Options For Treating Infertility

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Infertility affects one in every 7 couples hoping to have a baby and usually multiple issues are involved. Treatments for infertility are often provided by physicians trained in subspecialties, including artificial insemination, ovulation induction, and hormonal support of the menstrual cycle. The increasing shift of treatment toward Assisted Reproductive Technologies (ART), including in vitro fertilization (IVF) and intracytoplasmic sperm injection, has further removed infertility treatment from the realm of the generalist or family physician. ART is expensive, invasive, and involves some risk to women. There are also concerns about short- and long-term outcomes for the children. 

The most prominent concerns relate to the incidence of multiple pregnancies with ART treatment and the subsequent perinatal complications, including low birth weight and prematurity. 

Increasing the availability of integrated primary methods for infertility treatment that can be effectively provided by an OB/GYN or a trained general physician such as a family practitioner would improve access to care for couples dealing with infertility, with low risk to women and offspring. Natural Procreative Technology (NaProTechnology, NPT) is a systematic medical approach for optimizing physiologic conditions for natural conception. When utilized by a trained practitioner, NPT has produced live birth rates comparable those associated with more invasive treatments, including ART. However, NPT is less expensive than ART and has minimal risk of multiple births. 

Thomas W. Hilgers, MD, of Creighton University School of Medicine in Omaha, Nebraska, and Director of Fertility Care Centers of America, states that “most problems related to infertility have an underlying organic and/or hormonal/functional cause. The latter usually results in some type of abnormality in ovulation, while the former creates other difficulties including obstruction of the fallopian tubes, biochemical disturbances that disrupt fertility, etc.” A standardized NPT investigation (involving a patient exam and lab work ) usually results in the diagnosis of one or more abnormalities associated with infertility, including decreased production of cervical mucus, irregular menstrual bleeding or spotting, short or variable luteal phases, and suboptimal levels of the ovarian hormones estrogen and progesterone. The physician trained in NPT then determines a course of treatment that aims to correct the underlying abnormality, with the goal of optimizing physiologic conditions for conception. Common interventions include induction or stimulation of ovulation and medications to enhance cervical mucus production, including vitamin B6 and guaifenesin. Vitamin B6 also increases the utilization of estrogen at the level of the cervix and improves cervical fluid production to some extent. Guaifenesin is used to loosen the cervical fluid around the time of ovulation. 

Luteal phase support can be provided by human chorionic gonadotropin (HCG), compounded progesterone vaginal suppositories, or compounded progesterone in oil for intramuscular injection. Bioidentical progesterone is administered to support the uterine lining in the postovulatory phase. It is often used beginning on day 14 of the cycle and is given for 2 weeks. Doses of all medications are adjusted according to the response indicated by changes in serum levels of estrogen and progesterone measured in the mid-luteal phase, and other lab values. When infertility is associated with a luteal phase defect, support is frequently required during pregnancy. 

A study evaluated outcomes in couples receiving treatment for infertility from two NPT-trained family physicians between February 1998 and January 2002. A total of 1,239 couples had an initial consult for NPT, of which 1072 had been trying for at least a year to conceive and initiated NPT. The average female age was 35.8 years, the mean duration of attempting to conceive was 5.6 years, 24% had a prior birth, and 33% had previously attempted treatment with assisted reproductive technology (ART). All couples were taught to identify the fertile days of the menstrual cycle with the Creighton Model Fertility Care System, and most received additional medical treatment, including the drug clomiphene (75%). The cumulative proportion of first live births for those completing up to 24 months of NPT treatment was 52.8 per 100 couples. Younger couples and couples without previous ART attempts had higher rates of live birth. Among live births, there were 4.6% twin births. 

The 364 couples who ultimately conceived with NPT treatment were slightly younger (average 34.8 years); had not been attempting conception as long (mean duration, 4.8 years); were likely to have had a previous birth (30%); and less likely to have attempted ART (21%). Adjusting for withdrawals from treatment and continuing treatment at the end of study follow-up, the cumulative proportion of first live births was 27.1 for those who used NPT for up to 12 months, and 52.8 for those who used NPT for up to 24 months. 

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