♀ Infertility Treatment including Clomiphene, Metformin, FSH, IVF (In Vitro Fertilization) and ICSI

What is the importance of the fallopian tubes?

Your Fallopian tubes have four functions:

It is in the Fallopian tubes that ova are fertilised by spermatozoa.
The tubes actively transport the ova to the uterine cavity by the coordinated action of tiny fine hair-like structures called cilia.

During their passage along the tubes, ova are nourished.

Approximately 14% of infertility is attributable to the 'tubal factor'.

Infection ascending to the Fallopian tubes following pregnancy or through sexual transmission accounts for the majority of patients with Fallopian tube problems (pelvic inflammatory disease).

Related Medical Abstracts - Click on the paper title:-

How can we assess whether the fallopian tubes are functioning?

Tubal function tests generally provide evidence of patency only. We wish to know if there are blocked fallopian tubes.

The earliest work on the subject was published in 1920 by Rubin - The Rubin Test, when it was demonstrated that if the tubes are patent, oxygen introduced through the cervix would pass into the peritoneal cavity. Initially, passage of the gas was checked by listening over the lower abdomen with a stethoscope. The concept that investigation of tubal patency may be therapeutic (increase the likelihood of pregnancy) also dates from about that time.

More reliable tests are:

In the 1940s hysterosalpingography (HSG) was introduced. A radio-opaque dye was introduced through the cervix and an x-ray picture was taken to track the dye through the uterus and Fallopian tubes (Figure 9.3).

Figure 9.3 A hysterosalpingogram

One concern with hysterosalpingograms is that some patients find them painful. In one study,⁰⁸⁰¹the efficacy of oral naproxen with intrauterine instillation of 1% lignocaine was compared for pain relief. Methods: Intrauterine lignocaine was no more effective than a single oral dose of 375 mg of naproxen 1 hour prior to HSG.

The arrival of fibroptic light technology and the first reports of the laparoscope (Q23.24) into the English literature opened the world of direct visualisation of the pelvic organs. When combined with methylene blue dye insufflation (the dye is passed through the cervix), a new technique for assessing tubal patency became available (laparoscopy with dye insufflation). Often hysterosalpingography and laparoscopy provide differing evidence on tubal patency.

In 1984, ultrasound assessment of the Fallopian tubes (hysterosalpingo-contrast-sonography – Hy-Co-Sy) was first reported to demonstrate free fluid in the pelvis after introducing fluid through the cervix; there was good correlation with hysterosalpingography in a series of 35 infertile women.

Current routine techniques for the evaluation of the tubal factor are basically patency tests; they do not assess other functions such as the ability of the fimbria (Q 2.3) to pick up the oocytes or move them along to the uterus. There have been reports of evaluation of Fallopian tube function by introducing starch suspensions, vaseline droplets and Indigo Carmen into the pelvis and checking to see if the tubes pick these up and transport them into the uterus by looking to see if they appear at the cervix some hours later. These tests never progressed beyond the realms of research.

In a study of 104 infertile couples, the women had both hysterosalpingography and laparoscopy with dye insufflation. There was an overall agreement between the two techniques in 62.5% of cases. It was concluded that whenever the HSG demonstrated tubal patency with free flow of dye, laparoscopic may not be necessary. At one time it was argued that laparoscopy had the advantage as it would allow a diagnosis of minimal endometriosis. This no longer seems relevant as such findings are of no clinical relevance (Q9.11). Several experts have come to the conclusion that in the absence of clinical indicators of significant pelvic disease and a normal hysterosalpingogram there is little to be gained by submitting infertile women to laparoscopy.

Related Medical Abstracts - Click on the paper title:-

Tubal Surgery for Tubal Factor Infertility

The success rates following tubal surgery will depend on the severity of the disease. Careful pre-operative assessment, including semen analysis and often hysterosalpingography and laparoscopy, is required.

The commonest site of tubal damage is at the fimbrial end (opening near the ovaries –Figure 9.1), with birth rates after surgery in the order of 25 per cent. Surgery for proximal tubal occlusion (the blockage is close to the uterus) is more successful, with live birth rates of 50% and ectopic rates of 10%. Just over a half of intrauterine pregnancies following tubal surgery may occur more than one year after surgery. Reversal of sterilisation, with removal of clips and re-anastomosis (reconnection), carries a relatively high success rate of up to 80%.

Tubal microsurgery involves the use of magnification as well as the adoption of a set of techniques including the use of special instruments, minimal handling of the Fallopian tubes and fine non-reactive suture material. There have been no controlled trials to prove conclusively an advantage over conventional surgical techniques but several surgical teams have reported improved success rates. It is technically possible to transplant Fallopian tubes and large numbers of these organs would undoubtedly be donated by women undergoing sterilisation or hysterectomy (hysterectomy). Research interest in this area seems to have diminished following the development of IVF (24).

IVF Introducing IVF - In Vitro Fertilisation (USA Fertilization)

IVF literally means fertilisation outside the body. IVF was initially developed for women who had severe tubal disease or who had their Fallopian tubes removed but this treatment has also proved successful for unexplained infertility and male factor infertility. IVF is a major treatment in infertility when other methods of assisted reproductive technology have failed. A typical IVF treatment cycle is outlined in (Figure 10.3). Originally, eggs were collected laparoscopically (laparoscopy) but we now collect the eggs by ultrasound guidance usually through the vagina.

Please see IVF - In Vitro Fertilisation (UK) or IVF - In Vitro Fertilization (USA)

Egg Donation and Egg Sharing

Some women are unable to produce healthy eggs either because they have reached their menopause early, they are approaching their menopause (Figure 10.7) or because their eggs carry abnormal genes. The only realistic chance of a successful pregnancy in these circumstances is if another woman donates some of her eggs. There are some remarkable women who, for altruistic reasons, come forward voluntarily and go through the regimen for IVF egg collection and donation. Egg donors should usually be aged 35 years or less.

Figure 10.7

The demand for egg donation greatly exceeds supplies. There are many women who have healthy eggs and need IVF but for economic reasons IVF is beyond them. The combined requirements of funding for IVF for the less privileged and of others for egg donors has led to the development of eggs sharing. If a woman requiring egg donation will fund the two treatments, she may receive perhaps half the eggs provided by the woman who hasQuality eggs but cannot afford the treatment.

Tubal Surgery and IVF Compared

Information about success rates is essential for couples to make informed decisions. In vitro fertilization (IVF) provides an alternative to tubal surgery. For mild tubal disease and previous sterilisation, tubal surgery is probably the treatment of first choice. With severe tubal disease, IVF carries the better success rate. For intermediate disease, the optimum method in terms of success is less certain. IVF is becoming increasingly successful (Figure 10.5) and appropriately more popular (Figure 10.6).

Figure 10.5

Figure 10.6

The merits of tubal surgery and assisted reproduction (Assisted Reproductive Technology ART) need careful comparison. In-vitro fertilisation is becoming more readily available with a corresponding reduction in the use of tubal surgery.

IVF is associated with a higher incidence of multiple pregnancy. Perinatal mortality rates following assisted conception procedures are treble that of spontaneous conception although most of the increase is related to multiple pregnancy. There is a five-fold increase in perinatal mortality (stillbirths and first week losses) with triplets compared with singletons. The predicted costs associated with delivery of each baby for a singleton pregnancy in the USA in 1991 was $9,845, for a twin pregnancy $18,974 and for triplets $36,588. Between 1986 and 1991, assisted reproduction techniques were found to be responsible for 35% of twins and 77% of higher order pregnancies.

In the NHS only about 25% of purchasing authorities are currently supporting IVF treatment and the number is falling. There can be little doubt, that from a purely economic point of view, a greater number of pregnancies could be achieved with a given amount of funding using low tech treatments. Many couples would prefer tubal surgery in the first instance and the opportunity to conceive naturally, only resorting to IVF if this fails.

Tubal Surgery for Tubal Factor Infertility

Egg Donation and Egg Sharing

IVF and Tubal Surgery Compared

Infertility Support Groups

Members of a support group, provide each other with various types of help for a particular shared difficulty. The support may take the form of providing relevant information, relating personal experiences, listening to others' experiences, providing sympathetic understanding and establishing social networks. A support group may also provide ancillary support, such as serving as a voice for the public or engaging in advocacy. Support groups maintain interpersonal contact among their members in a variety of ways. Support groups also maintain contact through printed newsletters, telephone chains, internet forums, and mailing lists.

Support groups offer companionship and information for people coping with diseases or disabilities. Support groups may not be appropriate for everyone, and some find that a support group actually adds to their stress rather than relieving it.

http://www. Asrm.org/	The American Society for Reproductive Medicine is a voluntary, non-profit organization devoted to advancing knowledge and expertise in reproductive medicine, including infertility, menopause, contraception, and sexuality.
http://www.nor.com. Au/community/aisg/	The Australian Infertility Support Group
http://www. Theafa.org/	American Fertility Association
http://www.epigee.org/guide/infert.html	Epigee - Natural Fertility
http://www.fertilethoughts.net/	Infertility Pregnancy Adoption Parenting Surrogacy
http://www. Inciid.org/	International Council on Infertility Information Dissemination
http://www. Indiaparenting.com	India Fertility Issues, Preconception, Adoption, Baby Names
http://www. Infertility-info.com	Tim Appleton - doctorates in cell biology, is an ordained Anglican Priest, and has been an independent Fertility Counsellor
http://www.noah-health.org	Fertilty, Infertility, Surrogacy
http://www.resolve.org	The National Infertility Association
http://www.fertilitynetwork.com	Find Infertility specialists, fertility doctors, who perform advanced Infertility treatment, like IVF and ICSI,
http://www.hfea.gov.uk	The Human Fertilisation and Embryology Authority is the UK's independent regulator overseeing safe and appropriate practice in fertility treatment and embryo research.
http://www. Infertilitynetworkuk.com	Infertility Network UK - Advice, Support and Understanding
http://www. Ivfglossary.org.uk	Glossary of Infertility and IVF Terminology
http://www.dcnetwork.org/	A self-help network of over 1,000 families created with the help of donated eggs, sperm or embryos; couples and individuals seeking to found a family this way; and adults conceived using a donor.
http://www.ngdt.co.uk/	Clear and practical information mainly for those considering becoming an egg or sperm donor but also for health professionals and those requiring treatment with donor eggs or sperm.
http://www. Acebabes.co.uk/	ACeBabes was established as a UK charity in 1998 to support the growing number of people who were using assisted conception as a way to bring about their longed for family

The aim of this web site is to provide a general guide and it is not intended as a substitute for a consultation with an appropriate specialist in respect of individual care and treatment.

David Viniker retired from active clinical practice in 2012.
In 1999, he setup this website - www.2womenshealth.com - to provide detailed
information many of his patients requested. The website attracts thousands of visitors every day from around the world.
If you would like advice on how to make more from your website, please visit his website Keyword SEO PRO or email him on david@page1-on-google.com.

	Infertility Treatment - Clomiphene - Metformin - FSH - IVF - In Vitro Fertilisation - ICSI

Infertility Treatment - Clomiphene - Metformin - FSH - IVF - In Vitro Fertilisation - ICSI

How can we assess whether the fallopian tubes are functioning?

Tubal Surgery for Tubal Factor Infertility

IVF Introducing IVF - In Vitro Fertilisation (USA Fertilization)

Egg Donation and Egg Sharing

Tubal Surgery and IVF Compared

Tubal Surgery for Tubal Factor Infertility

Egg Donation and Egg Sharing

IVF and Tubal Surgery Compared

Infertility Support Groups