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Medical Diseases and Conditions
Female Infertility
What is infertility?
Infertility is the inability to conceive after a year of unprotected intercourse. Infertility affects 15 percent of the population, or about one of every six or seven couples.
What causes infertility?
Infertility can be caused by many different factors, including:
  • Blocked or scarred fallopian tubes 
  • Ovulatory problems 
  • Endometriosis (growth of endometrial tissue outside of the uterus) 
  • Male factor infertility (abnormal semen analysis; low sperm count or motility) 
  • Unexplained infertility (in 10 to 15% of infertile couples, the cause of infertility cannot be detected.) 
How is the cause of infertility determined?
A brief infertility evaluation is performed to identify any treatable causes. Your physician may order a semen analysis, hysterosalpingography (an X-ray dye test to check the uterus and fallopian tubes), and hormone levels to evaluate ovulation. Your physician may also recommend laparoscopy (using an endoscope, a slender fiberoptic scope attached to a video camera, to view the pelvic organs).
What are the treatments for infertility?
Treatment options include medical therapy, reproductive surgery, intrauterine insemination, and assisted reproductive technologies.

Medical therapy
Medical therapy is a treatment option for correcting ovulation dysfunction (irregular or infrequent periods). If there are no underlying causes of ovulation problems (such as a thyroid disease), the first line of treatment is an oral medication such as Clomid, Femara, or Glucophage. They induce normal ovulatory function in more than 80 percent of patients. Unfortunately, only about half of these women conceive. Patients may experience mild side effects and there is a slightly increased incidence of twins. If oral medication fails to correct the problem, or conception does not occur within six good ovulatory cycles, the couple should consider other treatment options.
Gonadotropin therapy (Follistim, Gonal-F, Bravelle, and Menopure) is the next line of medical therapy. It is very effective in inducing ovulation when oral agents do not work. It can also enhance fertility by causing multiple eggs to ovulate during the cycle. (Normally, only one egg is released each month.) This therapy may also be offered for unexplained infertility or when other factors have been corrected but pregnancy has not occurred. It is given as a daily injection, like an insulin shot, for approximately 1 week. During this time, the patient is monitored with blood tests and ultrasound to optimize timing and reduce the risk of multiple pregnancy and to prevent overstimulating the ovaries.

Reproductive surgery
The vast majority of reproductive surgery can be performed endoscopically on an outpatient basis. Using a laparoscope (a type of endoscope) inserted through the naval, the surgeon can remove scar tissue, treat endometriosis, remove cysts on the ovaries, and unblock the fallopian tubes. A hysteroscope placed into the uterus through the cervix can be used to remove polyps and fibroid tumors, divide scar tissue, and open blocked tubes.
The advantages of these endoscopic procedures include reduced cost, quicker recovery, fewer complications, less pain, better cosmetic results, and success rates as good as if not better than those performed by laparotomy (open surgery). Laparotomy may still be required for reversing tubal ligations and removing large fibroid tumors, but even those procedures can usually be performed through a very small incision as an outpatient.

Intrauterine insemination
Intrauterine insemination refers to an office procedure in which semen undergoes a "washing" process and the sperm are then placed into the uterus using a slender plastic catheter inserted through the cervix.
Intrauterine insemination is performed in couples with mildly abnormal semen analyses. Intrauterine insemination is also used for couples being treated with fertility drugs because pregnancy rates are higher with combined treatment. In cases when the male partner has no sperm at all, or the numbers are severely low, the procedure can also be performed using anonymous donor sperm.
Assisted reproductive technology
In vitro fertilization (IVF)
In vitro fertilization refers to a procedure in which oocytes (eggs) are fertilized in a culture dish and placed into the uterus. First, the woman takes gonadotropins to stimulate multiple eggs to mature. When monitoring shows that the eggs are mature, they are collected nonsurgically using a vaginal ultrasound probe with a needle guide. This is performed in an office setting under deep sedation. The number of embryos transferred is based primarily on a woman's age, but is also influenced by the embryo quality and number of prior IVF attempts.

The sperm are collected, washed, and added to the eggs in a culture dish. For couples with abnormal semen analysis, as well as couples whose eggs did not fertilize well during a previous IVF cycle, intracytoplasmic sperm injection (ICSI) may be an option. This procedure involves injecting a single sperm directly into each mature egg using a micro-needle. Several days later, the embryos (fertilized eggs) are returned to the uterus using a catheter similar to intrauterine insemination . Any extra embryos may be cryopreserved (frozen) for later use.

In vitro fertilization is the only option for couples with uncorrectable tubal disease, or severe male factor infertility, but is also recommended when all other treatment options have failed. Success rates among couples vary depending on the age of the patient, the duration of infertility, and the severity of the infertility factor(s). Overall, more than 40% of patients conceive per attempt. (The normal monthly pregnancy rate in the general fertile population is only about 20%.) In vitro fertilization increases a woman's risk of having a multiple pregnancy, but does not change the risk for miscarriage and birth defects. Adhering to established guidelines which limit the number of embryos transferred helps to reduce the multiple pregnancy rate.

Freezing the extra embryos increases the cumulative pregnancy rates, since the patient may have multiple attempts to conceive with fresh and frozen embryos from a single egg collection procedure. The costs, risk and inconvenience are also reduced by avoiding the need for fertility drugs and another egg recovery procedure.
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