Fertility Treatment Basics
Basic Infertility Work-up
- Rubella, varicella, Rh, RPR, HIV, Hep B, day 3 FSH, TSH, PRL (fasting), and offer genetic testing
- Documented negative gonorrhea and Chlamydia and Pap for the woman trying to conceive
- Semen analysis
- Salpingography (and ideally antral follicle count) and/or a hysterosalpingogram with adequate traction on the cervix and two different planes of view for uterine cavitary assessment
Basic PCOS Work-up
- 2-hour GTT with insulin levels and fasting lipid panel for assessing metabolic syndrome
- Fasting follicular phase 17-hydroxyprogesterone (exclude congenital adrenal hyperplasia)
- Total testosterone to exclude ovarian tumors and DHEA-S to exclude adrenal tumors (both are useful even in nonhirsute patients for assessing hyperandrogenism)
When to Perform Intrauterine Insemination and Ovulation Induction
- Inseminations/ovulation induction in isolation are increasingly believed to be ineffective for unexplained infertility (see Bhattacharya, BMJ, 2008 for a recent randomized controlled trial)
- When total motile sperm count is 5-10 million or less, IVF with intracytoplasmic sperm injection is more cost effective than ovulation induction
- Some evidence still suggests that multi-follicular recruitment through ovulation induction may have some benefit for ovulatory women
- Be careful with multi-follicular recruitment as this can lead to multiple gestation
- Patients trying letrozole or clomiphene in isolation that do not conceive over an extended period of time are reading online about the low efficacy of this approach and can become frustrated with their physician due to the delay and cost (though inexpensive). This trend is especially relevant to patients over 35 years old, where ovarian reserve might be an issue.
Performing Ovulation Induction
- Letrozole 5 mg PO QD cycle days 3-7 or clomiphene citrate 50-100 mg PO QD cycle days 5-9
- Multiple cycles of clomiphene can thin the endometrial lining, decreasing pregnancy rates
- Be wary of the patient requiring more than 100 mg of clomiphene both because of lower success rates and potentially high follicular recruitment when they do finally ovulate
- Ultrasound cycle day 12-14 or ovulation predictor kits
- We prefer ultrasound to ensure that 3+ follicles are not being recruited and will cancel cycles as needed so as to decrease the risk of triplets, quadruplets, etc.
- A > 12 mm lead follicle grows at a rate of ~ 2 mm/day
- Intrauterine insemination (IUI) or intercourse
- For IUI, administer hCG (Ovidrel 250 micrograms SC) on the day the lead follicle is ~ 18-20 mm and perform 24 to 36 hours later. If using ovulation predictor kits, perform the IUI the day after the kit turns positive
- With ultrasounds, patients planning intercourse instead of IUI should do so the day of Ovidrel injection and the following two days. If using ovulation predictor kits for timing intercourse, patients should have intercourse the day of the positive result and the day after.
- We typically perform a maximum of three to six cycles of oral and/or injectable medications with IUIs prior to moving on to IVF, unless there are indications for being more assertive, such as diminished ovarian reserve, severe male factor infertility, severe tubal disease, or patients are older than 35 years with unexplained infertility.