While opting for fertility treatment, you will need to keep in mind that treatments and procedures could vary from couple to couple. Some treatments are less invasive and expensive than others, although you may find yourself moving from one to another. Here is an overview of some of the treatments you may be offered.

Ovulation Stimulation

The first step for many couples is a course of drugs to help stimulate and regularize ovulation as at least 20 per cent of all women attending infertility clinics have an ovulation problem. Clomiphene citrate is a synthetic drug taken in tablet form, usually once a day between Days 2 and 6 of the woman’s cycle, with the aim of stimulating her ovaries into ovulation.

For many women, a course of clomiphene ‘kick-starts’ the ovaries into regular ovulation and intercourse at the most fertile time of the cycle is more likely to result in a pregnancy. However, the treatment does not work for all women and there are some side effects.

Other types of medication like an injection of HCG (Human Chorionic Gonadotropin) can control the time of ovulation. Ovulation will then occur approximately 36 hours later and proper timing of intercourse would result in pregnancy.

Artificial Insemination

A relatively straightforward method of assisted conception, the two most common types of Artificial Insemination (AI) are:

Intracervical Insemination (ICI)
A semen sample is injected into the top of the vagina whilst the woman is lying down with her knees up. A plastic cap (similar to those used for contraceptive purposes) is sometimes placed in the vagina to keep the sperm near the cervix. It can then be removed 6-8 hours later.

Intrauterine Insemination (IUI)
A fine plastic tube is inserted into the woman’s uterus through which the male partner or donor’s sperm is introduced. The sperm is introduced directly into the woman’s uterus to help it get closer to the site of fertilization, usually combined with ovulation stimulation in advance.

For intrauterine insemination, the sperm has to be ‘washed’ before being placed in the uterus. Semen is made up of two parts: plasma and the sperm cells themselves. The sperm cells are washed to separate them from the plasma. This has to be done because neat semen can cause severe uterine pain, cramps and sometimes fainting. The sperm are then incubated before being carefully placed in the uterus.

Insemination is timed to take place during the most fertile part of the woman’s cycle, sometimes on two or three days in a row. This means that egg release can then be timed carefully (by giving another hormone) to coincide with the sperm being reintroduced into the uterus and seems to produce better results with up to 30 per cent success rates in some clinics.

After both procedures the woman will need to rest for a short time afterwards, and can then go home.
Because successful AI/ IUI depends on the ability of sperm to fertilize an egg, the man will need to produce enough normal sperm in reasonable numbers. If this is not the case, using donor sperm can be an option.

In Vitro Fertilization (IVF)

In vitro fertilization (IVF) can be of benefit to many couples. In IVF, eggs are gathered from the woman’s ovaries and mixed with the man’s sperm outside the body, usually in a glass dish in a laboratory. ‘In vitro’ is a Latin word that literally means ‘in glass’, a reference to the glass container where fertilization takes place (hence the term “test-tube baby”). The fertilized eggs are then cultivated to embryo stage and transferred to the woman’s uterus.

IVF is especially beneficial to infertile couples if:

• The woman has damaged or blocked fallopian tubes
• The man has a low sperm count or his sperm don’t move forward well and so may never reach the egg without assistance
• Infertility is caused by immunological factors
• Infertility is ‘unexplained’

While the procedure described above sounds simple, in reality IVF is a complex and emotionally demanding process.

The first stage involves stimulating the woman’s ovaries so that several eggs mature. The response of the ovaries will be carefully monitored using ultrasound scanning to show the size and number of developing follicles.

When the ultrasound scan shows a sufficient number of large follicles, the woman is given an injection to give the eggs their last ‘push’ towards maturity. Ovulation normally occurs 37-40 hours after this injection.

The eggs are usually collected using a fine, hollow needle guided by ultrasound. Around the same time, the man needs to produce his semen sample. The semen is assessed and if it’s of sufficient quality, it is ‘washed’ to separate the best quality sperm in preparation for fertilization.

As soon as they’re extracted, the eggs are put into a nutrient medium with the sperm and then cultured in an incubator. The next day, they’ll be observed through a microscope to see if fertilization has occurred. If it has, cell division will have started 24 hours later and the embryo might now have two or four cells.

The embryos will be checked by an embryologist and placed into the woman’s uterus through her cervix. Afterwards, the woman will be advised to rest for a short time and then go home and ‘carry on as normal’.

It will be about two weeks before a pregnancy test can be done, and during this time, the woman will be prescribed progesterone, to provide hormonal support to any potential pregnancy.

Advanced Fertility Procedures

Intracytoplasmic Sperm Injection (ICSI)/ Sub-zonal Insemination (SUZI)
These are advanced procedures of In Vitro Fertilization. Intracytoplasmic Sperm Injection (ICSI) allows a single sperm to be injected directly into the centre of the egg. An alternative is sub-zonal Insemination (SUZI), where a single sperm is placed just beneath the zona pellucida (the protein shell which surrounds the egg). ICSI and SUZI can be of great benefit to couples where the man has:

• A low sperm count
• Low numbers of motile sperm
• Poor forward progression of sperm
• A high proportion of sperm with abnormalities
• A sperm blockage, as sperm can be obtained directly from the testicles with a fine needle under anaesthesia

Surgical Sperm Retrieval (TESA, PESA & MESA)

The following sperm retrieval processes are especially useful for men with congenital difficulties resulting in Azoospermia (lack of or no sperm).

Testicular Sperm Aspiration (TESA)
A needle biopsy of the testicle is used to obtain small amounts of sperm.

Percutaneous Epididymal Sperm Aspiration (PESA)
PESA is indicated for men with irreparable obstruction resulting in Azoospermia (lack of or no sperm), congenital absence of the deferens or who have had vasectomies or failed vasectomy reversals. A small needle is passed directly into the head of the epididymis and fluid is aspirated. Next, the IVF laboratory team retrieves the cells from the fluid and prepares them for ICSI.

Micro-Epididymal Sperm Aspiration (MESA)
An operation to retrieve sperm from the epididymis in men who have a blocked vas deferens, carried out under general anaesthetic.