Infertility : Surgery, Artificial Insemination, In Vitro Fertilization

by Food and Drug Administration (FDA)

(Page 2 of 4)

Surgery

Surgery is another tool often used to treat infertility in both men and women.

Many men have varicocele, a collection of swollen veins in the scrotum that often looks and feels like a bag of worms, but may be less obvious. Some men with a varicocele easily sire children and so are clearly fertile. For those who seemingly are not and whose sperm are sluggish, surgical repair of the varicocele may better their chances of fatherhood.

However, according to Larry Lipshultz, M.D., professor of urology at the Baylor University College of Medicine in Houston, there is a debate among physicians about when the operation is appropriate. He does not, therefore, usually recommend it to his patients unless he is unable to find other reasons for their infertility.

Another male infertility problem often treated by surgery is damage to the vas deferentia, through which sperm must pass for ejaculation. A common cause of such damage is vasectomy, male sterilization. Though it should be considered irreversible, some men later wish to have it reversed. This is sometimes possible through microsurgery. Other candidates for such surgery are men whose vas deferentia have been blocked by scar tissue caused by earlier unrelated surgery or a sexually transmitted or other infection.

Microsurgery is not a cure-all, however. It cannot help men with extensive damage to these structures, and many with limited damage may not be able to father a child, despite the operation's apparent success.

A sterilization procedure for women, tubal ligation, involves tying, cutting or burning the fallopian tubes and so scarring them. Damage to the tubes by earlier unrelated surgery or infection — again, sometimes sexually transmitted — can also cause female infertility.

In both cases, corrective surgery is sometimes, but not always, a possibility. Nor do seemingly successful surgical repairs of damaged fallopian tubes necessarily mean that any eggs fertilized in them will be able to make their way to the uterus.

Sometimes, instead, an ectopic (literally, out-of-place) pregnancy occurs, in which the fertilized egg gets trapped in the tube where it cannot survive when it grows. Any woman can have an ectopic pregnancy, but those whose tubes have been damaged are at greatest risk, even after corrective surgery. Although surgical repair of the damage lowers the risk of having an ectopic pregnancy, it remains higher than for women with tubes that have never been damaged.

Endometriosis, a common disorder in women, also can cause or contribute to infertility when small pieces of the uterine lining escape and take up residence on the surfaces of organs in the abdominal cavity.

Inflammation and consequent chronic irritation from the misplaced tissue can eventually so badly scar the ovaries, fallopian tubes, inner or outer walls of the uterus, or other nearby structures that the woman cannot conceive. (See "Endometriosis: A Growing Cause of Infertility in Women" in the March 1986 FDA Consumer.)

Both surgery and drug treatments, sometimes combined, are used to treat endometriosis. Success rates in the hands of a physician skilled in treating this disorder are in the 50 to 60 percent range, and depend on several factors, including the patient's age and manifestations of the disease.

Artificial Insemination

Some infertility treatments attempt to get a pregnancy started without intercourse. Artificial insemination, the oldest of these treatments, has been used for more than a century. A hollow, flexible instrument — called a catheter — is used to place the donor's semen into the woman's uterus or vaginal canal.

All inseminations are performed around the time the woman should be ovulating, either naturally or after priming with a fertility drug. The semen may be from the woman's husband ("artificial insemination-husband" or AIH for short) or from an anonymous donor ("artificial insemination-donor" or AID).

A recent advance in AIH is for men who — because of spinal cord injury, cancer surgery, or other reasons — can't ejaculate normally. Electrical stimulation can be used to help them overcome this problem and the ejaculate collected and inseminated in their wives.

Fresh semen was once used for all inseminations and still is, as a rule, in AIH, but because of concern about AIDS and other sexually transmitted infections, FDA, the Centers for Disease Control, and the American Fertility Society now recommend that anonymous donor semen be frozen for at least 180 days before use. The delay allows the donor semen to be retested for possible infection.

Some women become pregnant with only one insemination. More often, repeat inseminations over the course of four to five menstrual cycles are required. And there are women who after a year or more of periodic insemination still do not conceive. Depending on the nature of the couple's infertility, studies show success rates between 50 and 65 percent.

In Vitro Fertilization

Much newer than artificial insemination is in vitro fertilization (IVF), made famous by the birth in England in 1978 of Louise Brown, the world's first "test tube" baby. IVF is an option when various other treatments have failed or are inappropriate. It can be used, for example, in women who have a uterus and at least one ovary, but whose fallopian tubes are damaged, missing or diseased.

The woman is prepared for this procedure with fertility drugs that ready several of her eggs for fertilization and the lining of her uterus to support a pregnancy. The eggs are then taken from her by one of several methods and placed in a laboratory dish where they are incubated with her partner's sperm for about 18 hours.

Assuming that some are fertilized and continue to develop normally for two days or so, one or more (as a kind of insurance policy it is usually several) are transferred by instrument into the woman's uterus. If at least one implants there within about two weeks, the woman is pregnant. Implantation can often be determined at that time by a blood test. However, this chemical assessment is sometimes misleading. Therefore, a conclusive diagnosis cannot be made until a week more or so has passed when — if the pregnancy is real, rather than just chemical — a sac will have formed around the embryo that can be detected by ultrasound.

As with other infertility treatments, couples undergoing IVF should not count their chickens before they hatch. In a study published in 1988, for example, 41 clinics that had treated 3,055 women with one or more cycles of IVF reported that only 485 (15.9 percent) became pregnant and just 311 (10.2 percent) delivered a living infant.

About the Author

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