Infertility and assisted conception

Ovulation induction using gonadotrophins

Gonadotrophin (FSH, LH, and human chorionic gonadotrophin) is used for women who have a problem with ovulation that either has not responded to clomifene, or that is not suitable for clomifene treatment. It may also be used for couples in whom the infertility has no obvious cause (unexplained infertility).

FSH or a combination of LH and FSH are given by daily injections. The response is monitored by ultrasound scans and blood tests. When the follicles have developed appropriately, another injection called human chorionic gonadotrophin is given. This causes ovulation to happen. The couple are then advised to have intercourse or intrauterine insemination (IUI) of the partner's sperm is performed at a pre-determined time after the HCG injection.

The success rate of this treatment depends in part on the cause of the problem, but is generally approximately 20 per cent per cycle. Anxieties associated with this treatment are overstimulation of the ovaries, which occurs in about 0.5 per cent of cycles. Also the rate of multiple pregnancy is increased compared to spontaneous conception. The chance of twins is approximately 20 to 25 per cent.

In vitro fertilization (IVF)

This is the test tube method, more correctly known as in vitro (in glass) fertilization (IVF). Fertilization takes place outside the woman's body. Most clinics suppress the action of the woman's own LH and FSH by using an injection or a nasal spray (down-regulation). The ovaries are then stimulated with daily injections in the same way as ovulation induction with gonadotrophins (see above).

Monitoring is again by ultrasound and blood tests. Once there are sufficient follicles of the correct size, an injection of HCG is given. The eggs are removed from the ovary 36 to 40 hours later. This is done using a fine needle placed into the vagina and is performed under sedation. The eggs are fertilized with sperm in a laboratory.

After a few days, when fertilization is confirmed, the fertilized egg (embryo) is returned to the womb. The chance of a positive pregnancy test after a fresh cycle of IVF varies, but is approximately 20 to 30 per cent. To maximize the chances of a pregnancy, two embryos are usually returned at the same time, which is why there is an increased chance of twin pregnancies.

If sufficient embryos of good quality develop there may be an option to freeze them and replace them, after thawing, in a subsequent cycle. The success of a frozen embryo transfer is slightly less than that of a fresh cycle.

The availability of IVF on the National Health Service varies considerably from one part of the country to the other. Couples often have to be prepared to pay to have their treatment at a private hospital.

Intra-cytoplasmic sperm injection (ICSI)

This is a technique used for male infertility, or for those patients where poor or no fertilization has been achieved after a cycle of IVF. The procedure is very similar to IVF. However, with ICSI a single sperm is injected into a single egg in the laboratory. The success rates are similar to those with IVF.

Normally sperm is obtained by masturbation. Under certain circumstances sperm may be obtained directly from the testis by a minor operation.

Other treatments