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Fertility for Patients of East Asian Heritage - Basics of Fertility Treatment

Course / Basics of Fertility Treatment

Introduction

 Navigating the path to parenthood often involves understanding a spectrum of medical treatments. As fertility experts, we guide intended parents through options ranging from simple, monitored cycles to advanced reproductive technologies. This course provides a clear, clinical overview of the primary fertility treatments available, which serve as the foundational steps before or alongside a surrogacy journey. 

Timed Intercourse

To maximize the probability of conception by ensuring sperm are present in the fallopian tubes at the time of ovulation. 

Clinical Protocol: 

  • Cycle Monitoring: The patient undergoes transvaginal ultrasounds around cycle days 3-5 and again around days 10-12 to track follicular development. The goal is to identify a dominant follicle and monitor its growth to a mature size of 18-24mm. 
  • Ovulation Trigger: Once follicular maturity is confirmed, an injection of hCG (e.g., Ovidrel) or a GnRH agonist is administered to precisely induce ovulation, typically within 36-40 hours. 
  • Timing Instruction: Patients are instructed to have intercourse on the day of the trigger and for the following 1-2 days. 

This approach is best for couples with unexplained infertility, mild male factor issues, or irregular ovulation where the fallopian tubes are known to be patent. It is a first-line intervention that adds structure to natural conception efforts. 

Oral Medication

To stimulate the ovaries to develop and release one or more mature eggs. 

Clinical Protocol: 

Medication Administration: Clomiphene Citrate or Letrozole is typically prescribed for 5 days early in the menstrual cycle (days 3-7 or 5-9). 

Mechanism of Action: 

  • Clomiphene Citrate: A selective estrogen receptor modulator (SERM) that tricks the brain into increasing FSH production, thereby stimulating the ovaries. 
  • Letrozole: An aromatase inhibitor that lowers estrogen levels, prompting the pituitary gland to release more FSH. 

Monitoring: Response is monitored via ultrasound to track follicle growth and prevent the risk of high-order multiples. An ovulation trigger shot may be used to time ovulation precisely. 

Patients with ovulatory disorders such as Polycystic Ovary Syndrome (PCOS). It is often used in conjunction with Timed Intercourse or IUI. 

Intrauterine Insemination

To bypass the cervical barrier and place a concentrated sample of motile sperm directly into the uterine cavity, closer to the egg. 

Clinical Protocol: 

  • Sperm Washing: On the day of the procedure, a semen sample is provided and processed in the lab. This “washing” procedure removes seminal fluid, dead sperm, and debris, leaving a concentrated sample of highly motile sperm in a small volume of culture medium. 
  • Insemination: Using a thin, flexible catheter, the prepared sperm sample is gently passed through the cervix and into the uterine fundus. The procedure is quick, typically painless, and resembles a pap smear. 
  • Timing: IUI is performed approximately 24-36 hours after an ovulation trigger shot, coinciding with ovulation. 

IUI is indicated for mild male factor infertility, cervical factor infertility, unexplained infertility, and when using donor sperm. It requires at least one patent fallopian tube. 

In Vitro Fertilization

To achieve fertilization in a controlled laboratory environment, create embryos, and facilitate implantation by transferring an embryo directly into the uterus (or a gestational surrogate’s uterus). 

Clinical Protocol: 

  • Ovarian Stimulation: The patient undergoes daily injectable gonadotropins (FSH/LH) for approximately 8-12 days to stimulate the development of multiple follicles. 
  • Monitoring: Frequent monitoring via ultrasound and blood work ensures optimal follicular growth and adjusts medication dosages to prevent complications like Ovarian Hyperstimulation Syndrome (OHSS). 
  • Egg Retrieval: When follicles are mature, a transvaginal ultrasound-guided needle aspiration is performed under sedation to collect the eggs. 
  • Fertilization & Embryo Culture: Retrieved eggs are combined with sperm (via conventional insemination or ICSI). The resulting embryos are cultured in an incubator for 5-6 days to the blastocyst stage. 
  • Embryo Transfer: A single blastocyst (or occasionally two) is selected and transferred into the uterine cavity using a thin catheter. Surplus high-quality embryos can be cryopreserved (frozen) for future use. 

 IVF is the treatment for severe tubal factor infertility, significant male factor infertility, severe endometriosis, advanced maternal age, and for all intended parents pursuing gestational surrogacy. It is also used for genetic screening (PGT). 

Where to Start: IUI or IVF?

The choice between starting with IUI or proceeding directly to IVF is a significant clinical decision based on medical factors, prognosis, and patient goals. 

Start with IUI when: 

  • Female Age: The patient is under 35. 
  • Tubal Status: At least one fallopian tube is open and healthy. 
  • Ovarian Reserve: Normal (AMH > 1.0 ng/mL, AFC > 10). 
  • Sperm Parameters: Mild male factor or normal semen analysis. 
  • Diagnosis: Unexplained infertility, mild endometriosis, or anovulation. 
  • Considerations: IUI is less invasive and less expensive per cycle, but it has a lower success rate per attempt (10-20%). 

Proceed directly to IVF when: 

  • Female Age: The patient is 38 or older, where time is a critical factor. 
  • Tubal Status: Bilateral tubal blockage or damage. 
  • Sperm Parameters: Severe male factor infertility requiring ICSI. 
  • Diagnosis: Severe endometriosis (Stage III/IV), diminished ovarian reserve, or genetic disorders requiring PGT. 
  • For Surrogacy Journeys: When the intended mother cannot carry a pregnancy or has absolute uterine factor infertility, IVF is required to create embryos for transfer into a gestational surrogate. 
  • Considerations: IVF offers the highest per-cycle success rates (often 50%+ for a single euploid blastocyst transfer) and allows for genetic testing and cryopreservation of embryos. 
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