Treatment Options 

The best option for you will depend on what your tests show; this section explains the different options and how they can help.

General Health

Weight Management – you can be referred to the ‘Get Healthy Rotherham’ programme by your GP or via the fertility clinic, or you can self-refer on their website https://www.gethealthyrotherham.co.uk/?msclkid=4f372ae8c61f11ecb099c255486ed91a&adlt=strict.

• Having a raised BMI also makes it more difficult to conceive and has higher chance of miscarriage other bad pregnancy outcomes for both the mother (need for caesarean section) and baby (preterm birth, neonatal death and others) – for this reason we would advise to suspend fertility treatment until you are a more healthy weight (BMI below 35)

Smoking Cessation – smoking has been shown to reduce female fertility and reduce the quality of sperm; stop smoking programmes help fertility and general health.

• Smoking also increases risks during pregnancy such as the baby being below a healthy weight and having a lower IQ

Counselling – fertility treatment can be an emotional time so counselling services are available if you wish to be referred.

Folic Acid – this pregnancy vitamin is best taken for 3 months prior to conception in addition to the first 12 weeks of pregnancy; it prevents neural tube defects (such as spina bifida) in the baby

• Note that the dose of folic acid will be determined by your weight to ensure an adequate supply to the baby

Regulating Ovulation

• To have regular ovulation, all the parts of the hormone network need to be working together
• You can have regular periods but not be ovulating
• You can have irregular periods, more frequent or less frequent periods, all of which can be associated with irregular or a lack of ovulation
• Having a healthy weight/BMI, not smoking and having a generally healthy lifestyle have been shown to improve ovulation
• If you have PCOS then taking a medication called Metformin can help with weight loss and improve ovulation by its effects on hormones involved with insulin-resistance (see the section above on PCOS)
• Metformin tablets are to be taken with or after food, starting with 1 tablet a day for 1 week, then 2 tablets a day for 1 week, then continue on 3 tablets a day and ask your GP for repeat prescriptions
• If you are still not ovulating then there is a surgery which may help if you have PCOS (see Laparoscopic Ovarian Drilling below)
• If there is no cause found for why you are not ovulating then we may be able to induce ovulation using medications such as Clomid or Letrozole, however this is not always successful

Oral Ovulation Induction using Clomifene (Clomid) or Letrozole

• Ovulation requires the ovary to have a mature follicle containing an egg which can be released
• Clomiphene (aka Clomid) is a medication that stimulates the ovaries to produce these follicles which increases the chance of ovulation occurring 
• Letrozole is a newer form of Clomid; it has less research behind it because it is new, but has been shown to increase rates of ovulation, has less effect on the lining of the womb, and causes fewer side effects
• Due to the mechanism of action (similar to oestrogen) Clomid and Letrozole are only licensed for women with a BMI less than 35 to reduce risks such as blood clots and heart disease (high BMI is linked with higher oestrogen in the body)  
• For women with PCOS we can give Clomid/Letrozole in addition to Metformin to help regulate your cycles and improve ovulation
• Clomid or Letrozole tablets are to be taken on Day 2-6 of the period (first day of bleeding is Day 1), we then check to see if you have ovulated
  • If you have ovulated then you will stay on the same dose for a maximum of 6 months (occasionally longer depending on your specific circumstances)
  • If you have not ovulated we can increase the dose until you successfully ovulate or we reach the maximum dose, again for a maximum of 6 months
• Side effects of both Clomid and Letrozole include:
  • Hot flushes
  • Fatigue
  • Dizziness
  • Chance of multiple pregnancies
    • For Clomid: 12% chance of twins, <1% chance of triplets
    • The chance of multiple pregnancies is less when using Letrozole
• Additional side effects of Clomid:
  • Mood swings
  • Abdominal pain or discomfort
  • Feeling sick
  • Headache 
  • Breast tenderness
  • Blurred vision (very rare, stop medication immediately)
  • Ovarian hyperstimulation syndrome (OHSS, see below)
• How to take Clomid/Letrozole with a regular menstrual cycle: 
  • On the 1st day of your period (Day 1) call and book an ultrasound for Day 14 and a blood test for Day 21 (see above section on ‘How To Arrange Your Tests’)
  • Take the tablet once a day for 5 days, from Day 2 to Day 6, even if your bleeding stops before the 6th day
  • Attend for your ultrasound scan on Day 14
  • Attend for blood test on Day 21 
  • Call the Fertility Clinic (01709 427641) on Day 24 or 25 for the results of your blood tests and whether we need to change the dose of Clomid/Letrozole
• How to take Clomid/Letrozole with irregular menstrual cycles: 
  • From Day 1 of your most recent period, if you have not started bleeding by Day 35 then do a urine pregnancy test
  • If the pregnancy test is negative you can take a course of Norethisterone or Medroxyprogesterone (Provera) tablets for 7 days which should cause a period bleed to start once the tablets are finished
  • Count from Day 1 of this bleed and start taking Clomid/Letrozole on Day 2-6 and book your Day 14 ultrasound and Day 21 blood test as above
  • If you do not start a period within 4 days of finishing the course of Norethisterone/Provera then do another pregnancy test; if this is negative then you can start Clomid/Letrozole the next day (class this as Day 2)
  • Attend for your ultrasound scan and blood test as above and call for your results 
• 80% of women who ovulate irregularly will ovulate while taking Clomid, and approx. 40% will achieve a pregnancy within the first 3 cycles; if you miss a period and have a positive pregnancy test please call the clinic to let us know so we can cancel your next appointment with us and arrange an early pregnancy scan
• We recommend having regular intercourse at least 2-3 times a week, particularly around ovulation (day 12-15 of a regular cycle) to optimise the sperm supply and increase the chance of pregnancy if ovulation occurs
• If no pregnancy is achieved after the full course of Clomid/Letrozole we will discuss with you further treatment options which may include assisted conception (see below)

Laparoscopic Ovarian Drilling (LOD)

• LOD is a keyhole surgery used for women with PCOS which can help to trigger ovulation if weight loss, Metformin and ovulation induction medications have not been successful
• The surgery involves 3 small cuts on the abdomen whilst you are asleep and takes about 30 minutes; we form 4-6 holes in each ovary which alters the levels of testosterone (high in PCOS) to restore hormone balance and encourage ovulation 
• This surgery is usually performed as a routine day case meaning you go home the same day, but some may need to stay overnight depending on the time of the surgery and any risk factors for complications such as other medical conditions 
• The recovery rate varies between women, but most will resume normal physical activity after 5 days, and be back at work within 1-2 weeks (may be longer if your job is physically demanding)
• Following this operation 80% of women resume ovulation without ovulation induction medication, and 50% will pregnant within a year (if there is no other cause for infertility)
• LOD has a lower risk of multiple pregnancy (twins, triplets etc) than ovulation induction and IVF treatments
• We can give you the choice of LOD first, or referring you on for assisted conception without LOD
• Although laparoscopic surgery is generally very safe there are risks including:
  • Infection 
  • Bleeding
  • Injury to bowel, bladder or blood vessels (may require open surgery to repair any injuries - uncommon) 
  • Scar tissue on the ovaries
  • Very rarely it can cause early ovarian failure/reduced egg reserve in the future 
  • Risks of the general anaesthetic
  • Failure of the procedure (due to operative reasons or if the procedure is completed but you are unable to ovulate afterwards) 
• Post-operative advice:
  • Dressings can be removed the day after the operation; keep clean and dry by patting after washing 
  • The stitches used on the abdomen will dissolve after 2 weeks 
  • You may experience shoulder tip pain due to irritation by the gas used to visualise the abdomen; this should settle in a few days 
  • We encourage you to mobilise out of bed as soon as possible to prevent blood clots forming in your legs 
  • You cannot drive for 24 hours after a general anaesthetic and will not be insured until you can safely perform manoeuvres (without pain impacting on your driving) 
  • Once home you should allow rest but continue to move around throughout the day to prevent blood clots 
  • You may have light vaginal bleeding/spotting/discharge for a few days; use a sanitary pad and avoid tampons to reduce your risk of infection
  • Avoid swimming and sexual intercourse for 2 weeks to prevent infections
  • We commonly use codeine for pain relief; this can cause you to feel sleepy/drowsy, nauseous and constipated
  • Avoid becoming constipated with a high fibre diet, 2L water intake per day and laxatives if required 
  • You need to call us for advice as you may need to be seen if you develop the following:
    • Bleeding becomes heavier or starts again once it has settled
    • Vaginal discharge that is smelly or getting heavier
    • Increasing abdominal pain
    • Pain or redness around the stitches
    • Burning/stinging when passing urine, increased frequency of passing urine or are unable to pass urine (this could be a urine infection)
    • Generally unwell with fevers, vomiting or lost appetite (this could be a systemic infection)
    • Leg becomes painful, red, hot or swollen with difficulty weight-bearing (this could be a blood clot in the leg)
    • Shortness of breath, chest pain, palpitations or coughing up blood (this could be a blood clot in the lungs - seek advice immediately)
• If no pregnancy is achieved after this procedure and the full course of Clomid/Letrozole we will discuss with you further treatment options which could include assisted conception (see below)

Management of Fallopian Tube Obstruction (due to endometriosis, PID or adhesions/scar tissue)

• The fallopian tubes can be blocked due to scarring caused by PID, adhesions caused by endometriosis, overgrowth of the womb lining, or previous pelvic surgery
• If you have risk factors for fallopian tube obstruction or your dye test showed a blockage then we would consider a laparoscopic surgery to visualise the pelvis and treat any adhesions or endometriosis; this is a Laparoscopic Dye Test
• During this surgery we do the same procedure as the HSG by injecting dye into the womb but we can directly visualise the dye flowing through the tubes and see where the blockage is

o   If the blockage is very minor it may be improved simply by the flow of the dye

o   If the blockage is close to the womb then passing a small tube through the cervix, into the womb then into the fallopian tube (this is called cannulation) can effectively nudge the tubes and allow the passage to reform (this would be a separate procedure)

• The risks of a Laparoscopic Dye Test include:

o   Infection

o   Bleeding

o   Injury to bowel, bladder or blood vessels (may require open surgery to repair any injuries – this is uncommon) 

o   Scar tissue formation  

o   Risks of the general anaesthetic 

o   Failure of the procedure (due to operative reasons of if we are unable to bypass the blockage)

• If the Dye Test is the only procedure being performed then it may be done as a day case (you would go home the same day), however if there are any other procedures (such as treatment to severe endometriosis or removal of an ovarian cyst) or any complications then you may have to stay overnight for pain relief and further monitoring 
• If no pregnancy is achieved after this procedure (either unexplained or due to a failed procedure) we will discuss with you further treatment options which could include assisted conception (see below)

Treatment for Uterine Abnormalities

 Abnormal Uterine Development

• Most uterine abnormalities will not cause infertility or problems during pregnancy
• The majority of pregnancies occurring in a bicornuate uterus will continue to full maturity without issues, however some may result in premature birth or a late miscarriage
• In severe cases, such as a septum dividing the uterus into almost 2 separate cavities, it is possible to gently divide the tissue forming the septum during an operation
• This operation would involve being put to sleep with general anaesthetic and having a camera inserted through the cervix (neck of the womb) to visualise the inside of the uterus (this is a hysteroscopy)
• This camera has attachments which allow us to gently remove any tissue which is distorting the shape of the uterine cavity, leaving a cavity suitable for implantation and a developing pregnancy
• If surgical management is not suitable then there may still be a possibility for a healthy pregnancy, but may require additional monitoring such as growth scans

 Uterine Polyps and Fibroids

• A fibroid extending outwards from the uterus (subserosal) should not affect a pregnancy, but if it causes other symptoms we may be able to remove the fibroid with a laparoscopic (keyhole) surgery
• Fibroids or polyps extending into the uterine cavity may be surgically removed with a hysteroscopy (see above)

  Improving Sperm Quality

Unfortunately many causes of reduced sperm quality are irreversible:

o   Scarring following infection

o   Previous cancer treatments can have long-term effects on sperm quality

o   Problems with production such as spinal injuries, genetic conditions and surgeries on the penis/prostate

• Some causes may be reversible by treating the cause:

o   Hormone imbalance such as overactive thyroid and diabetes

o   Medications (if a suitable alternative medication is available)

• Avoiding risk factors for low sperm quality such as:

o   Smoking cigarettes and marijuana

o   Drinking alcohol above the recommended limits

o   Anabolic (muscle-bulking) steroids

• Stopping use of anabolic steroids will restore semen quality in 3-6 months in most cases