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Fady I. Sharara, MD, FACOG
Assisted Reproductive Techniques (ART) – Part II
Virginia Center for Reproductive Medicine

Assisted Reproductive Techniques (ART) – Part II

In Part II of this series, I will review one of the most common causes of infertility, the tubal factor, along with other conditions such as endometriosis, and unexplained infertility. I will review the egg factor, aging, and polycystic ovarian disease (PCOS) in the coming months.

The Tubal Factor

In order for a pregnancy to occur, the egg and sperm have to “meet”. The sperm reaches the egg in the distal segment of the tube, where fertilization occurs. The tube is also responsible for the subsequent transport of the fertilized egg or embryo during the next 3-4 days to the uterine cavity where implantation takes place. It is therefore critical to find out if the fallopian tubes are healthy. This is achieved by a test called a hysterosalpingogram (HSG). This test involves the shooting of dye through the cervix and following the spill of the dye through the tubes via x-ray pictures. If an abnormality is noted, a laparoscopy to check the tubes might be needed.

There are three major instances where the tubes could be damaged.

(a) Congenital (or inherited) abnormalities This is extremely rare and easy to diagnose since the tubes are typically absent.

(b) Infections Usually caused by sexually transmitted diseases such as chlamydia or gonorrhea. These infections are notorious for damaging the tubes and causing infertility. In many patients, the person is not even aware that they ever had the infection.

(c) Surgeries Any surgery performed in the lower abdomen or pelvis can cause scarring around the tubes and ovaries that can affect the normal anatomy. Such surgeries include appendectomy, ovarian cyst surgery, fibroid surgery, bladder or bowel surgeries and others.

The severity of tubal damage would determine if it were worth surgical correction, then attempting to conceive naturally for a period of time.

As a general rule, following successful surgical treatment of tubal disease, it is reasonable to attempt to conceive for a period of six months, thereafter, the patient should turn to in vitro fertilization (IVF).

The inherent nature of IVF treatment is to bypass the tubes altogether, therefore the state of the tubes is secondary. It is also important to realize that artificial insemination or IUI to treat tubal disease is obsolete since we are really not treating the underlying disease. The same is true for ovulation inducing hormone treatment for patients with tubal disease. Such therapy could be a waste of time and money.

Other Factors

There are other instances when resorting to advanced infertility treatment such as in vitro fertilization is the most adequate therapy.

1) Endometriosis As long as the tubes are patent, it is reasonable to attempt fertility hormone therapy with artificial insemination for 4-6 months.

2) Unexplained infertility The same is true for couples who cannot conceive and all infertility testing is negative. These couples would also benefit from conventional and conservative treatment with fertility hormone therapy with artificial insemination for 4-6 months.

The typical management of a couple presenting with unexplained infertility, is oral fertility hormone therapy (Clomid, Serophene) with or without artificial intrauterine inseminations.
Unfortunately, in many of these cases this treatment lingers for many months despite failures to conceive. It is therefore important for every couple undergoing such treatment to discuss the long term plan with their physician and to limit such therapy to no more then 4-6 months. Most studies indicated that pregnancy rates drop significantly if a pregnancy is not achieved after six months of conventional treatment.

Couples suffering from mild endometriosis or unexplained infertility, may benefit from conventional infertility treatment for 4-6 months. In case of failure however, IVF should be the next step

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