Infertility treatments

by Ros Wood

For women with endometriosis there are different types of assisted reproductive technologies (ART) available.

Intra-uterine insemination (IUI)

Intra-uterine insemination (IUI) is a treatment that can be used to help women become pregnant. It involves artificially injecting the partner’s or a donor’s sperm into the woman’s uterus.

IUI treatment cycle
Intra-uterine insemination may involve controlled ovarian hyperstimulation, which is a treatment that uses hormonal drugs to stimulate the ovaries to produce additional eggs.

The main hormonal drugs used for controlled ovarian hyperstimulation are clomifene citrate (sold as Clomid, Serophene, Milophene) or artificial follicle stimulating hormone (sold as Gonal-F, Puregon, Menogon, Menopur).

Either of these drugs may be used on their own or in combination with a GnRH agonist such as leuprorelin (sold as Lupron, Lucrin), naferelin (sold as Synarel, Synarella), buserelin (sold as Suprecur, Suprefact injectable), goserelin (sold as Zoladex) and triptorelin.

For more information about intra-uterine insemination treatment, consult your local infertility treatment centre.

Success rates
The pregnancy rates achieved by women with minimal–mild endometriosis who undergo intra-uterine insemination with their partner’s or a donor’s sperm are lower than those of women without fertility problems [1,2]. One study found that the success rate of insemination in women with endometriosis is about half of that of other women [3].

However, women with minimal–mild endometriosis who undergo intra-uterine insemination and controlled ovarian hyperstimulation are more likely to conceive than those who try conceiving without such help [4,5,6]. Furthermore, stimulating the ovaries with artificial follicle stimulating hormone results in higher pregnancy rates than stimulating them with clomifene citrate [7].

Number of treatment cycles
Research indicates that if you have not conceived after 3–4 intra-uterine insemination cycles, you are not likely to conceive with further treatment cycles [8]. As a result, you will usually be advised to stop the treatment or to try another treatment such as IVF if you have not become pregnant after 3–4 treatment cycles [7].

In-vitro fertilsation (IVF)

In-vitro fertilisation (IVF) is another treatment that can be used to help women become pregnant, especially if the woman’s tubes are not functioning properly, the partner is also infertile, or other treatments have not been successful [7].

GnRH agonist pre-treatment
One well designed study indicates that undergoing 3–6 months treatment with a GnRH agonist before starting IVF increases the chances of becoming pregnant fourfold. However, the authors of the study stressed that more research is needed to confirm this finding [9].

IVF treatment cycle
For information about in-vitro fertilisation treatment, consult your local infertility treatment centre.

Ovarian endometriomas
There is considerable debate about how large ovarian endometriomas in women with endometriosis-related infertility should be treated [7].

Leaving an ovarian endometrioma in place does not seem to affect the success of IVF treatment. Studies indicate that while surgery to remove the endometrioma may result in fewer eggs being obtained during IVF, it does not affect the resulting pregnancy rates [10,11,12].

Nevertheless, it is recommended that you have a laparoscopy to remove any endometriomas greater than 4 cm in diameter before starting IVF treatment [7].

Removal of an ovarian endometrioma allows the diagnosis of endometriosis to be confirmed by a pathologist, and may reduce pain and discomfort. It may also make the ovary more responsive to controlled ovarian hyperstimulation, may make it easier for the gynaecologist to collect the ovarian follicles [7], may reduce the risk of infection following egg collection, and may reduce the risk of contaminating the egg culture medium.

However, removing the endometrioma may also result in the removal of some of the adjacent ovarian tissue, including some follicles (potential eggs). This may lead to decreased functioning of the ovary and occasionally even loss of ovarian function, particularly in women who have had previous ovarian surgeries [7].

Therefore, the decision to remove an endometrioma must be carefully considered in the light of your particular circumstances [7].

Success rates
The statistics on IVF pregnancy rates are contradictory. One systematic review of research studies indicates that IVF pregnancy rates in women with endometriosis are about one-third lower than those of women whose infertility is a result of tubal damage [13]. However, some large databases of women undergoing IVF treatment have found no differences in pregnancy rates [14].

References

1. Jansen RP. Minimal endometriosis and reduced fecundability: prospective evidence from an artificial insemination by donor program. Fertil Steril 1986;46:141-143.
2. Hammond MG, Jordan S and Sloan CS. Factors affecting pregnancy rates in a donor insemination program using frozen semen. Am J Obstet Gynecol 1986;155:480-485.
3. Hughes EG. The effectiveness of ovulation induction and intrauterine insemination in the treatment of persistent infertility: a meta-analysis. Hum Reprod 1997;12:1865-1872.
4. Tummon IS, Asher LJ, Martin JS and Tulandi T. Randomized controlled trial of superovulation and insemination for infertility associated with minimal or mild endometriosis. Fertil Steril 1997;68:8-12.
5. Nulsen JC, Walsh S, Dumez S, Metzger DA. A randomized and longitudinal-study of human menopausal gonadotropin with intrauterine insemination in the treatment of infertility. Obstet Gynecol 1993;82:780-786.
6. Costello MF. Systematic review of the treatment of ovulatory infertility with clomiphene citrate and intrauterine insemination. Aust N Z J Obstet Gynaecol. 2004;44:93-102.
7. ESHRE Guidelines, 2007 – online at http://guidelines.endometriosis.org
8. Deaton JL, Gibson M, Blackmer KM, Nakajima ST, Badger GJ and Brumsted JR. A randomized, controlled trial of clomiphene citrate and intrauterine insemination in couples with unexplained infertility or surgically corrected endometriosis. Fertil Steril 1990;54:1083-1088.
9. Sallam HN, Garcia-Velasco JA, Dias S, and Arici A. Long-term pituitary down-regulation before in vitro fertilization (IVF) for women with endometriosis. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD004635. DOI: 10.1002/14651858.CD004635.pub2.
10. Demirol A, Guven S, Baykal C and Gurgan T. Effect of endometrioma cystectomy on IVF outcome: a prospective randomized study. Reprod Biomed Online 2006;12:639-643.
11. Somigliana E, Vercellini P, Viganó P, Ragni G, Crosignani PG. Should endometriomas be treated before IVF-ICSI cycles? Hum Reprod Update 2006;12:57-64.
12. Gupta S, Agarwal A, Agarwal R, Loret de Mola JR. Impact of ovarian endometrioma on assisted reproduction outcomes. Reprod Biomed Online 2006;13:349-60.
13. Barnhart K, Dunsmoor-Su R and Coutifaris C.) Effect of endometriosis on in vitro fertilisation. Fertil Steril 2002;77:1148-1155.
14. Templeton A, Morris JK and Parslow W. Factors that affect outcome of in-vitro fertilisation treatment. Lancet 1996;348:1402-1406.

Thank you to the following for reviewing this article prior to its publication

Juan Garcia Velaso, IVI Madrid, Spain
Andrew Prentice, Consultant Gynaecologist, University of Cambridge, UK
Hugo C Verhoeven, Head of Reproductive Medicine, Med-Plus Krefeld, Germany