Ovulation induction is pretty much the standard way of treating people with ovulatory disorders. The classic treatment would be clomiphene. The thing you should know about clomiphene is that it is NOT a steroid; it is very similar to tamoxifen. The reason, by the way, that tamoxifen was chosen for the treatment of breast cancer, since it was discovered in the 1950’s, the exact same time as Clomid, is that Clomid is much more potent and you can’t give it to somebody every day for five to ten years, whereas you can with tamoxifen. But they have the same mechanism of action, they are partial agonists and antagonists, and what you are doing is essentially fooling the pituitary and hypothalamus into thinking that the estrogen level in the periphery is low, so gonadotropins go up; specifically, their FSH goes up and you are provoking ovulation.
Another tool that we can use for the infertile patient is laparoscopy. At one time, in the 1980’s, this was quite popular. Nowadays, it is pretty much reserved for people who have either unexplained infertility or infertility that you know is from something like a previous history of pelvic inflammatory disease or documented by hysterosalpingogram, blocked tubes that you want to try to open. There is usually some sort of therapeutic maneuver involved. It is quite rare to be used purely for diagnosis nowadays, because it is expensive and you can probably better spend those dollars elsewhere. If the person has some other issue, like pain, that might guide your therapy towards doing this. Examples of things that you might see would include endometriosis, thick and thin pelvic adhesions, which of course you could lyse while you are there.
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Hysterosalpingogram is the final test that you are going to do on pretty much everybody to assess their tubes. Anybody who comes in with infertility and you have no idea what is going on, should probably have some assessment of their tubes. If you have a normal semen analysis and no history to suggest that something should be wrong with a person’s tubes and she has a clear picture, it is perfectly reasonable to treat that person with Clomid empirically. Although some people would argue with me, I would say that it is reasonable not to put her through the expanse and the pain of HSG, but it is clearly part of the basic workup.
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There are different sorts of adhesions – thick, thin, vascular, avascular, that will lead to tenting of the structures. And remember that the tube is much more than just a conduit – it has to be able to move. So just because it is open on HSG does not make it a useful tube.
There is a very interesting study from Canada in which they randomized people going for laparoscopy for whatever purpose – usually pain – and who wanted to get pregnant, to either get treatment or just have a diagnostic laparoscopy and then pull out, unless they saw something very severe. If they had minimal or mild endometriosis, and those people who were randomized to treatment – had a significantly higher rate of pregnancy beyond 20 weeks than the group that was the control, that just had diagnosis. So the removal of endometriosis is definitely a useful tool in the treatment of infertility. This was published in the New England Journal of Medicine. Likewise, you can show that laparoscopy is superior to things like Danazol. Basically, the point here is that endometriosis is a surgical disease; if you have it and can see it and it is minimal or mild, you should remove it. That person will then clearly have an increased chance of getting pregnant.
Finally, a review of fibroids and all sorts of uterine defects. Clearly, if you have a fibroid that invades the tube and blocks it, that is a problem. If you have a submucous fibroid that impedes implantation, that is also a big problem. You can have all sorts of different kinds of fibroids and you can have other sorts of defects in the cavity as well, anything from Asherman’s syndrome to a septate uterus versus a bicornuate uterus. As a general rule, bicornuate uterus does not seem to lead to decreased fecundity.
New Treatments for Infertility