to be greater than 20 million per cubic centimeter with a low percentage of abnormal sperm.

If the woman does not show signs of ovulation, then, clomid 50mg is given on day 5 through 9 of her cycle (day 1 is the first day of menstrual flow). The progesterone levels are repeated on the 23rd day for two (2) cycles. If progesterone levels are still inadequate, two (2) clomiphene are taken on day 5 through 9 and the laboratory analysis repeated on day 23 for two (2) more cycles. Then, referral can be made to an infertility expert.

If the woman can ovulate on clomiphene, a small amount of estradiol vaginal cream is inserted high in the vagina on days 5 to 11 to prepare the cervical mucus.

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