Fertility treatment in Iran
Overview
Infertility is defined as not being able to get pregnant despite having frequent, unprotected sex for at least a year for most couples. Your infertility treatment plan will depend on the cause or causes behind your infertility, whether the problem is from the woman’s side, the man’s side, both sides, or remains unexplained.
Fertility treatment typically refers to medications that stimulate egg or sperm production, or procedures that involve the handling of eggs, sperm, or embryos.
Symptoms of infertility
The main symptom of infertility is not getting pregnant. There may be no other obvious symptoms. Sometimes, a woman with infertility may have irregular or absent menstrual periods. In some cases, a man with infertility may have some signs of hormonal problems, such as changes in hair growth or sexual function.
Most couples will eventually conceive, with or without treatment.
When to see a doctor
You probably don’t need to see a doctor about infertility unless you have been trying regularly to get pregnant for at least one year. Women should talk with a doctor earlier, however, if they:
. Are age 35 or older and have been trying to conceive for six months or longer
. Are over age 40
. Have irregular or absent periods
. Have very painful periods
. Have known fertility problems
. Have been diagnosed with endometriosis or pelvic inflammatory disease
. Have had multiple miscarriages
. Have undergone treatment for cancer
Men should talk to a doctor if they have:
. A low sperm count or other problems with sperm
. A history of testicular, prostate or sexual problems
. Undergone treatment for cancer
. Small testicles or swelling in the scrotum
. Others in your family with infertility problems
Causes of infertility
All of the steps during ovulation and fertilization need to happen correctly in order to get pregnant. Sometimes the issues that cause infertility in couples are present at birth, and sometimes they develop later in life.
Infertility causes can affect one or both partners. In general:
. In about one-third of cases, there is an issue with the man
. In about one-third of cases, there is an issue with the woman
. In the remaining cases, there are issues with both the man and the woman, or no cause can be found.
Causes of male infertility
These may include:
. Abnormal sperm production or function due to undescended testicles, genetic defects, health problems such as diabetes, or infections such as chlamydia, gonorrhea, mumps or HIV. Enlarged veins in the testes (varicocele) also can affect the quality of sperm.
. Problems with the delivery of sperm due to sexual problems, such as premature ejaculation; certain genetic diseases, such as cystic fibrosis; structural problems, such as a blockage in the testicle; or damage or injury to the reproductive organs.
. Overexposure to certain environmental factors, such as pesticides and other chemicals, and radiation. Cigarette smoking, alcohol, marijuana, anabolic steroids, and taking medications to treat bacterial infections, high blood pressure and depression also can affect fertility. Frequent exposure to heat, such as in saunas or hot tubs, can raise body temperature and may affect sperm production.
. Damage related to cancer and its treatment, including radiation or chemotherapy. Treatment for cancer can impair sperm production, sometimes severely.
Causes of female infertility
Causes of female infertility may include:
. Ovulation disorders, which affect the release of eggs from the ovaries. These include hormonal disorders such as polycystic ovary syndrome. Hyperprolactinemia, a condition in which you have too much prolactin — the hormone that stimulates breast milk production — also may interfere with ovulation. Either too much thyroid hormone (hyperthyroidism) or too little (hypothyroidism) can affect the menstrual cycle or cause infertility. Other underlying causes may include too much exercise, eating disorders or tumors.
. Uterine or cervical abnormalities, including abnormalities with the cervix, polyps in the uterus or the shape of the uterus. Noncancerous (benign) tumors in the uterine wall (uterine fibroids) may cause infertility by blocking the fallopian tubes or stopping a fertilized egg from implanting in the uterus.
. Fallopian tube damage or blockage, often caused by inflammation of the fallopian tube (salpingitis). This can result from pelvic inflammatory disease, which is usually caused by a sexually transmitted infection, endometriosis or adhesions.
. Endometriosis, which occurs when endometrial tissue grows outside of the uterus, may affect the function of the ovaries, uterus and fallopian tubes.
. Primary ovarian insufficiency (early menopause), when the ovaries stop working and menstruation ends before age 40. Although the cause is often unknown, certain factors are associated with early menopause, including immune system diseases, certain genetic conditions such as Turner syndrome or carriers of Fragile X syndrome, and radiation or chemotherapy treatment.
. Pelvic adhesions, bands of scar tissue that bind organs that can form after pelvic infection, appendicitis, endometriosis or abdominal or pelvic surgery.
. Cancer and its treatment. Certain cancers — particularly reproductive cancers — often impair female fertility. Both radiation and chemotherapy may affect fertility.
Risk factors
Many of the risk factors for both male and female infertility are the same. They include:
. Age. Women’s fertility gradually declines with age, especially in the mid-30s, and it drops rapidly after age 37. Infertility in older women is likely due to the lower number and quality of eggs, and can also be due to health problems that affect fertility. Men over age 40 may be less fertile than younger men.
. Tobacco use. Smoking tobacco or marijuana by either partner may reduce the likelihood of pregnancy. Smoking also reduces the possible effectiveness of fertility treatment. Miscarriages are more frequent in women who smoke. Smoking can increase the risk of erectile dysfunction and a low sperm count in men.
. Alcohol use. For women, there’s no safe level of alcohol use during conception or pregnancy. Alcohol use may contribute to infertility. For men, heavy alcohol use can decrease sperm count and motility.
. Being overweight. Among American women, an inactive lifestyle and being overweight may increase the risk of infertility. For men, sperm count also may be affected by being overweight.
. Being underweight. Women at risk of fertility problems include those with eating disorders, such as anorexia or bulimia, and those who follow a very low-calorie or restrictive diet.
. Exercise issues. A lack of exercise contributes to obesity, which increases the risk of infertility. Less often, ovulation problems may be associated with frequent strenuous, intense exercise in women who are not overweight.
Prevention
Some types of infertility aren’t preventable. But several strategies may increase your chances of pregnancy.
Couples
Have regular intercourse several times around the time of ovulation for the highest pregnancy rate. Intercourse beginning at least five days before and until a day after ovulation improves your chances of getting pregnant. Ovulation usually occurs in the middle of the cycle — halfway between menstrual periods — for most women with menstrual cycles about 28 days apart.
Men
Although most types of infertility aren’t preventable in men, these strategies may help:
. Avoid drug and tobacco use and drinking too much alcohol, which may contribute to male infertility.
. Avoid high temperatures found in hot tubs and hot baths, as they can temporarily affect sperm production and motility.
. Avoid exposure to industrial or environmental toxins, which can affect sperm production.
. Limit medications that may impact fertility, both prescription and nonprescription drugs. Talk with your doctor about any medications you take regularly, but don’t stop taking prescription medications without medical advice.
. Exercise moderately. Regular exercise may improve sperm quality and increase the chances for achieving a pregnancy.
Women
For women, a number of strategies may increase the chances of becoming pregnant:
. Quit smoking. Tobacco has many negative effects on fertility, not to mention your general health and the health of a fetus. If you smoke and are considering pregnancy, quit now.
. Avoid alcohol and street drugs. These substances may impair your ability to conceive and have a healthy pregnancy. Don’t drink alcohol or use recreational drugs, such as marijuana, if you’re trying to get pregnant.
. Limit caffeine. Women trying to get pregnant may want to limit caffeine intake. Ask your doctor for guidance on the safe use of caffeine.
. Exercise moderately. Regular exercise is important, but exercising so intensely that your periods are infrequent or absent can affect fertility.
. Avoid weight extremes. Being overweight or underweight can affect your hormone production and cause infertility.
Diagnosis
Before infertility testing, your doctor or clinic works to understand your sexual habits and may make recommendations to improve your chances of getting pregnant. In some infertile couples, no specific cause is found (unexplained infertility).
Infertility evaluation can be expensive, and sometimes involves uncomfortable procedures. Some medical plans may not cover the cost of fertility treatment. Finally, there’s no guarantee — even after all the testing and counseling — that you’ll get pregnant.
Tests for men
Male fertility requires that the testicles produce enough healthy sperm, and that the sperm is ejaculated effectively into the vagina and travels to the egg. Tests for male infertility attempt to determine whether any of these processes are impaired.
You may have a general physical exam, including examination of your genitals. Specific fertility tests may include:
. Semen analysis. Your doctor may ask for one or more semen specimens. Semen is generally obtained by masturbating or by interrupting intercourse and ejaculating your semen into a clean container. A lab analyzes your semen specimen. In some cases, urine may be tested for the presence of sperm.
. Hormone testing. You may have a blood test to determine your level of testosterone and other male hormones.
. Genetic testing. Genetic testing may be done to determine whether there’s a genetic defect causing infertility.
. Testicular biopsy. In select cases, a testicular biopsy may be performed to identify abnormalities contributing to infertility or to retrieve sperm for assisted reproductive techniques, such as IVF.
. Imaging. In certain situations, imaging studies such as a brain MRI, transrectal or scrotal ultrasound, or a test of the vas deferens (vasography) may be performed.
. Other specialty testing. In rare cases, other tests to evaluate the quality of the sperm may be performed, such as evaluating a semen specimen for DNA abnormalities.
Tests for women
Fertility for women relies on the ovaries releasing healthy eggs. The reproductive tract must allow an egg to pass into the fallopian tubes and join with sperm for fertilization. The fertilized egg must travel to the uterus and implant in the lining. Tests for female infertility try to find out if any of these processes are impaired.
You may have a general physical exam, including a regular gynecological exam. Specific fertility tests may include:
. Ovulation testing. A blood test measures hormone levels to determine whether you’re ovulating.
. Hysterosalpingography. Hysterosalpingography evaluates the condition of your uterus and fallopian tubes and looks for blockages or other problems. X-ray contrast is injected into your uterus, and an X-ray is taken to determine if the cavity is normal and to see if the fluid spills out of your fallopian tubes.
. Ovarian reserve testing. This testing helps determine the quantity of the eggs available for ovulation. This approach often begins with hormone testing early in the menstrual cycle.
. Other hormone testing. Other hormone tests check levels of ovulatory hormones, as well as pituitary hormones that control reproductive processes.
. Imaging tests. Pelvic ultrasound looks for uterine or ovarian disease. Sometimes a sonohysterogram, also called a saline infusion sonogram, is used to see details inside the uterus that are not seen on a regular ultrasound.
Depending on your situation, rarely your testing may include:
. Hysteroscopy. Depending on your symptoms, your doctor may request a hysteroscopy to look for uterine disease. During the procedure, your doctor inserts a thin, lighted device through your cervix into your uterus to view any potential abnormalities.
. Laparoscopy. This minimally invasive surgery involves making a small incision beneath your navel and inserting a thin viewing device to examine your fallopian tubes, ovaries and uterus. A laparoscopy may identify endometriosis, scarring, blockages or irregularities of the fallopian tubes, and problems with the ovaries and uterus.
Not everyone needs to have all, or even many, of these tests before the cause of infertility is found. You and your doctor will decide which tests you will have and when.
Treatment
Infertility treatment depends on:
. What’s causing the infertility?
. How long you’ve been infertile
. Your age and your partner’s age
. Personal preferences
Some causes of infertility can’t be corrected.
In cases where spontaneous pregnancy doesn’t happen, couples can often still achieve a pregnancy through use of assisted reproductive technology. Infertility treatment may involve significant financial, physical, psychological and time commitments.
Treatment for men
Men’s treatment for general sexual problems or lack of healthy sperm may include:
. Changing lifestyle factors. Improving lifestyle and certain behaviors can improve chances for pregnancy, including discontinuing select medications, reducing or eliminating harmful substances, improving frequency and timing of intercourse, exercising regularly, and optimizing other factors that may otherwise impair fertility.
. Medications. Certain medications may improve sperm count and likelihood for achieving a successful pregnancy. These medicines may increase testicular function, including sperm production and quality.
. Surgery. For some conditions, surgery may be able to reverse a sperm blockage and restore fertility. In other cases, surgically repairing a varicocele may improve overall chances for pregnancy.
. Sperm retrieval. These techniques obtain sperm when ejaculation is a problem or when no sperm are present in the ejaculated fluid. They may also be used in cases in which assisted reproductive techniques are planned and sperm counts are low or otherwise abnormal.
Treatment for women
Some women need only one or two therapies to improve fertility. Other women may need several different types of treatment to achieve pregnancy.
. Stimulating ovulation with fertility drugs. Fertility drugs are the main treatment for women who are infertile due to ovulation disorders. These medications regulate or induce ovulation. Talk with your doctor about fertility drug options — including the benefits and risks of each type.
. Intrauterine insemination (IUI). During IUI, healthy sperm are placed directly in the uterus around the time the ovary releases one or more eggs to be fertilized. Depending on the reasons for infertility, the timing of IUI can be coordinated with your normal cycle or with fertility medications.
. Surgery to restore fertility. Uterine problems such as endometrial polyps, a uterine septum, intrauterine scar tissue and some fibroids can be treated with hysteroscopic surgery. Endometriosis, pelvic adhesions, and larger fibroids may require laparoscopic surgery or surgery with a larger incision of the abdomen.
Assisted Reproductive Technologies (ART)
Assisted reproductive technologies (ART) refer to fertility treatments that involve the handling of eggs or embryos. This includes IVF, GIFT, and ZIFT.
IVF is the most common form of ART in use today. Less than 2 percent of ART procedures are GIFT, and ZIFT is used less than 1.5 percent of the time.
. IVF (In Vitro Fertilization): In a typical IVF procedure, fertility drugs are used to stimulate the ovaries to produce eggs. Assuming all goes well at this stage, those eggs are then retrieved from the woman’s ovaries in an out-patient procedure.
Next, the eggs are placed together with sperm, in a special cocktail of nutrients, and left alone until fertilization takes place. After fertilization, one to three embryos are placed inside the woman’s uterus.
This is a very basic explanation of IVF treatment. There are many additional assisted technologies that may be used with IVF, including…
. Intracytoplasmic Sperm Injection (ICSI)
. Assisted hatching
. Pre-implantation genetic diagnosis (PGD) (also known as pre-implantation genetic screening, or PGS)
. Cryopreservation (freezing) of eggs, sperm, or embryos
. Third-party reproduction (more on this below)
. Mini-IVF: An option you may not know about is mini-IVF. The primary difference between IVF and mini-IVF is that fewer medications are used. The goal is to stimulate the ovaries only enough to get a few eggs and not several.
Mini-IVF is less expensive than full IVF but slightly more expensive than IUI treatment. It may be more successful than IUI, and it comes with a lower risk of ovarian hyperstimulation syndrome.
. GIFT: With GIFT (gamete intrafallopian transfer), the egg and sperm, or gametes, are not fertilized outside the body. Instead, they are placed together into one of the woman’s fallopian tubes.
. ZIFT: With ZIFT (zygote intrafallopian transfer), the zygote is placed in one of the fallopian tubes. This is usually done via laparoscopic surgery.
Fertility treatment Risks and Side effects
Risks and side effects vary depending on what fertility treatment is being used. Clearly, surgical fertility treatments will have different risks than Clomid.
The most common side effects from fertility drugs include headache, bloating, and mood swings. In rare cases, side effects can be life threatening.
. OHSS. Ovarian hyperstimulation syndrome (OHSS) is a risk with any fertility drug use. When mild, OHSS can lead to bloating and discomfort. In its severe form, if left untreated, OHSS can become life threatening.
Serious OHSS when taking Clomid is rare, but 10 percent of women will develop it during IVF treatment. If you have any symptoms, contact your doctor.
. Multiple pregnancy. Fertility drug use and IVF treatment increase your risk of conceiving multiples. Your highest risk for multiples comes from gonadotropins (or injectable fertility drugs.)
While your risk of conceiving twins on Clomid is around 10 percent, your odds for twins (or more!) with injectable fertility drugs are closer to 30 percent. Multiple pregnancy comes with many risks to both the mother and baby.
. IUI treatment comes with an increased risk of infection and ectopic pregnancy.
Along with the risk of OHSS and multiples, IVF treatment risks include possible infection, ectopic pregnancy, bleeding, puncture to the bladder, bowel, or other surrounding organs; and premature delivery (even if you’re not carrying twins.) There are also risks from the anesthesia used during egg retrieval.
. IVF treatment may increase the risk of some birth defects, though this is debatable. It’s unclear if the risk is increased because of treatment or due to infertility itself.
. IVF with ICSI (which is when a sperm cell is directly injected into an egg) may increase the odds of a male child also being infertile.
. Some worry that fertility treatments increase your risk for cancer. According to the latest research, fertility treatments are mostly in the clear.
However, infertility itself and never carrying a pregnancy or breastfeeding can increase your cancer risks.
Will Fertility Treatments work?
Success rates depend on what treatment is being used, the cause for your infertility, how long you’ve experienced infertility, and your age.
For example, a woman with PCOS being treated with Clomid at age 23 doesn’t have the same live birth success rate as a 42-year-old woman with low ovarian reserves.
Be sure to discuss with your doctor their experience with cases like yours, and what he thinks your odds for successful treatment are.
IVF treatment is often thought of as foolproof, but this isn’t true. IVF is not successful for everyone.
Most couples will require a few cycles of IVF treatment to achieve pregnancy. One large study found that the odds for pregnancy success after three cycles are between 34 and 42 percent.
What happens if Fertility Treatment fails?
There is so much hope when you begin a fertility treatment cycle. Everyone wishes for the first treatment cycle to be “the one.” Unfortunately, it doesn’t always work that way. In fact, it’s unlikely to happen that way.
Remember that even couples with perfect fertility are unlikely to get pregnant on the very first month they try.
If one cycle fails, don’t assume this means your future is bleak. Most treatments need to be tried between three and six times before you can know if it’s going to be a success.
Your doctor should discuss with you what the next step is after a negative pregnancy test.
Some people assume if the first basic treatments fail, IVF is next. However, there are many variations and “levels” of fertility treatment before IVF is the next step.
That said, for some couples, IVF is the first recommended treatment.
Some couples will choose to continue trying on their own. (This may or may not be possible, depending on the cause for infertility. But a small percentage of couples will get pregnant on their own even after infertility.)