management of infertility

Last reviewed 02/2022

Male factors - loose clothing, abstinence from hot baths, clomiphene, intrauterine or donor insemination.

Ovulatory dysfunction - clomiphene citrate, gonadotrophins, pulsatile GnRH, bromocriptine.

Luteal phase deficiency - progesterone, clomiphene.

Tubal damage - surgery.

Cervical factor - bicarbonate douches, intrauterine insemination.

Endometriosis - laparoscopic ablation may increase fecundity in the short term i.e. the capacity to become pregnant, but not long term fertility rates. Assisted reproduction may be advised especially as it will bypass any peritoneal presence of inhibitory factors to gamete function.

Unexplained infertility (1)

• do not offer oral ovarian stimulation agents (such as clomifene citrate, anastrozole or letrozole) to women with unexplained infertility
• offer IVF treatment to women with unexplained infertility who have not conceived after 2 years (this can include up to 1 year before their fertility investigations) of regular unprotected sexual intercourse

Intrauterine insemination (1)

• for people with unexplained infertility, mild endometriosis or 'mild male factor infertility', who are having regular unprotected sexual intercourse:
  • do not routinely offer intrauterine insemination, either with or without ovarian stimulation (exceptional circumstances include, for example, when people have social, cultural or religious objections to IVF) advise them to try to conceive for a total of 2 years (this can include up to 1 year before their fertility investigations) before IVF will be considered

Notes:

• The World Health Organization (WHO) classifies ovulation disorders into 3 groups.

  • Group I: hypothalamic pituitary failure (hypothalamic amenorrhoea or hypogonadotrophic hypogonadism)
    
    
  • Group II: hypothalamic-pituitary-ovarian dysfunction (predominately polycystic ovary syndrome)
    
    
  • Group III: ovarian failure

  
  WHO Group I ovulation disorders

  • advise women with WHO Group I anovulatory infertility that they can improve their chance of regular ovulation, conception and an uncomplicated pregnancy by:
    • increasing their body weight if they have a BMI of less than 19 and/or
    • moderating their exercise levels if they undertake high levels of exercise
  • offer women with WHO Group I ovulation disorders pulsatile administration of gonadotrophin-releasing hormone or gonadotrophins with luteinising hormone activity to induce ovulation
    
    

  WHO Group II ovulation disorders

  In women with WHO Group II ovulation disorders receiving first-line treatment for ovarian stimulation:

  • advise women with WHO Group II anovulatory infertility who have a BMI of 30 or over to lose weight. Inform them that this alone may restore ovulation, improve their response to ovulation induction agents, and have a positive impact on pregnancy outcomes
    
    
  • offer women with WHO Group II anovulatory infertility one of the following treatments, taking into account potential adverse effects, ease and mode of use, the woman's BMI, and monitoring needed:
    • clomifene citrate or
    • metformin
    • or a combination of the above
      
      
  • for women who are taking clomifene citrate, offer ultrasound monitoring during at least the first cycle of treatment to ensure that they are taking a dose that minimises the risk of multiple pregnancy
    
    
  • for women who are taking clomifene citrate, do not continue treatment for longer than 6months
    
    
  • women prescribed metformin should be informed of the side effects associated with its use (such as nausea, vomiting and other gastrointestinal disturbances)
    
    

  In women with WHO Group II ovulation disorders who are known to be resistant to clomifene citrate:

  • for women with WHO Group II ovulation disorders who are known to be resistant to clomifene citrate, consider one of the following second-line treatments, depending on clinical circumstances and the woman's preference:
    • laparoscopic ovarian drilling or
    • combined treatment with clomifene citrate and metformin if not already offered as first-line treatment or
    • gonadotrophins
      
      
  • women with polycystic ovary syndrome who are being treated with gonadotrophins should not be offered treatment with gonadotrophin-releasing hormone agonist concomitantly because it does not improve pregnancy rates, and it is associated with an increased risk of ovarian hyperstimulation

  
  Hyperprolactinaemic amenorrhoea -dopamine agonists

  • women with ovulatory disorders due to hyperprolactinaemia should be offered treatment with dopamine agonists such as bromocriptine. Consideration should be given to safety for use in pregnancy and minimising cost when prescribing

Reference:

• NICE (September 2017).Fertility - Assessment and treatment for people with fertility problems