Infertility Treatment Options: From Diagnosis to Assisted Reproduction
Infertility affects 1 in 6 couples. Understanding the diagnostic process and treatment ladder — from simple lifestyle changes to IUI and IVF — can guide couples on their journey to parenthood.
By Dr. Amrendra Prasad Kushwaha
Infertility is defined as the inability to conceive after 12 months of regular, unprotected intercourse (or 6 months if the woman is over 35). It is more common than many people realise, affecting approximately 1 in 6 couples worldwide.
The good news: most causes of infertility are treatable, and the majority of couples who seek specialist help will eventually achieve a pregnancy.
Understanding the Causes
Infertility can originate from female factors, male factors, or a combination of both.
Female Factors (~40% of cases)
- Ovulatory disorders — Polycystic Ovary Syndrome (PCOS), hypothalamic dysfunction, premature ovarian insufficiency
- Tubal factor — blocked or damaged fallopian tubes (often from past infections or endometriosis)
- Uterine abnormalities — fibroids, polyps, Asherman's syndrome (intrauterine adhesions)
- Endometriosis — affects egg quality, tubal function, and implantation
- Age-related decline in egg quality and quantity
Male Factors (~40% of cases)
- Low sperm count (oligospermia)
- Poor sperm motility (asthenospermia)
- Abnormal sperm morphology (teratospermia)
- Azoospermia (no sperm)
- Hormonal imbalances
Combined or Unexplained (~20%)
In some couples, no specific cause is identified despite thorough investigation. This is termed unexplained infertility.
The Diagnostic Work-Up
A thorough evaluation is essential before any treatment is started.
For Women
- Hormonal blood tests — FSH, LH, oestradiol, AMH (ovarian reserve), thyroid function, prolactin
- Transvaginal ultrasound — antral follicle count, uterine assessment, ovarian morphology
- Hysterosalpingography (HSG) or laparoscopy — to check tubal patency
- Mid-luteal progesterone — to confirm ovulation
For Men
- Semen analysis — count, motility, morphology, volume
- Hormonal assessment if indicated
- Scrotal ultrasound if varicocele suspected
The Treatment Ladder
Treatment is matched to the underlying cause and is usually approached in a stepwise manner.
Step 1: Lifestyle Optimisation
Before any intervention:
- Achieve a healthy BMI (18.5–25)
- Quit smoking and alcohol
- Manage stress
- Take folic acid (400 mcg/day for women)
- For men: avoid heat exposure to the scrotum (laptops, hot baths)
Step 2: Medical Management of Ovulatory Disorders
- Clomiphene citrate or letrozole — oral medications to stimulate ovulation
- Metformin — for women with PCOS and insulin resistance
- Gonadotrophin injections — for women who do not respond to oral medications
- Thyroid or prolactin treatment — where these are the underlying cause
Step 3: Surgical Correction
- Laparoscopic surgery for endometriosis, ovarian cysts, tubal adhesions
- Hysteroscopy for uterine polyps, fibroids (submucous), or intrauterine adhesions
- Varicocelectomy for men with varicocele
Step 4: Intrauterine Insemination (IUI)
IUI involves placing prepared sperm directly into the uterus around the time of ovulation. It is recommended when:
- Sperm parameters are mildly abnormal
- Unexplained infertility (mild cases)
- Cervical factor infertility
- When donor sperm is required
Typically 3–6 cycles are attempted before moving to IVF.
Step 5: In Vitro Fertilisation (IVF)
IVF is the most effective assisted reproductive technology. It involves:
- Ovarian stimulation with injectable hormones
- Egg collection (transvaginal ultrasound-guided)
- Fertilisation in the laboratory
- Embryo culture for 3–5 days
- Embryo transfer to the uterus
ICSI (Intracytoplasmic Sperm Injection) — used when male factor infertility is significant; a single sperm is injected directly into the egg.
Emotional Support
Infertility is not just a physical challenge — it carries a significant emotional burden. I encourage couples to:
- Communicate openly with each other
- Seek counselling if stress or anxiety is affecting quality of life
- Connect with support groups
- Be patient: treatment often takes multiple cycles
When to Seek Help
- Under 35: After 12 months of trying
- 35–40: After 6 months
- Over 40: Seek evaluation promptly
- Any age: Immediately if you have known risk factors (irregular periods, past pelvic infection, previous ectopic pregnancy, known male factor)
Infertility is a journey that many couples face, and you do not need to navigate it alone. With the right diagnosis and a stepwise treatment approach, the path to parenthood is achievable for most couples.
Contact: 984-3504431 | Hope Hospital, Kathmandu