Referral - Infertility Specialist
If an obvious cause of infertility exists early referral is appropriate eg vasectomy or anovulation. Otherwise referral is usually delayed until patients have tried to conceive for twelve months. In older couples more prompt referral is appropriate with most specialists advising review after 6 months if the female partner is >35 years of age.
If the female partner is ovulatory and her partner has normal sperm production, the next step is usually tubal patency testing which can be done via laparoscopy or hysterosalpingography (HSG).



Laparoscopy involves a day admission to hospital, a general anaesthetic and the insertion of a camera/scope inside the abdomen through the umbilicus to inspect the pelvis. It is usually combined with a hysteroscopy to inspect the uterine cavity. Dye is flushed through the tubes to confirm patency. It has the benefits of being able to diagnose and treat endometriosis and minor pelvic adhesions, remove polyps, etc. However as it is a surgical procedure it does pose some small risks. Its benefits are greatest in younger women and in women who have obvious pelvic pathology that requires assessment/treatment picked up on ultrasound.



A HSG involves a small plastic catheter being placed in to the cervix, a balloon is inflated and dye injected up into the uterus until it spills out the end of the tubes as visualised by X-ray using an image intensifier. It is a simple, safe outpatient procedure but can not treat pelvic pathology nor diagnose endometriosis.

Both laparoscopy and hysterosalpingography have some therapeutic benefits with increased fecundity rates in the months following presumably as flushing the tubes removes minor impediments such as mucous.



Infertility Treatments
Common treatment options include: ovulation induction eg Clomid or FSH, tubal or scrotal microsurgery, artificial insemination with husband's sperm (AIH) and donor insemination (DI). Many patients will require IVF in order to conceive.



Clomid
Clomiphene citrate is a selective estrogen receptor modulator used to induce ovulation by increasing negative feedback to the anterior pituitary. It is usually given for 5 days just after menses. A midluteal progesterone level is done in the first cycle to confirm it has induced ovulation. Sometimes several dose increases will be required before ovulation is seen. Side-effects can include hot flushes, headaches, breast tenderness, ovulation pain and visual disturbances. Multiple eggs may be ovulated and the risk of multiple pregnancy is around 5-10% of all pregnancies.
Clomid will not always be effective with around 20-40% of women not responding. Of the women who do respond a significant percentage will still not achieve pregnancy. Live birth rates after 6 months of Clomid use are 20-40% depending on age and BMI. Clomid can generally not be prescribed by general practitioners under NSW regulations. It has not been shown to be helpful for women who are ovulating and have unexplained infertility.



Metformin
May help to induce ovulation in women who are Clomid resistant. It has little benefits on its own with several studies now showing very low cumulative birth rates in women treated with metformin alone.



Intrauterine insemination (IUI)
This involves monitoring the female menstrual cycle to determine when ovulation is occurring. A sample of sperm is then prepared and the sperm inseminated into the uterus at ovulation. Ovulation induction drugs may be used in combination with IUI. Sperm may be provided by the male partner or by a donor.
IUI is not nearly as effective as IVF and under the Medicare system the relative costs don’t make it particularly worthwhile for many couples. However for couples with sexual issues or who have ethical objections to IVF it may be worthwhile. Single women and same sex couples also frequently use this technique with their sperm donors.



IVF
This involves stimulating the ovaries with FSH injections to induce the growth of a cohort of follicles/eggs. The eggs are then retrieved via an ultrasound guided trans-vaginal needle aspiration. In the laboratory the eggs are combined with sperm in a dish to create embryos which are then grown in the lab for several days. One to two embryos are then transferred back inside the uterine cavity via a trans-cervical catheter. Excess embryos can be frozen and stored for subsequent attempts/children.
IVF success rates have improved remarkably over the last 20 years with younger couples capable of success using this technique. Female age is the biggest predictor of success. Most causes of infertility benefit from IVF.



ICSI
Or intra-cytoplasmic sperm injection is a technique where the eggs retrieved during an IVF cycle are fertilised by direct injection of a single sperm into the oocyte’s cytoplasm by a scientist. It is used with significant sperm problems and in cases of fertilisation issues. Sperm can be used from men who in the past could not have fathered a child. Sperm may be obtained from direct retrieval from the epidydimis or testicle.



Donor Sperm
Has become much less commonly used by couples as sperm retrieval techniques have improved. Donors are also much less readily available than in the past as they can not be paid and are no longer anonymous.



Donor Egg
This involves a suitable female donor going through a cycle of IVF and her eggs then being fertilised by the recipient husband’s sperm. The embryos created are then transferred into the uterus of the recipient female. Under NSW law the birth mother is the legal mother. This technique is used for women who have gone through early menopause or who is unable to achieve a pregnancy using her own eggs.



Surrogacy
Is not covered by a legislative framework in NSW but never the less still occurs. The surrogate goes through pregnancy for the recipient couple. The child is then adopted by the recipients. Women who have no uterus (E.g. cancer treatment, obstetric complications, congenital abnormalities) may consider this option.



Pre-implantation Genetic Diagnosis
A relatively new technique where embryos are biopsied and specific genetic or chromosomal anomalies tested for. Unaffected embryos can then be transferred avoiding the risk of certain genetic conditions E.g. Cystic fibrosis, Down syndrome
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Psychological Aspects of Infertility
Infertility places stress upon couples. An infertile couple suffers a feeling of loss with each period - i.e. loss of the imagined child. Most are able to cope with this but doctors involved with their care should be aware that some need help. As well as the stress of not conceiving, other stress includes:

• Pressure upon a couple's sexual relationship.

• Pressure (personal or from their doctor or partner or family) to participate in treatment, e.g. IVF

• Pressure to consider donor gametes.

• Pressure to consider adoption.

•  Grief when coming to terms with life without children

Original text Dr Jock Shumack
Revised MWB June 1998
Revised Myvanwi Mcilveen 2012