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Treatment
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Female Treatments
The treatment of female infertility can be
categorised into three defined stages. These take the form of
consecutive steps. In many cases the first step may be successful,
hence negating the need for the second and third steps. We'll
address each of these steps in turn:
Some Background to Treatments
Hormones under the control of the hypothalamus, the pituitary gland
and the ovaries regulate the female reproductive cycle. If this
basic control system does not work correctly, ovulation will be
disturbed or absent. Ovulatory disorders are characterized by
anovulation (complete failure to ovulate) or infrequent and/or
irregular ovulation.
The World Health Organisation (WHO) has adopted a
treatment-orientated classification of anovulating patients:- Group I patients have
hypothalamic-pituitary failure. They are amenorrheic and lack both
follicle stimulating hormone (FSH) and luteinizing hormone
(LH).
- Group II patients have
hypothalamic-pituitary dysfunction and present with a variety of
cycle disorders including amenorrhoea, oligomenorrhoea and luteal
phase deficiencies. About 97% of anovulatory patients fall into
this group, including polycystic ovarian disease (PCOD, a condition
commonly characterized by hirsutism, obesity, menstrual
abnormalities, infertility, and enlarged ovaries; thought to
reflect excessive androgen secretion of ovarian origin), which is
thought to be the most common cause of ovarian dysfunction.
Ovulation induction (OI) aims to correct hormonal
imbalances, allowing where possible, mono-ovulation to occur. More
than 80% of infertile women without anatomical disorders are
treated successfully with fertility agents that promote the growth
and development of ovarian follicles via the stimulation of FSH and
LH.
Agents most commonly used for ovulation
induction are:
- Clomiphene citrate, acting on the
hypothalamus to increase the release of gonadotropin releasing
hormone (GnRH), which, in turn, stimulates the pituitary gland to
release FSH and LH.
- Gonadotropins (FSH preparations acting
directly on the ovary, promoting follicular development).
In WHO Group I patients, gonadotropin therapy
with both FSH and LH is required for follicular development and
ovulation. WHO Group II patients may respond to clomiphene citrate.
FSH treatment is normally reserved for those who do not respond to
clomiphene.
 OI is usually combined with timed intercourse
or with artificial insemination (also called intrauterine
insemination: IUI) in order to increase the probability of
successful fertilization. If conception has not taken place after
approximately three to five cycles with clomiphene citrate and a
further three to five cycles with gonadotropin treatment, the
patient may be referred for ART. The number of clomiphene
citrate/gonadotropin treatment courses is related to the type of
infertility, the result of the investigations and reimbursement
schemes practiced in each individual country.
FSH is effective in ovarian stimulation. Human chorionic
gonadotropin (hCG) injections are used in conjunction with FSH to
provoke egg release (hCG is given to mimic the natural LH surge).
An occasional adjunct to FSH therapy is synthetic luteinizing
hormone releasing hormone (LHRH) analogues that work by suppressing
the ovaries. In their suppressed state, the ovaries are more
receptive to FSH therapy and higher quality eggs are produced as a
result. This is particularly useful for women with PCOD (Polycystic
Ovary Disease) not responding to FSH alone.
Bromocriptine is a useful agent in the treatment of
hyperprolactinemia, a condition where there is excess of the
hormone prolactin in the blood. This condition results in the
suppression of GnRH release contributing to anovulation.
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