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Chapter IV

Infertility Treatment (Definition, Types, Types, Causes, Risks and Side Effects ) In Conventional Perspective

A. Hormone Imbalance

I. Definition

Conventional medication used to treat hormone imbalance containing agents which help to stimulate the ovaries in mature egg production, thereby increasing the chance of pregnancy for infertile couple. The medication is only given to women who are diagnosed with ovulation dysfunction.

II. Types of medication

1. Progesterone supplement

Types of medication specially used for women with luteal phrase deficiency (lasts under 10 days and it is considered a luteal phase deficiency) It helps to increase the levels of progesterone, thereby, preventing the abnormal developing of uterine lining and interfering with fertilized egg implantation.

2. Ovulation introduction agent

A medication is used for women with highly irregular ovulation cycle including not ovulation at all. It is used in the day 5 to 9 of the cycle effective for younger women with successful rate over 90% but only about 35% actually conceive.

3. Follicle-stimulating hormone ( FSH)

This types of medication are prescribed for women with ovation disorder to stimulate follicle and egg production. It is recommended that using these drugs including Gonal-f, Follistism, Fertinex and Metrodin, should be closely monitored by your doctor in order to prevent hyperstimulation of ovaries. They are used widely for intrauterine insemination.

4. Human menopause gonadotrophins (HMG)

Medication such as Menopur, Pergonal, Humegeon. etc. help women who do not ovulate regularly to stimulate the ovaries to produce more than one egg by working directly on ovaries to stimulate follicle development.

5. Humam chorionic gonadotropin (HCG)

HCG is a type of medication made directly from placeneta of pregnant women. It is synthesis chemically similar to LH, leading to increase or surge of LH hormone and triggering ovulation resulting in increasing the egg production and supporting uterine lining in fertilized egg implantation. Medication include Novarel, and Profasi.

6. Gonadotrophin-releasing hormone (GnRH)

It helps to regulate the pituitary gland in production of , FSH and LH hormone, thereby decreasing the risk of ovulation in the wrong time. In other word, It stimulates the pituitary gland to produce FSH and LH for women who do not ovulate at all. Medication include Fertrel and Lutrepulse.

a) Agonist

The medication ( Leuprolide and Synarel ) is used to blocks the egg production by the ovaries by regulating the hormone secretion until the egg to reach certain size, thereby increasing the quality of egg and preventing the release of premature egg for some women.

b) Antagonist

By regulating the production of FSH and LH from pituitary gland, it decreases the surge of LH that triggers ovation at the wrong time. It is used when a women undergoes fertility procedure for artificial insemination, so her doctor can better predict the timing of ovation for egg retrieval.

7. Prolaction medicine

For men and women who suffer infertility because of over production of prolactin hormone resulting in interfering the production of FSH and LH, leading to abnormal ovulation in women and low quality sperm in men.

III. Side effects

The common side effects of above medication include

1. Dizziness

2. Hot flashes

3. irregular menstruation

4. Headache

5. Insomnia

6. Irritability

7. Vomiting

8. Etc.

IV. Risk

1. Complication

2. Ovarian hyper stimulation

3. Nervous disorder

4. Ectopic pregnancy

5. Ovarian twisting and cancer

6. Cyst development

7. Etc.

Almost 100% of women who take these types of medication will ovulate, but not all women will get pregnant. If a couple can not conceive after the infertile female taking the treatment in their first 6 treatment than the chance of pregnancy is reduced by 50%.

B. Types of Non Surgical Infertility Method

If a couple can not get pregnant after 1 year of unprotected sex or carry the fetus to full term, they are considered as infertile couple. Most people under this circumstance, they will seek help from conventional doctor. After lengthy examination and diagnosis, if non surgical problem is found, then the followings are recommended by their specialist depending to what has been diagnosed

I. Definition

Non surgical infertility problem is considered as aproblem which can not be treated by medication and surgery such as impotence and sexual dysfunction in men and hyperproclatinemia. The fertility of a couple is assisted by some types of assisting reproductive technologies.

II. Types of artificial inseminations

1. Intra cervical insemination

Artificial insemination (AI) or intra cervical insemination is the process by which sperm is placed into the reproductive tract of a female for the purpose of impregnating the female by using means other than sexual intercourse.

2. Intrauterine insemination

Intrauterine insemination is defined as the selection of good quality sperm from a infertile male sperm semen by injecting the good quality sperm fluid into the uterus of his female partner, thereby increasing the chance of sperm to reach the Fallopian tubes where fertilization of the egg occurs.

3. Gamete intrafallopian tube transfer (DIFT)

Gamete intrafallopian transfer (GIFT) is a technique which places one egg in the Fallopian after removing from the ovaries along with the sperm semen of her male partner.

4. Zygote intrafallopian tube transfer (ZIFT)

It is a procedure which is often used to treat infertility, if diagnosis found that there is blockage in the female partner Fallopian tubes that prevents the sperm to fertilize the mature egg. Under zygote intrafallopian tube transfer (ZIFT), after egg cells are removed from a woman's ovaries, it is put in vitro fertilized and finally the zygote is placed into the fallopian tube by laparoscopy.

5. Tubal embryo transfer (TET)

By transferring the more advance embryos (cleaved embryos) into the female partner Fallopian tubes, it increases the chance of fertility after achieving fertilization in the laboratory. It is only suitable for women who have at least one healthy Fallopian tube.

6. Intrasytoplastic sperm injection (ICSI)

By injecting only one quality sperm into the egg for fertilization. Intracytoplasmic sperm injection is commonly used only for male whose sperm are diagnosis with egg penetrating problem as a method of in vitro fertilization.

7. Testicle sperm extraction (TEST)

Testicular Sperm Aspiration (TESA) is most commonly used for male who for what ever reasons, has problem in ejaculating, or whose sperm contain little or no living or motile sperm, but with good sperm in the testicles. By collecting the sperm semen directly from the testicles, the fertilization process can occur in vitro fertilization (IVF) by using the intrasytoplastic sperm injection method.

8. Assisted Hatching

By collecting egg from ovaries from the infertile woman and after the egg is fertilized in vitro fertilization (IVF), the assisted hatching helps the embryo hatch out of its protective layering and artificially implants into the uterus.

9. Cryopreservation

For what ever reason some couple decide to have children in the future, they may want to use the cryoptresevation to freeze the eggs or sperm in the sub- zero temperatures, such as between 77 K or −196 °C. Most comom cryppreservation includes

a) Freezing sperm

b) Freezing embryo c) Freezing eggs

d) Freezing ovaries

C. Types and Risks of Conventional Surgery In Treating Infertility

I. Types of conventional surgery for infertility

1. Laparotomy microsurgery

Laparotomy microsurgery is surgical procedure which helps to remove the endometrial scar tissues which in some ways interfere with the female fertilization process by reconstructing or repairing the Fallopian tube using a microscope.

2. Laparsoscope

After a small incision, the laparoscope is inserted for the doctor to view the pelvic organs. If any abnormality is found, another incision is needed for the doctor to remove any scar tissue, endometriosis or cyst, etc. It helps your doctor to have a clean view of your abdomen and repair the blockage of the fallopian tubes, if necessary.This procedure is often used to treat female infertility with blockage of fallopian tubes and endometriosis .

3. Hyteroscope

By using a fiber optic scope connecting to the hyteroscope and stretching the cervical canal, your doctor has a clean view of your uterine. If any abnormality is found such as fibroids, polyps, and scarring, hysteroscopy, they will be is remove, as they may obstruct the fertility processes. Hysteroscopy is routinely performed on an outpatient setting and the recovery time is typically between 2-3 days.

4. Falloposcope

By inserting a tiny flexible fibre-optic scope through the cervix, uterus and into the Fallopian tubes, you doctor can view your fallopian clearly. It is performed in out patient setting, if your doctor suspects there are tubal obstruction problem which interferes with the egg fertilization. It is often used to determine whether fallopian corrective surgery or IVF is the better treatment for infertility.

II. Risks

Like other surgeries, there are always some risks in reproductive diagnosis and surgery including

a) Infection b ) Bleeding

c) Reactions to anaesthesia

d) Damage to the other reproductive organs such as. intestine or urinary tract.

D. Types of Medication Treatment In Conventional Medicine

DA. Progesterone Supplement: Definition, Effects, Side Effects and Risk

1. Definition

Progesterone is a type of hormone produced in our body in regulating the menstrual cycle. Women body start to produce progesterone just before ovation in order to make mucus friendly to sperm invasion. The rise of levels of progesterone after ovulation helps to soften the uterine lining for preparation of fertilized egg.

2. How progesterone supplement effects infertile women

Types of medication specially used for women with luteal phrase deficiency (lasts under 10 days and it is considered a luteal phase deficiency) leading to increasing risk of abnormal development of uterine lining and interfering with fertilized egg implantation.

a) Uterus Lining

The rise of levels of progesterone by using progesterone supplement increases the softness of the endometrium which is vital for egg implantation. With enough progesterone, the endometrium is not soft enough for the egg to attach to it, leading to early miscarriage.

b) Unfriendly to Sperm

It helps to increase levels of progesterone just before ovulation that stimulates the expansion of tiny glands in the endometrium leading to production of uterine fluid which helps to nourish sperms and allow sperm to travel to the Fallopian tube for egg fertilization. Deficiency of progesterone causes sticky mucus which is hostile to sperm invasion.

c) Egg Movement

progesterone supplement boost the levels of progesterone, because after fertilization, the fertilized moves from the fallopian tube to the uterine and ready for implantation. without enough levels of progesterone, the uterine mucus may interfere with that movement, leading to miscarriage.

4. Maintaining pregnancy

it helps the levels of progesterone remain high during the last part of menstrual cycle, if the pregnancy occurs, because it is vital for embryo development. Deficiency during pregnancy causes abnormal development of embryo resulting in miscarriage.

3. Side effects

Although progesterone helps to increase the chance of fertilization, it causes some side effect including

a) Blood clots in the lungs ( sudden shortness of breath) and legs, or even stroke ( blocking the blood circulation)

b) Chest pain.

c) Blurred vision.

d) Numbness or tingling in the arms or legs.

4. Risk

a) Breast cancer

b) Heart disease and strokes

D.B Ovulatory Dysfunction Agent-Definition, Effect and Side Effects of Conventional Medication In Treating Hormone Imbalance

1. Definition

Since ovulatory dysfunction is one of the most common causes for infertility in otherwise fertile couples. Ovulatory dysfunction medication is defined as conventional medication which helps to restore the successful ovulation resulting in fertility.

2. How Ovulatory dysfunction agent effects infertile women a) Stimulating the production of LH and FSH

The medicine inhibits the levels of estrogen that causes the pituitary gland to produce more FH and FSH leading to production of follicle in releasing the mature eggs as resulting of man made ovulation.

b) Irregular menstrual cycle

While it helps to stimulate the production of LH and FSH by the pituitary gland, it also helps to restore the normal menstrual for women, if the causes of infertility is irregularly related problem.

c) Egg production

Ovulatory dysfunction agent also helps to trigger eggs production, it is used often for women, if the mature egg production is the underline causes of infertility.

d) Luteal phrase deficiency

Women with shorten of luteal phrase is usually with low levels of progesterone as resulting of interfering of mature egg production or abnormal of FH and FSH hormone. The medication increases the production of FH and FSH, leading to the surge of levels of progesterone resulting in correcting the luteal phrase that is vital for egg implantation.

3. Side effects

a) Hot flash as resulting of low levels of estrogen

b) Mood swing caused by production of FH and FSH from the pituitary gland

c) Breast tenderness, shorten of breath and vision problem as resulting of high levels of progesterone.

d) Ovarian cysts as resulting of over stimulating the production of egg during ovulation, it is a cyst-like structure called a follicle is formed inside the ovary

4. Risks

The only risk is multiple birth.

DC. Follicle-stimulating hormone ( FSH): Definition, Effects, Side Effects and Risk

1. Definition

Follicle-stimulating hormone ( FSH) is made from purified urine of postmenopause women. It is uses to treat ovulation disorder and stimulate the follicle and egg production.

2. How follicle-stimulating hormone ( FSH) effects infertile women

The medication if only given for women with ovulation problem such as without responding to the ovulatory dysfunction medicine but with high levels of LH as we mentioned in the previous article

a) Follicle enhancer

Since follicle-stimulating hormone (FSH) secreted by the anterior pituitary gland as resulting of secreting of gonadotropin-releasing hormone, low levels of GrNH in the women body may causes little secreting of FSH leading to low levels o f FSH and interfere with the ovulation as well as development of follicles that are vital for production of eggs from the ovaries.

b) Egg production

Beside helping the production of follicles, it also helps to improve the production of mature and assists mature egg extruding to the Fallopian tube that are vital for the women to conceive.

Women who undergoes the follicle stimulating hormone treatment is required to be monitored closely by their doctor.

III. Side effects

Study show that FSH medication increase the risk of menstrual change and amenorrhea including vagina bleeding and abnormal pain and cramps.

IV. Risks

a) Ectopic pregnancy as resulting of over production of mature eggs being extruded into the Fallopian tube or somewhere else.

b) Miscarriage as resulting of not enough progesterone to support the development of embryo c) Ovarian cysts Almost 100% of women who take these types of medication will ovulate, but not all women will get pregnant.

DD. - Human menopause gonadotrophins (HMG): Definition, Effects, Side Effects and Risks

1. Definition

Human menopausal gonadotropins (HMG) contain both (LH) luteinizing hormone(LH) and follicle stimulating hormone(FSH) which are used for women with ovulation disorder by triggering the ovulation in production of follicle and egg. HMG is one of the fertility medical treatment which may be necessary for women, if artificial insemination is required such as IUI, IVF and other ART.

2. How HMG effects infertile women

By using the HMG to increase the levels of LH and FSH as resulting of inability of pituitary gland in LH, and FSH production, it helps to stimulate ovulation as we mentioned in previous article.

a) Ovulatory disorders

Ovulatory disorder ussually caused by low levels of LH and FSH as resulting in either of low levels of estrogen or damage of hypothalamus in releasing of GrNH, HMG increases the levels of LH and FSH directly without the need of hypothalamus secretion.

b) Pituitary gland abnormality

For what ever reason, some women's pituitary gland is not responsed to the secreting of the GrNH in production of LH and FSH or low levels of LH and FSH as resulting of pituitary gland malfunction. HMG increases levels of FH and FSH naturally, leading to ovulation.

c) Eggs production

HMG besides enhancing ovulation, it also acts directly to the ovarian in follicle and mature eggs production.

3. Side effects

a) Hyperovarian stimulation as resulting of over production of follicles inside of the ovaries.

b) Nervous disorder as resulting of interfering of hormone production. Symptoms include mood swing and depression.

4. Risk

Increasing the risk of multiple pregnancy by 40% of all pregnancies.

DE. Humam chorionic gonadotropin (HCG): Definition, Effects, Side Effects and Risks

1. Definition

Humam chorionic gonadotropin (HCG) is either made from urine of pregnant women or hormone produced by human placenta. It is used conjunction with FSH and HMG as we mentioned in previous article.

2. How humam chorionic gonadotropin (HCG) effects fertility a) Ovulation

The medication is synthesis luteinizing hormone (LH) that helps to increase the production of LH and induce ovulation by controlling hyperstimulation. b) Support the uterine lining Beside helping in eggs production, it also increases the normal development of uterine lining that is essential for fertilized egg implantation. without supporting from the softening of endometrium, the fertilization process may end in miscarriage.

3. Side effects

a) Hot Flash caused by high levels of LH

b) Headache caused by over stimulation of the medication which interfere with the outer brain nervous system

c) Fluid retention as resulting in interfering with the function of lymphatic and kidney function in regulating fluid in the body

a) Others such as bloating and mild nausea.

4. Risks

a) Ectopic pregnacy caused by over stimulation of more than one egg. b) Multiple pregnancy

As we mentioned in a)

c) Spontaneous abortion

As resulting of multiple fertilizing egg or inability of endometrial uterine lining in supporting too many fertilization eggs or abnormal function of endometrium.

d) Premature delivery

As resulting of many eggs have developed, leading to little space in the uterus for the fetus to grow.

DF. -Gonadotrophin-releasing hormone (GnRH): Definition, Effects, Side Effects and Risks

I. Definition

Gonadotrophin-releasing hormone (GnRH) is a synthesis GnRH hormone which helps to replace or increase the levels of GnRH in stimulating the production of LH and FSH by the pituitary gland II. How Gonadotrophin-releasing hormone effects infertile women GnRH may be used for infertile women, after HCG and ovulation dysfunction medication have been failed to stimulate the women reproductive ovulation. The process of LH and FSH production are controlled by the size and frequency of GnRH pulses.

1. Ovulation

At the begining, synthesis GnRH stimulates the low frequency GnRH pulses that cause the pitiutary gland to release FSH that helps to stimulate ovulation and the production of follicle and egg.

2. Egg Extrading

As the follicle mature, synthesis GrNH helps to increase the production of estradiol that stimulates the high frequency GrRH pulses and stops the putuitary in secreting FSH and increases the production of LH leading to egg releasing into the Fallopian tube.

3. Side effects a) Hot flashes.

b) Mood swings.

c) Vaginal dryness.

d) Decreased sexual interest. e) Insomnia.

f) Headaches.

4. Risk

a) Bone loss

b) Heart disease

Raising the level of LDL cholesterol and decreasing your HDL cholesterol.

DG. Prolaction Medicine: Definition, Effects, Side Effects and Risk

1. Definition

Prolactin medicine is a synthesis prolactin hormone which inhibits the levels of prolaction hormone in the body. High levels of prolaction may interfere with ovulation leading to infertility.

2. How progesterone supplement effects infertile women

If the levels of prolactin hormone is high, which causes abnormal function of pituitary gland in thinking the women is in pregnancy state, leading to low levels of FSH and LH.

a) Restore normal function of FSH production

By inhibiting the levels of prolactin in the body, the medication helps to restore the normal function of pituitary gland in production of FSH, leading to ovulation and follicle production from the ovaries.

b) Restore the normal function of LH production

Since the levels of prolaction is dropped to normal levels, the process of hormone production by the pituitary gland is not disrupted. After eggs have been produced, the pituitary gland switch to to the production of LH, leading to mature egg being extruded into Fallopian tube for fertilization.

3. Side effects

a) Low blood pressure

b) Nervous tension includes insomnia and dizziness.

4. Risk

a) Breast cancer

b) Stomach ulcers or bleeding from the stomach c) Fibroids

d) The possibility of a tumour