Treatment

Medical Treatments

The study of Infertility allows us to diagnose some pathologies that can be corrected with medical treatment, namely hormonal and infectious problems.

Ovulation induction

In situations in which ovulation disorders are detected, medical treatment may be used to regularize or induce it.

About 50% of women can become pregnant in less than six cycles of treatment.

There are several medications that induce ovulation but their use should be pondered, starting always with the simplest treatments.

Cyclic monitoring ultrasound is often required to evaluate the response to the treatment and to avoid complications such as a multiple pregnancy or ovarian hyperstimulation.

Clomiphene Citrate, Tamoxifen, Aromatase Inhibitors

These are medications that are administered orally, in the initial phase of the cycle. They act in such a way that circulating oestrogens are not recognized. The ovaries will then respond to this “lack” of oestrogen by inducing follicle growth and ovulation. The oldest and most used of these drugs is clomiphene citrate.

Gonadotrophins

They are injectable drugs, administered subcutaneously. Gonadotrophins (FSH and LH) act directly on the ovary. Its use requires monitoring ultrasound of the treatment cycle to evaluate follicular growth. It may be necessary to stop one cycle if there is insufficient response or, at the other extreme, excessive response, with risk of multiple pregnancies.

Mixed Protocol

Protocols are sometimes used to associate clomiphene citrate or aromatase inhibitors with gonadotropins, allowing the dosage to be lower. It is still mandatory to perform monitoring ultrasounds of the treatment cycle.

Treatment of other hormonal disorders

The elevation of the prolactin hormone may alter the quality of ovulation and should therefore be studied and treated.

Hyperandrogenism (excess of male hormones) may indicate for corticosteroid therapy.

Similarly, changes in thyroid gland function (both hypo and hyperthyroidism) may impair ovarian function and should be studied and corrected.

Others

Correcting subclinical infections or improving cervical mucus with appropriate medical treatments (antibiotics, oestrogens, mucolytics) can often solve the problem of the couple.

Surgical Treatments

Laparoscopic Surgery

The first step in laparoscopic surgery is the introduction of gas into the abdomen, allowing spacing and better visualization of the pelvic organs. It is then possible, through a small incision, to introduce a light system that is connected to a monitor, where the entire surgery will be visualized.

Through other small incisions the surgical instruments are introduced. It is then possible to perform excision of fibroids, ovarian cysts, or damaged tubes, as well as to release adhesions or fulguration of foci of endometriosis.

In situations of polycystic ovary with avovulation resistant to medical therapy, the “drilling” of the ovaries can be performed, which allows, in many cases, ovulatory cycles in the following months.

The recovery in the postoperative period is very fast, usually allowing the patient to be discharged the day after the surgery.

iii) Hysteroscopic surgery

The hysteroscope is an apparatus with a light system that is introduced vaginally into the uterus, allowing direct visualization of the uterine cavity. It is possible, therefore, to perform excision of fibroids, polyps, septa or cure of synechiae.

The patient may be discharged on the same day.

1. iv) Conventional or laparotomy surgery

Surgery that uses the wide opening of the abdominal wall is reserved for more complex cases, where it is expected that the laparoscopic route cannot resolve the situation.

Medically Assisted Procreation (MAP)

Intrauterine insemination

Intrauterine Insemination (IUI) is the simplest of the Medically Assisted Procreation techniques and consists of placing the sperm inside the uterus through a small catheter.

In the IUI cycle, a controlled induction of ovulation is performed through oral or injectable medication. The sperm is prepared in the laboratory, allowing to select the best spermatozoa that are placed inside the uterus at the time of ovulation.

It is indicated for mild male infertility cases, incompatibility between the muco-cervical and the sperm, and in situations with no apparent cause.

It is also the first-line technique when it is necessary to access to donor sperm in women with permeable tubes.

In Vitro Fertilization

In Vitro Fertilization (IVF) is a MAP technique, which consists of the union of the female and male gametes in the laboratory. The ova are placed together with the spermatozoa in a suitable culture media, and fertilization occurs spontaneously.

This technique was initially used in women with obstructed tubes (tubal factor) but is currently applied in many other cases (mild male factor, endometriosis, cervical factor and infertility without apparent cause).

ICSI

The purpose of ICSI (Microinjection of the spermatozoon in the ovum) is to facilitate fertilization by reducing or eliminating the obstacles that the sperm find in their attempt to penetrate the egg and succeed in fertilizing it.

It consists of the direct microinjection of a spermatozoa inside the oocyte. It is performed in the laboratory by the embryologist, who uses micro-manipulators to drill the cell membrane of the oocyte and to introduce the selected sperm into the interior.

This technique is reserved for cases in which IVF fertilization is predicted to fail and has contributed to the resolution of many cases of severe male infertility.

Embryo Transfer

Embryo Transfer is, in most cases, a simple method, performed vaginally and without anaesthesia.

The embryologist places the embryos in the transfer catheter, along with a small amount of culture medium. The gynaecologist inserts the catheter through the cervix and deposits the embryos into the uterine cavity.

The number of embryos to be transferred may vary from case to case. Usually one or two embryos are transferred.

o Cryopreservation

 Oocytes

Women can preserve their fertility through a freezing technique that ensures good oocyte survival rates for future use – vitrification.

.

For this, they must undergo ovarian stimulation and follicular puncture.

This may be a fertility-preserving option in cancer patients undergoing chemotherapy treatments, which can deplete their follicular reserve.

Vitrification of oocytes may also be used in women who, undergoing IVF or ICSI treatments, achieve a high number of good-quality oocytes but do not intend to cryopreserve embryos.

There are more and more women who want to postpone maternity for personal or professional reasons and who preserve their fertility by freezing their oocytes.

Ideally, this technique should be performed before the age of 35 years.

 Embryos

In the course of the IVF or ICSI cycle, it may happen that a larger number of embryos are obtained than those required to transfer.

In these situations, surplus embryos are cryopreserved and, if possible, transferred later, without the need to resort to new ovarian stimulation.

In certain clinical situations it may be necessary to freeze all embryos and postpone transfer to a later, non-stimulated cycle.

According to the law in force, cryopreserved embryos must be used by the couple in a new transfer, within a maximum of three years. After this period, the embryos can be donated to another couple, used in scientific research or eliminated.

If it is the option of the couple, it is possible to cryopreserve fertilized oocytes before cell division occurs (pre-embryos).

 Sperm

Sperm may be frozen prior to the treatment cycle in cases where harvesting difficulties are anticipated on the day of follicular puncture or in some cases of oligoastenozoospermia.

Patients with oncological conditions who undergo pelvic chemotherapy or radiotherapy should freeze sperm previously in order to preser fertility, which may be affected by the treatments.

Defrosting can affect sperm quality. This change will be more pronounced the worse its characteristics at the moment of freezing.

 Testicular tissue

In cases of azoospermia in which testicular biopsy was performed with collection of spermatozoa, these can be frozen for use in subsequent treatment.