There are multiple strategies for causing ovulation in clomid or letrozole resistant patients. Some of these include adding medications such as dexamethasone or metformin to the treatment regimen. Another approach is changing to gonadotropin injections. Rather than tricking the brain into sending a stronger signal to the ovaries to cause follicle recruitment, gonadotropins directly stimulate the ovary to recruit multiple follicles.
Amenorrhea (including hypothalmic amenorrhea) is a condition in which there is an absence of menstrual periods in a woman. There are two types of amenorrhea: primary and secondary. Treatment of amenorrhea depends on the type. In primary, surgery may be an option and in secondary amenorrhea medication or lifestyle changes may be treatment options. We go over the definition of amenorrhea, causes, and treatment options for amenorrhea.
Treatment with Clomid tablets plus IUI improves fertility rates. For unexplained infertility, studies have shown that for women under 35, monthly success rates for Clomid plus insemination are about 10% per cycle. This pregnancy rate holds up for about 3 tries and the success rate is considerably lower after that. More about success rates with IUIs is on the insemination page and on the Clomid for unexplained infertility page. The insemination component boosts fertility more than the Clomid does - but success rates are higher when both are used together. 

Once the embryos are ready, you will return to the IVF facility so doctors can transfer one or more into your uterus. This procedure is quicker and easier than the retrieval of the egg. The doctor will insert a flexible tube called a catheter through your vagina and cervix and into your uterus, where the embryos will be deposited. To increase the chances of pregnancy, most IVF experts recommend transferring up to three embryos at a time. However, this means you could have a multiple pregnancy, which can increase the health risks for both you and the babies.
IVF has many steps, and it takes several months to complete the whole process. It sometimes works on the first try, but many people need more than 1 round of IVF to get pregnant. IVF definitely increases your chances of pregnancy if you’re having fertility problems, but there’s no guarantee — everyone’s body is different and IVF won’t work for everyone.
For couples who have no difficulty achieving a pregnancy, the natural chance of pregnancy per month of ovulation is largely dependent on the age of the woman. For women in their early 30s or younger, the natural pregnancy rate is about 20 to 25 percent per cycle. This drops off significantly through her mid-to late-30s; by her early 40s, the chance of pregnancy is about 5 percent per cycle. This age-related decrease is primarily due to a decline in the quality of the eggs within the ovaries.
Amongst these two patient populations (which we’ll refer to now as PCOS), IUI with clomid and letrozole generally shows no improvement versus when these drugs are taken without IUI. When IUI is coupled with gonadotropins, success rates reach 14 - 26% per cycle, which is higher than almost any other patient class, but still pales in comparison to IVF. It’s also worth noting that PCOS patients who are taking gonadotropins have a very high risk of multiples.
Many people have never heard the term "secondary infertility"; fewer understand it. I discovered it a year into my struggle to conceive a second child and fell on it, amazed. What I was undergoing had a name! I wrote it down and immediately felt better, as if the phrase exuded a talismanic power that might protect me from the likes of my neighbour.

Certain kinds of IVF, in particular ICSI (first applied in 1991) and blastocyst transfer (first applied in 1984) have been shown to lead to distortions in the sex ratio at birth. ICSI leads to slightly more female births (51.3% female) while blastocyst transfer leads to significantly more boys (56.1% male) being born. Standard IVF done at the second or third day leads to a normal sex ratio.
The eggs are retrieved from the patient using a transvaginal technique called transvaginal oocyte retrieval, involving an ultrasound-guided needle piercing the vaginal wall to reach the ovaries. Through this needle follicles can be aspirated, and the follicular fluid is passed to an embryologist to identify ova. It is common to remove between ten and thirty eggs. The retrieval procedure usually takes between 20 and 40 minutes, depending on the number of mature follicles, and is usually done under conscious sedation or general anaesthesia.
If both partners are young and healthy and have been trying to conceive for one year without success, a visit to a physician or women's health nurse practitioner (WHNP) could help to highlight potential medical problems earlier rather than later. The doctor or WHNP may also be able to suggest lifestyle changes to increase the chances of conceiving.[62]
Treatment depends on the cause of infertility, but may include counselling, fertility treatments, which include in vitro fertilization. According to ESHRE recommendations, couples with an estimated live birth rate of 40% or higher per year are encouraged to continue aiming for a spontaneous pregnancy.[63] Treatment methods for infertility may be grouped as medical or complementary and alternative treatments. Some methods may be used in concert with other methods. Drugs used for both women and men[64] include clomiphene citrate, human menopausal gonadotropin (hMG), follicle-stimulating hormone (FSH), human chorionic gonadotropin (hCG), gonadotropin-releasing hormone (GnRH) analogues, aromatase inhibitors, and metformin.
The Fallopian tubes are the site for fertilization before the embryo makes its way to the uterine cavity for implantation. If the Fallopian tubes are damaged, fertilization may not occur. If one Fallopian tube is blocked, it may be due to inherent disease involving both Fallopian tubes; even if the other Fallopian tube is open, it may not be able to provide the appropriate nurturing environment for fertilization and early embryo growth to take place. 

The Human Fertilisation and Embryology Authority said in September 2018 that parents who are limited to one cycle of IVF, or have to fund it themselves, are more likely choose to implant multiple embryos in the hope it increases the chances of pregnancy. This significantly increases the chance of multiple births and the associated poor outcomes, which would increase NHS costs. The president of the Royal College of Obstetricians and Gynaecologists said that funding 3 cycles was "the most important factor in maintaining low rates of multiple pregnancies and reduce(s) associated complications".[165]

Endometriosis implants are most commonly found on the ovaries, the Fallopian tubes, outer surfaces of the uterus or intestines, and on the surface lining of the pelvic cavity. They also can be found in the vagina, cervix, and bladder. Endometriosis may not produce any symptoms, but when it does the most common symptom is pelvic pain that worsens just prior to menstruation and improves at the end of the menstrual period. Other symptoms of endometriosis include pain during sex, pain with pelvic examinations, cramping or pain during bowel movements or urination, and infertility. Treatment of endometriosis can be with medication or surgery.

It is possible that a significant contributor to unexplained infertility can be attributed to changes in sperm epigenetics. Methylation patterns in sperm DNA which affect the expression of various genes may be the missing link for this unique patient population. By employing epigenetic analysis, we may be able to identify more causes of infertility and suggest the optimal course of therapy. Preliminary evidence even suggests that these epigenetic signatures influence the probability of conception, embryogenesis, and successful carrying of pregnancy to term. Future research on sperm epigenetics holds the promise of revolutionizing reproductive medicine and empowering patients in the process.
Addressing lifestyle issues is not meant to be a quick fix, and typically does not lead to instant success. However, with unexplained infertility every little bit counts, so don’t fret or give up. Do not assume just because the cause of infertility is unexplained, it is untreatable or there is no pathway to parenthood. When a specific cause is not determined for women, and male infertility has also been ruled out, our fertility specialist may begin a course of treatment to improve the chances of conception and pregnancy. The speed with which interventions are offered depends on each individual’s own needs and desires as determined by age and other factors.

Today, with assisted-reproductive technology, the chance of successful treatment is very good. Intrauterine insemination with superovulation is the simplest approach since it increases the chances of the egg and sperm meeting, but some patients may also need GIFT and IVF. IVF can be helpful because it provides information about the sperm's fertilizing ability; GIFT, on the other hand, has a higher pregnancy rate and is applicable in these patients since they have normal fallopian tubes.


3-6 months of treatment with Clomid pills (clomiphene citrate) might improve fertility by as much as 2 times as compared to no treatment. This is a very low level infertility treatment. Infertility specialists do not usually recommend Clomid treatment( without insemination) for unexplained infertility for women over the age of about 35. Most fertility specialists do not use it (without IUI) on any couples with unexplained infertility. If a woman is already having regular periods and ovulating one egg every month, giving Clomid, which will probably stimulate the ovaries to release 2 or 3 eggs per month (instead of one) is not really fixing anything that is broken - and is not likely to be successful.
Fertility preservation for cancer or other health conditions. If you're about to start cancer treatment — such as radiation or chemotherapy — that could harm your fertility, IVF for fertility preservation may be an option. Women can have eggs harvested from their ovaries and frozen in an unfertilized state for later use. Or the eggs can be fertilized and frozen as embryos for future use.

Secondary infertility is similar to other types of infertility and shares many of the same signs. However, in secondary infertility you’re unable to conceive or carry a baby to full-term after having a previous successful pregnancy. Infertility can be caused by either the man or woman. Treatment options can include medications to induce ovulation, in vitro fertilization (IVF) or surgery.

Undergo minor surgery to retrieve eggs. Following a round of injections, your doctor will determine the best date to retrieve eggs from the follicles of your ovaries. If you choose to use donor eggs, the retrieval process will occur with the donor, or the frozen eggs may be collected and used. A partner’s sperm or donor sperm will also be collected.
Oral drugs used to stimulate ovulation include clomiphene citrate and aromatase inhibitors. While taking these drugs, you will be monitored to see if and when ovulation occurs. This can be done by tracking your menstrual cycle or with an ovulation-predictor kit (an at-home urine test). You may be asked to visit your doctor for a blood test or ultrasound exam.
The eggs are retrieved from the patient using a transvaginal technique called transvaginal oocyte retrieval, involving an ultrasound-guided needle piercing the vaginal wall to reach the ovaries. Through this needle follicles can be aspirated, and the follicular fluid is passed to an embryologist to identify ova. It is common to remove between ten and thirty eggs. The retrieval procedure usually takes between 20 and 40 minutes, depending on the number of mature follicles, and is usually done under conscious sedation or general anaesthesia.
In the UK, previous NICE guidelines defined infertility as failure to conceive after regular unprotected sexual intercourse for two years in the absence of known reproductive pathology.[11] Updated NICE guidelines do not include a specific definition, but recommend that "A woman of reproductive age who has not conceived after 1 year of unprotected vaginal sexual intercourse, in the absence of any known cause of infertility, should be offered further clinical assessment and investigation along with her partner, with earlier referral to a specialist if the woman is over 36 years of age."[12]
^ Jump up to: a b Broer SL, van Disseldorp J, Broeze KA, Dolleman M, Opmeer BC, Bossuyt P, Eijkemans MJ, Mol BW, Broekmans FJ (2012). "Added value of ovarian reserve testing on patient characteristics in the prediction of ovarian response and ongoing pregnancy: an individual patient data approach". Human Reproduction Update. 19 (1): 26–36. doi:10.1093/humupd/dms041. PMID 23188168.
Very slight elements of risk are associated with any medical intervention but for IVF the most notable risk in the past has been multiple births. The impact of multiple births on birth weight, premature delivery, and post-natal complications is well known. This is largely due to the practice over the past 30 years of transferring two or more embryos during IVF. Thanks to PGT-A testing and Single Embryo Transfer (SET), however, doctors can now feel confident about transferring just one normal embryo. At RMA, we have established SET as the standard of care going forward. With SET, the risk of multiple births is drastically reduced.

Availability of IVF in England is determined by Clinical commissioning groups. The National Institute for Health and Care Excellence recommends up to 3 cycles of treatment for women under 40 years old with minimal success conceiving after 2 years of unprotected sex. Cycles will not be continued for women who are older than 40 years old.[156] CCGs in Essex, Bedfordshire and Somerset have reduced funding to one cycle, or none, and it is expected that reductions will become more widespread. Funding may be available in "exceptional circumstances" – for example if a male partner has a transmittable infection or one partner is affected by cancer treatment. According to the campaign group Fertility Fairness at the end of 2014 every CCG in England was funding at least one cycle of IVF".[157] Prices paid by the NHS in England varied between under £3,000 to more than £6,000 in 2014/5.[158] In February 2013, the cost of implementing the NICE guidelines for IVF along with other treatments for infertility was projected to be £236,000 per year per 100,000 members of the population.[159]
First, you take medication that makes several of your eggs mature and ready for fertilization. Then the doctor takes the eggs out of your body and mixes them with sperm in a lab, to help the sperm fertilize the eggs. Then they put 1 or more fertilized eggs (embryos) directly into your uterus. Pregnancy happens if any of the embryos implant in the lining of your uterus.
Our physicians generally perform IUIs 1 and a 1/2 days after the trigger injection, which sets ovulation in motion. The exact timing of insemination is not critical to the exact time of ovulation. Both the sperm and the egg remain viable in the female genital tract for many hours, so the physician may time the insemination within a window of several hours around the time of ovulation. Following the IUI, you will take daily supplemental progesterone—usually in the form of a capsule inserted into your vagina twice a day—to support the endometrial lining of the uterus and implantation of the embryo.
Our physicians generally perform IUIs 1 and a 1/2 days after the trigger injection, which sets ovulation in motion. The exact timing of insemination is not critical to the exact time of ovulation. Both the sperm and the egg remain viable in the female genital tract for many hours, so the physician may time the insemination within a window of several hours around the time of ovulation. Following the IUI, you will take daily supplemental progesterone—usually in the form of a capsule inserted into your vagina twice a day—to support the endometrial lining of the uterus and implantation of the embryo.
When I think back to that time, I recall an almost constant sense of grief. Every 28th day represented another failure, another loss. All around me my friends were having their second and then third babies. My son looked at his classmates with their siblings wistfully, he wished with every birthday candle for a brother or sister and one day he asked, "Can you play tig on your own?"
Couples experiencing infertility have a range of treatment options. Women can take fertility drugs to stimulate ovulation, or undergo certain surgeries and procedures, like intrauterine insemination, which carefully places healthy sperm in the uterus right before an egg is released to increase the chances of fertilization. Men can also take fertility medication or undergo surgery to increase the chances of conception.
Our team here at the Center for Human Reproduction has recently developed an infographic explaining one of the most common causes of female infertility: unexplained infertility. This diagnosis is given to 30% of infertility cases and yet, we believe it really is a non-diagnosis. In our clinical experience, with proper testing, up to 90% of unexplained infertility diagnoses can be attributed to treatable causes.
Women are born with about 1 million to 2 million eggs but release only 300 to 400 through ovulation during their lifetimes. Usually, you release just one each month. The egg travels along one of the two fallopian tubes that connect your ovaries to your uterus. If the timing is right, sperm may fertilize it on its way to the uterus. If fertilization doesn't happen within 24 hours of the egg leaving the ovary, the egg dissolves. Sperm can live for about 3 to 5 days, so knowing when you are ovulating can help you and your partner plan sex for when you're most likely to conceive.
In males with hepatitis B, The Practice Committee of the American Society for Reproductive Medicine advises that sperm washing is not necessary in IVF to prevent transmission, unless the female partner has not been effectively vaccinated.[37][38] In females with hepatitis B, the risk of vertical transmission during IVF is no different from the risk in spontaneous conception.[38] However, there is not enough evidence to say that ICSI procedures are safe in females with hepatitis B in regard to vertical transmission to the offspring.[38]

In order for pregnancy to happen, sperm has to meet the egg. This normally takes place at the end of the fallopian tube, and this is called fertilization. There are a number of obstacles that can prevent this from happening, and the process itself even in healthy young fertile women is very complex- hence the low pregnancy rate each month. Obstacles such as cycle timing, low sperm count, poor sperm motility, blocked fallopian tubes, or endometriosis must be overcome to achieve a pregnancy. Timing is often the most common obstacle to conception. What does it mean for you when common causes of infertility are ruled out and you’re told you have unexplained infertility? It should mean a time of hope.


Ovary stimulation. For eight to 14 days near the beginning of your menstrual cycle, you take a gonadotropin, a type of fertility drug that stimulates your ovaries to develop multiple mature eggs for fertilization (instead of just one). You also need to take a synthetic hormone like leuprolide or cetrorelix to keep your body from releasing the eggs too early.

Since marriage is a contract between the wife and husband during the span of their marriage, no third party should intrude into the marital functions of sex and procreation. This means that a third party donor is not acceptable, whether he or she is providing sperm, eggs, embryos, or a uterus. The use of a third party is tantamount to zina, or adultery.


The percentage of cycles cancelled between egg retrieval and embryo transfer is an indication of failed fertilization. This figure is halved with ICSI as compared to conventional IVF, indicating that it can indeed improve fertilization when the sperm is at fault. However, there are no differences in pregnancy, miscarriage or live birth rates between conventional IVF and ICSI, indicating overall similar success rates1.
The educational health content on What To Expect is reviewed by our medical review board and team of experts to be up-to-date and in line with the latest evidence-based medical information and accepted health guidelines, including the medically reviewed What to Expect books by Heidi Murkoff. This educational content is not medical or diagnostic advice. Use of this site is subject to our terms of use and privacy policy. © 2020 Everyday Health, Inc
In December 2015, the Ontario provincial government enacted the Ontario Fertility Program for patients with medical and non-medical infertility, regardless of sexual orientation, gender or family composition. Eligible patients for IVF treatment must be Ontario residents under the age of 43 and have a valid Ontario Health Insurance Plan card and have not already undergone any IVF cycles. Coverage is extensive, but not universal. Coverage extends to certain blood and urine tests, physician/nurse counselling and consultations, certain ultrasounds, up to two cycle monitorings, embryo thawing, freezing and culture, fertilisation and embryology services, single transfers of all embryos, and one surgical sperm retrieval using certain techniques only if necessary. Drugs and medications are not covered under this Program, along with psychologist or social worker counselling, storage and shipping of eggs, sperm or embryos, and the purchase of donor sperm or eggs.[151]
Acknowledge your feelings. When dealing with secondary infertility, it’s very common to feel shock or denial. After all, making one baby might have been a piece of cake for you, so you probably assumed that having a second one would be easy, too. Your friends and even your doctor may also downplay your current infertility problems (telling you not to take it so hard or to “just keep trying”) since you had no trouble before. But secondary infertility is much more common than most people realize. So allow yourself the chance to accept the idea that you may be battling secondary infertility — because once you do, you can tackle the problem head-on.
Though there are some risk with older women pregnancies, there are some benefits associated with caesareans. A study has shown that births over 40 have a lower rate of birth trauma due to increased delivery by caesarean. Though caesarean is seen to benefit mothers over 40, there are still many risk factors to consider. Caesarean section may be a risk in the same way that gestational diabetes is.
Availability of IVF in England is determined by Clinical commissioning groups. The National Institute for Health and Care Excellence recommends up to 3 cycles of treatment for women under 40 years old with minimal success conceiving after 2 years of unprotected sex. Cycles will not be continued for women who are older than 40 years old.[156] CCGs in Essex, Bedfordshire and Somerset have reduced funding to one cycle, or none, and it is expected that reductions will become more widespread. Funding may be available in "exceptional circumstances" – for example if a male partner has a transmittable infection or one partner is affected by cancer treatment. According to the campaign group Fertility Fairness at the end of 2014 every CCG in England was funding at least one cycle of IVF".[157] Prices paid by the NHS in England varied between under £3,000 to more than £6,000 in 2014/5.[158] In February 2013, the cost of implementing the NICE guidelines for IVF along with other treatments for infertility was projected to be £236,000 per year per 100,000 members of the population.[159]
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