Treatment of female causes

According to cause many different approaches of treatment are available. But last resort of treatment of infertility is in vitro-fertilization (IVF) and embryo transfer when all other measures are failed. For some couples it is the first line of treatment as other approaches are not feasible like azoospermia that is absence of sperm in male partner. Female partner should be treated according the specific causes. If there is any endocrine problem like hypothyroidism, hyperthyroidism, hyperprolactinaemia, diabetes it is treated accordingly. Any other medical diseases like tuberculosi, hepatic or renal diseases is treated accordingly. All infectious diseases treated by specific antibiotics.

Treatment options for female partner:

  • Ovulation induction
  • Laparoscopic adhesiolysis (in PID and endometriosis) and Laparoscopic “drilling” (in PCOS) of the ovarian capsule.
  • Tubal reconstructive surgery in some cases.
  • Myomectomy in fibroid uterus.
  • Adenomyomectomy in adenomyosis.
  • Cystectomy in ovarian cyst both chocolate and simple cyst.
  • Hysteroscopic adhesiolysis (in uterine synachea) and septum resection.
  • Intrauterine insemination
  • In-vitro fertilization and embryo transfer

1. Ovulation induction:

This is relatively simple procedure that may offered when the woman has at least one fallopian tube healthy and patent and male partner has normal semen parameter. Different drugs are used to produce eggs depending upon the patient’s status. Polycycstic ovarian syndrome(PCOS) is the main cause of anovulation and other causes are hypothyroidism, hyperthyroidism, hyperprolactinaemia, diabetes mellitus. Anovulation due to hypothalamic or pituitary causes is called type 1 anovulation and PCOS is called type 11 anovulation.

Treatment of type 1 anovulaion:

Gonadotropin

HMG, and FSH

Dose varies according to age and ovarian reserve of the patients. Patients are monitored regularly by transvaginal sonography to see the response of drugs and to avoid hyperstimulation syndrome. Chances of development of multiple follicles are more and as such multiple pregnancy.

GnRHa

It is given when there is any problem in hypothalamus. Application of GnRHa in pulsatile fashion causes release of pituitary gonadotropins, which stimulats ovaries to produce eggs. Less chance of development of hyperstimulation syndrome so extensive monitoring is not needed.

Treatment of type 11 anovulation:

Clomiphene citrate (CC):

Clomiphene citrate is an antioestrogen, which blocks the oestrogen receptors and reduce the oestrogenic activity in the body. As a result pituitary secretes FSH to stimulate ovaries to produce eggs and oestrogen.

It is the first line drug for ovulation induction. Usually given at a dose of 50 -150 mg  per day  from D3 to D7 of the regular or progesterone withdrawal cycle. It can be started at any day from D2 to D5 of the cycle. Cycles are monitored by transvaginal ultrasosnogram for assessing development of follicles which contain eggs. Monitoring usually started from D12 of menstrual cycle. Dose of the drug is adjusted according to response of the drug. Satisfactory response is development of follicle size of at least up-to18 mm and development of trilaminar endometrium. After getting satisfactory response couple are advised to have sexual intercourse at this phase and to continue this treatment at least for six cycles. Multiple follicles may develop causing multiple pregnancy. Chances of development of hyperstimualtion syndrome is less.

Some patients do not develop any eggs in spite of high dose of CC ( 150 mg per day) and they are called CC resistant. In other cases in spite of developing mature eggs some patients do not get pregnant and they are called CC failure. Ovulation rate is 75% to 80% and pregnancy rate is 40% to 50%. This disparity is due to some negative effects of CC on endometrium.

Tamoxephene:

Another antioestrogen can be used for ovulation induction in the same manner from D2 to D6 of the cycle. Usual dose is 20 mg to 40 mg per day. Cycles are monitored to see the response.

Aromatase inhibitors:

Aromatase inhibitor (Letrozole) is also an antioestrogen, which blocks the synthesis of oestrogen by inhibiting the enzyme aromatase. It is also given at any day from D2 to D5 of the cycle for 5 days. Usual dose is 2.5 mg to 7.5 mg per day. Cycles are monitored to see the response. Chances of development of multiple follicles are less. Usually single follicle is developed.

Gonadotropins:

rFSH is used if previous drugs fail to produce eggs. Step up or step down protocol is used to produce less number of follicles ( One to three). Usual dose is 50 IU to 75 IU per day or every other day. Cycles are monitored extensively to avoid hyperstimulation syndrome. PCOS are more prone to develop ovarian hyperstimulation syndrome. More

Metformin:

In CC resistant patients it is used to sensitise the ovaries to ovulation inducing drugs. Usual dose is 1500 mg per day. Starting dose is 500 mg daily after meal and is to be increased 500 mg weekly to adjust the drug. More

2. Laparoscopic adhesiolysis ( in PID and endometriosis) and Laparoscopic
“drilling” (in PCOS) of the ovarian capsule.

In pelvic inflammatory diseases (PID) and in endometriosis there may be adhesion in the pelvic organs causing anatomical derangement, which interferes the ovarian and tubal activity and causes infertility. By laparoscopy adhesions removed called adhesioslyis and restores the normal anatomy of pelvis as much as possible, which helps the ovaries and tubes to function properly. In PCOS when ovulation inducing drugs fail to produce eggs laparoscopic ovarian drilling causes spontaneous ovulation or increases ovarian response to drugs.

3. Tubal reconstructive surgery in some cases.

Tubal reconstructive surgery can be done where damage is not so severe. After tuboplasty  at least 4 cm functioning tube should be retained. Success rate is 20%.

4. Myomectomy in fibroid uterus.

If myoma is the cause of infertility or abortion then myomectomy is to be done. Site, size and number of myomas are the indicator for myomectomy. Success is also depends on size, site and number of myomas.

5. Adenomyomectomy in adenomyosis.

Adenomyoma like myoma can cause infertility and abortion. If it is big and is the causative factor for infertility adenomyomectomy is to be done. Procedure is a bit difficult than myomectomy and result is also not as good as myomectomy.

 

6. Cystectomy in ovarian cyst both chocolate and simple cyst.

Ovarian cyst either chocolate or simple or neoplastic is to be removed. Cystectomy can be done either by laparoscopy or laparotomy.

 

7. Hysteroscopic adhesiolysis (in uterine synachea) and septum resection

Sometimes two walls of the uterus become adherent due to some previous infections or currattage. It causes infertility. Uterine septum (developmental) may also causes infertility. Both can be corrected by hysteroscopy

8. Intrauterine insemination.

9. In-vitro fertilization and embryo transfer