A perspective view of the treatment of infertility

Modern medical treatment of infertility commenced with the development of In Vitro Fertilisation (IVF), and is still largely based on it. The treatment comprises five main components:

  1. stimulation of ovulation with hormones
  2. removal of eggs from the stimulated ovary
  3. preparation of a sample of viable sperm
  4. fertilisation and incubation of the eggs with the sperm
  5. replacement of (a number of) fertilised eggs in the womb

At its best, this can achieve a 30% success rate at the first attempt, rising to a cumulative total of around 50% over three cycles, after which the success rate falls away rapidly. The procedure can prove traumatic for the woman, due to psychological effects of the hormones, and the fact that egg removal is a significant surgical procedure requiring general anaesthesia and an overnight hospital stay. Moreover, IVF is costly, typically around £4,000 per cycle in the UK, and $10,000 in the USA. For these multiple reasons, both patients and doctors are reluctant to use it as soon as a couple seeks help.

Up till now few suitable methods of establishing the cause of infertility have been widely adopted. Often, a couple will progress from natural attempts at conception, to ovarian stimulation, firstly using Clomiphene and normal intercourse. If this fails then it is followed by more vigorous stimulation with gonadotropins, usually with Intra-uterine Insemination (IUI), in which a semen sample is processed to sort viable from non-viable sperm and then inserted directly into the uterus at the time of ovulation. Commonly between 3 and 5, sometimes up to 10 cycles of IUI are tried, with the cumulative success rate around 30% (except where donor sperm are used).

It should be pointed out that stimulated IUI, while it may work for women whose main problem is failure to ovulate, will not work for women who have abnormalities of the reproductive organs (see below). These account for 25-30% of all female infertility. Generally, only when IUI has failed is IVF attempted, and this is also without a detailed process of diagnosis. Up to a point, this works, because IVF is able to overcome a number of possible problems.

However, in fact many of the problems that IVF is able to overcome are capable of being diagnosed and treated much more simply, cheaply, and without distress to the woman. The main problem is to identify them early on, and treat them appropriately. The reason this does not happen is that the diagnostic procedures normally used are very limited in their utility. In fact, they are limited to an assessment of ovarian function. There is generally no routine assessment of abnormality or disease of the upper reproductive tract, even though this is a frequent cause of infertility.