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Fertility may be restored by appropriate treatment in many patients with endocrine imbalance, particularly those with hypothyroidism or hyperthyroidism Antibiotic treatment of cervicitis is of value Women who engage in vigorous athletic training often have low sex hormone levels; fertility improves with reduced exercise and some weight gain
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Excision of ovarian tumors or ovarian foci of endometriosis can improve fertility Microsurgical relief of tubal obstruction due to salpingitis or tubal ligation will reestablish fertility in a significant number of cases In special instances of cornual or fimbrial block, the prognosis with newer surgical techniques has become much better Peritubal adhesions or endometriotic implants often can be treated via laparoscopy or via laparotomy immediately following laparoscopic examination if prior consent has been obtained With varicocele in the male, sperm characteristics are often improved following surgical treatment
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1 Gross deficiencies of sperm (number, motility, or appearance) require repeat analysis Zona-free hamster egg penetration tests are available to evaluate the ability of human sperm to fertilize an egg 2 Obvious obstruction of the uterine tubes requires assessment for microsurgery or in vitro fertilization 3 Absent or infrequent ovulation requires additional laboratory evaluation Elevated FSH and LH levels indicate ovarian failure causing premature menopause Elevated LH levels in the presence of normal FSH levels confirm the presence of polycystic ovaries Elevation of blood prolactin (PRL) levels suggests pituitary microadenoma 4 Ultrasound monitoring of folliculogenesis may reveal the occurrence of unruptured luteinized follicles 5 Endometrial biopsy in the luteal phase associated with simultaneous serum progesterone levels will rule out luteal phase deficiency 6 Hysterosalpingography using an oil dye is performed within 3 days following the menstrual period if structural
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1 Clomiphene citrate Clomiphene citrate stimulates gonadotropin release, especially LH Consequently, plasma estrone (E1) and estradiol (E2) also rise, reflecting ovarian follicle maturation If E2 rises sufficiently, an LH surge occurs to trigger ovulation After a normal menstrual period or induction of withdrawal bleeding with progestin, one should give 50 mg of clomiphene orally daily for 5 days If ovulation does not occur, the dosage is increased to 100 mg orally daily for 5 days If ovulation still does not occur, the course is repeated with 150 mg daily and then 200 mg daily for 5 days, with the addition of chorionic gonadotropin, 10,000 units intramuscularly, 7 days after clomiphene The rate of ovulation following this treatment is 90% in the absence of other infertility factors The pregnancy rate is high Twinning occurs in 5% of these patients, and three or
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more fetuses are found in rare instances (< 05% of cases) An increased incidence of congenital anomalies has not been reported Painful ovarian cyst formation occurs in 8% of patients and may warrant discontinuation of therapy Several studies have suggested a twofold to threefold increased risk of ovarian cancer with the use of clomiphene for more than 1 year In the presence of increased androgen production (DHEA-S > 200 mcg/dL), the addition of dexamethasone, 05 mg, or prednisone, 5 mg, at bedtime, improves the response to clomiphene Dexamethasone should be discontinued after pregnancy is confirmed 2 Bromocriptine Bromocriptine is used only if PRL levels are elevated and there is no withdrawal bleeding following progesterone administration (otherwise, clomiphene is used) To minimize side effects (nausea, diarrhea, dizziness, headache, fatigue), bromocriptine should be taken with meals The initial dosage is 25 mg once daily, increased to two or three times daily in increments of 125 mg The drug is discontinued once pregnancy has occurred 3 Human menopausal gonadotropins (hMG) hMG or recombinant FSH is indicated in cases of hypogonadotropism and most other types of anovulation (exclusive of ovarian failure) Because of the complexities, laboratory tests, and expense associated with this treatment, these patients should be referred to an infertility specialist 4 Gonadotropin-releasing hormone (GnRH) Hypothalamic amenorrhea unresponsive to clomiphene will be reliably and successfully treated with subcutaneous pulsatile GnRH Use of this substance will avoid the dangerous ovarian complications and the 25% incidence of multiple pregnancy associated with hMG, although the overall rate of ovulation and pregnancy is lower than when hMG is used
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