Infertility Treatments and Ethics

Medicine always has an impact beyond the walls of the clinic, and this is doubly true of fertility medicine. Aspects of some fertility treatments remain controversial, and will probably always remain so: they touch on basic elements of human culture, and in a very real sense are too important to be left to the doctors. There are few right answers here, and not even any obvious ways to balance the interests of the parents, the child, and society as a whole. So we don’t attempt to give any answers, but simply to point you towards some of the big questions.

Multiple babies

The practice of implanting multiple embryos in IVF and related treatment means that a few cases treatment will be too successful, and several embryos will survive. This is a large part of the reason for a 50% increase in the number of twins born in the USA since the beginning of IVF treatment. Multiple births are some 20 times more likely after IVF treatment than in the population as a whole, with the difference being even higher for triplets and larger groups.

Alternatives to Fertility Treatment

Surrogacy arrangements involve paying another woman to carry a child. In most cases, the surrogate mother is artificially inseminated with sperm. In a few cases, mainly where a woman has healthy eggs but would have difficulties during pregnancy, the surrogate has her eggs implanted, so that the child is biologically not hers at all.

The advantage of surrogacy is that it is the only option in cases where the cause of infertility is a woman’s inability to carry an embryo to term. There are, though, practical difficulties. Finding a woman willing to bear a baby for somebody else is not hard, and in many countries this can only be achieved through making large financial payments to the surrogate mother.

In the UK this is illegal – surrogate mothers can only be used if they are not being paid. The small number of people willing to endure the difficulty of pregnancy without some personal benefit has kept the number of surrogate pregnancies quite low in the UK. In the US, where surrogacy is legal in some states, surrogacy is limited by the high cost. Overall, surrogacy can cost tens of thousands of dollars.

Ovulation-stimulating Drugs

Drugs which can be used to encourage ovulation include Clomiphene, which works by inhibiting the effects of estrogen, and a class of drugs called gonadotropins, which mimic the hormones which stimulate the gonads.

Clomiphene

Clomiphene, also known as Serophene, Clomid, and Milophene, is used to increase ovulation. It works by inhibiting the effects of estrogen. That might sound like a bizarre way to increase ovulation, but it makes sense. The pituitary gland is tricked into believing that there is not much estrogen in the body. The pituitary responds by increasing the levels of female hormones, which encourages ovulation.

Treatment with Clomiphene usually takes place for only a few days – just long enough to stimulate ovulation. After that it is safe to stop taking it, thus reducing the severity of the side-effects. Clomiphene side-effects are rarely serious or long-lasting: nausea, mood swings and pain are not uncommon, but these will go away once you stop taking Clomiphene.

Infertility treatment for Women

When infertility is the result of physical problems with the uterus or fallopian tubes, these can often be repaired by means of surgery. Surgery is commonly performed to deal with blocked fallopian tubes or with endometriosis, but it is not limited to these situations.

Intrauterine Insemination (IUI)

In IUI, sperm are inserted directly into the uterus. The aim of treatment is that, once in the uterus, the sperm will be able to fertilize an egg without further assistance. This is particularly appropriate when a post-coital test has identified that sperm are not managing to pass the cervix.

Prior to intrauterine insemination, the sperm can be prepared in a number of ways. This is known as ‘washing’ the sperm, and can involve increasing the concentration of sperm in the fluid to be injected. The washed sperm are then inserted using a catheter.

IUI is a good solution when a couple is sub-fertile but may be able to conceive. It will not be of any use if functional sperm cannot be obtained (e.g. in some cases of total aspermia or azoospermia), nor if the woman is not ovulating.

IVF

Male Infertility Treatments

In male-factor infertility, the great challenge is often to extract sperm from the male body. Once sperm has been obtained, it can then be used for IUI, ICSI, or IVF (described below). The various sperm-collection procedures must all overcome the same difficulties:

    1.Getting enough sperm. Typically, 5-8 million sperm are needed for IUI. If it is not possible to get this number of sperm, it may be necessary to use more difficult techniques like ICSI, so as to make the most of the sperm which have been obtained.
    2.The sperm must be functional. If the sperm are dead (necrospermia) or otherwise ineffective, extracting them will be useless.
    3.The procedure should involve as little risk and discomfort for the patient as possible.

Now we’ve seen what sperm extraction techniques must achieve, let’s see what the options are. There are three forms of surgery to extract sperm, which are collectively known as ‘sperm aspiration’. These are:

    PESA sperm extraction
    MESA (Mirosurgical Epididymal Sperm Extraction)
    TESE (Testicular Sperm Extraction)
    TESA (Testicular Sperm Aspiration)

Treatment for Infertility

Infertility can be treated in a variety of ways. It can be treated by way of conventional medicine, surgery, assisted reproductive technology (ART) or artificial insemination. Sometimes one treatment will be tried and if it does not prove successful, another will be attempted. In other cases, more than one treatment is combined for optimum results.

Prognosis Positive

Approximately two thirds of all couples that seek help for infertility are able to have a baby at some point in time. In an estimated 80 to 85 percent of cases, infertility is treated by way of surgery or drugs.

A doctor will determine particular treatments for infertility based on a number of different factors which include the results of diagnostic tests, the length of time which a couple has been attempting to conceive, the age of both partners, the overall general health of both partners, and whether or not the partners have a preference for having a boy or a girl baby.

Male Factor

Diagnosing Infertilty

Tests and investigations to find the causes of infertility include:

    Levels of Follicle-Stimulating Hormone (FSH)
    Ultrasound
    Hysteroscopy
    Laparoscopy
    Semen analysis
    Post-Coital Test

Ovarian reserve tests

Several tests attempt to determine the level of the ovarian reserve – that is, how many eggs there are left in the ovaries. This is an important factor in the fertility of older women. One test measures the levels of Follicle Stimulating Hormone (FSH) in the body. FSH, along with another hormone called Luteinizing Hormone (LH), controls the menstrual cycle.

As the ovarian reserve declines, the body increases production of these hormones, in an attempt to push the last few eggs out of the ovaries. So a high level of follicle-stimulating hormone means that your ovarian reserve is low, and you will likely have difficulty conceiving.

Physical examinations

Causes of Female Infertility

Endometriosis

Endometriosis is one of the most common reasons for female infertility, and a problem which increases with age. The tissue which usually lines the uterus begins to form in other areas of the body, such as the uterus or the bowel. The cause seems to be during menstruation, when tissue falling off the uterus gets caught elsewhere. It can then begin to grow where it lands.
This in itself might not be such a great problem.

However, since these tissues are originally from the uterus, they try to bleed during menstruation. But, since they aren’t in the uterus, it is difficult for the tissues to leave the body. Thus some of the fluid which would otherwise be menstruated is trapped, and leads to inflammation and irritation. While endometriosis does not inevitably lead to infertility, in many cases it does block the ducts or make it impossible to reach the sperm.

Uterine Fibroids