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خرید پکیج
تعداد آیتم قابل مشاهده باقیمانده : 3 مورد
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Female infertility: Treatments

Female infertility: Treatments
Literature review current through: Jan 2024.
This topic last updated: Jun 07, 2023.

INTRODUCTION — Infertility is a complex disorder with significant medical, psychosocial, and economic aspects. Great strides have been achieved in infertility therapy, particularly the development of assisted reproductive technology (ART).

Once the cause of infertility is identified, therapy aimed at correcting reversible etiologies and overcoming irreversible factors can be implemented. The couple is also counseled on lifestyle modifications to improve fertility, such as smoking cessation, reducing excessive caffeine and alcohol consumption, and appropriate frequency of coitus (every one to two days around the expected time of ovulation) (table 1). (See "Natural fertility and impact of lifestyle factors".)

The patient should be involved in fertility treatment choices. These choices involve four major factors: effectiveness (eg, live birth rate), burden of treatment (eg, frequency of injections and office visits), safety (eg, risk of ovarian hyperstimulation and multiple gestation), and financial costs [1].

This topic will provide an overview of the treatment of female. The evaluation of female infertility, as well as the causes and treatment of male infertility, are discussed separately:

(See "Female infertility: Causes".)

(See "Female infertility: Evaluation".)

(See "Causes of male infertility".)

(See "Treatments for male infertility".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive individuals.

CONTRAINDICATIONS — The only absolute contraindications to infertility therapy are contraindication to pregnancy and contraindication to use of the drugs or surgeries used to enhance fertility. The ethics of restricting infertility therapy for other reasons, such as parental child-rearing ability, severe obesity, lifestyle issues (tobacco smoking, alcohol consumption), are controversial and beyond the scope of this review [2-4]. The parent's marital status, sexual orientation, and HIV status should not be used to deny fertility treatment [5,6].

OVULATORY DISORDERS — The World Health Organization (WHO) classifies ovulatory disorders into three groups (table 2).

WHO class 1 – Hypogonadotropic hypogonadal anovulation is the least common, occurring in 5 to 10 percent of cases. Examples of women in this category are women with hypothalamic amenorrhea from functional etiologies such as excessive exercise or low body weight.

WHO class 2 – Normogonadotropic normoestrogenic anovulation is the most common, accounting for 70 to 85 percent of cases. Women with polycystic ovary syndrome usually fall into this category.

WHO class 3 – Hypergonadotropic hypoestrogenic anovulation occurs in 10 to 30 percent. Women with primary ovarian insufficiency (previously called premature ovarian failure) or gonadal dysgenesis, comprise the majority of these cases.

Hyperprolactinemic anovulation is a separate category; gonadotropin concentrations in this condition are usually normal or decreased.

Oligoovulation unrelated to ovarian failure can usually be treated successfully with ovulation induction; these women achieve fecundability nearly equivalent to that of normal couples (ie, 15 to 25 percent probability of achieving a pregnancy in one menstrual cycle) [7]. However, normal fecundability is achieved at the expense of an increased risk of multiple pregnancy.

The method of ovulation induction selected should be based upon the underlying cause of anovulation and the efficacy, costs, risks, and potential complications associated with each method as they apply to the individual woman. Options include:

Weight modulation

Clomiphene citrate

Aromatase inhibitors

Gonadotropin therapy

Metformin or other insulin-sensitizing agents

Laparoscopic ovarian diathermy

Bromocriptine or other dopamine agonist (only in cases of hyperprolactinemia and anovulation)

Assisted reproductive technology

Most of these approaches are effective for WHO class 2 patients. WHO class 1 patients respond best to therapy involving lifestyle modification or gonadotropins. Some WHO class 3 patients respond to gonadotropin therapy and in vitro fertilization (IVF), but those who fail require oocyte donation. A synopsis of these therapies is reviewed below; recommendations regarding the choice and dosing of first-line, second-line, and further therapy for ovulation induction according to WHO class are provided separately. (See "Overview of ovulation induction".)

Weight modulation — Women who are far above or below ideal body weight are prone to ovulatory dysfunction and subfertility [8]. Weight modulation in these women can enhance fertility.

High body weight — Women with elevated baseline weight or body mass index (BMI) greater than 27 kg/m2 and anovulatory infertility are advised to lose weight (table 3) (calculator 1). For obese women with polycystic ovarian syndrome (PCOS), the loss of just 5 to 10 percent of body weight is sufficient to restore ovulation in 55 to 100 percent of these women within six months [9-13]. Weight loss is an inexpensive, low-intervention modality with no side effects and with other health benefits and thus should be a first-line treatment for obese anovulatory women (table 4). (See "Treatment of polycystic ovary syndrome in adults".)

A large, multicenter trial of obese (BMI ≥29 kg/m2) and infertile women reported no difference in rates of vaginally delivered term singletons at 24 months among women who received a six-month structured weight-loss intervention prior to infertility treatment and control women who went directly to infertility treatment [14]. In the trial, women who underwent a six-month lifestyle intervention to lose weight prior to fertility treatment were more likely to conceive spontaneously compared with control women (26 versus 16 percent). The women in the intervention groups also underwent fewer fertility treatment cycles compared with the control women (679 versus 1067 treatment cycles). However, weight reduction was not associated with increased fecundability, as the overall term singleton vaginal birth rates and live birth rates were the same between groups. In addition, there were no differences in the obstetric outcomes of gestational diabetes or hypertensive disorders of pregnancy between intervention and control groups. Study limitations include that target weight loss was reached by only 38 percent of women in the intervention group and the intervention discontinuation rate was 22 percent. It is not known if greater weight reduction per person, increased proportion of women reaching target weight loss, or increased patient continuation rates would increase fecundability. However, we continue to advise weight loss for infertile women with an elevated BMI because weight reduction appears to aid spontaneous conception and reduce the need for fertility treatment, in addition to providing long-term benefits for overall health. (See "Natural fertility and impact of lifestyle factors", section on 'Overweight and obesity'.)

Low body weight — Anovulatory women with low BMI (less than 17 kg/m2) (table 3) (calculator 1), with eating disorders, or strenuous exercise regimens, may develop hypogonadotropic hypogonadism and/or hypothalamic amenorrhea (WHO class 1) [15]. Psychogenic stress may also disrupt the gonadotropin releasing hormone (GnRH) pulse generator and impair ovarian function as a result of reduced pituitary gonadotropin secretion [16-21]. Such women should be advised to gain weight, modify diet, and reduce exercise; however, these women are often reluctant to alter their behaviors. (See "Functional hypothalamic amenorrhea: Pathophysiology and clinical manifestations" and "Eating disorders: Overview of prevention and treatment".)

The importance of modifying suboptimal behavior was underscored in a randomized trial of women with functional hypothalamic amenorrhea [22]. These women were randomly assigned to either observation or 16 sessions of intrapersonal therapy that assessed eating behavior, nutritional intake, energy expenditure, exercise, and attitudes. The goal of therapy was to correct nutritional deficiencies, energy deficit, and problematic attitudes. Treatment was effective: ovarian function recovered in 87 percent of women who received therapy, but in only 25 percent of women who did not receive the intervention. However, as discussed above, women with eating disorders, other psychiatric conditions, or compulsion to excessive exercise are often unable to change these behaviors after just a brief exposure to counseling.

Patients with hypogonadotropic hypogonadism due to eating disorders or intensive exercise who do not respond to behavioral modification may conceive with pulsatile GnRH therapy [23]. Pulsatile GnRH therapy for ovulation induction has been approved by the FDA, but no pharmaceutical company makes it available in the United States at this time. This treatment is available in Europe. (See "Overview of ovulation induction", section on 'Pulsatile GnRH therapy'.)

Ovulation induction agents

Clomiphene — Clomiphene citrate is a selective estrogen receptor modulator (SERM) with both estrogen antagonist and agonist effects that increase gonadotropin release. It is an effective method of inducing ovulation and improving fertility of oligoovulatory women in WHO class 2 (normogonadotropic normoestrogenic ovulatory dysfunction). By comparison, clomiphene is often ineffective in WHO class 1 (hypogonadotropic hypogonadism) and class 3 (hypergonadotropic hypogonadism) patients.

Ovulation induction with clomiphene is reviewed in detail elsewhere. (See "Ovulation induction with clomiphene citrate".)

Aromatase inhibitors — Anovulatory WHO 2 patients who have a poor outcome with clomiphene (no ovulation or thin endometrium) may have a better response with aromatase inhibitors. Advantages of these agents over clomiphene include (1) production of fewer follicles and lower estradiol levels, thereby decreasing the risk of multiple gestation, and (2) shorter half-life (50 hours versus 5 days), resulting in reduced antiestrogen effects on the endometrium and cervical mucus. In patients with polycystic ovarian syndrome, a multicenter randomized double-blind trial showed that letrozole was superior to clomiphene in inducing ovulation and live birth [24]. This topic is reviewed in detail elsewhere. (See "Ovulation induction with letrozole".)

Aromatase inhibitors in combination with gonadotropins have also emerged as novel ovarian stimulants for performing IVF in women with breast cancer. A presumed advantage of ovarian stimulation with aromatase inhibitors is that the resultant peak estradiol levels are close to those observed in natural cycles.

The FDA has not approved aromatase inhibitors for treatment of infertility.

Gonadotropin therapy — Gonadotropin therapy is used in normogonadotropic (WHO class 2) anovulatory women who have not ovulated or conceived with clomiphene treatment and/or insulin sensitizing agents, and in hypogonadotropic (WHO class 1) anovulatory women with hypopituitarism or as second-line therapy in women with hypothalamic amenorrhea. In one trial of normogonadotropic anovulatory women who did not conceive with six cycles of clomiphene citrate therapy, subsequent treatment with gonadotropins was associated with an increased livebirth rate compared with continued treatment with clomiphene (52 versus 41 percent) [25]. However, compared with clomiphene, treatment with gonadotropins requires close hormonal and sonographic monitoring, is expensive, and typically carries a higher risk of multiple gestation. Dosing protocols, monitoring, side effects, and outcomes of gonadotropin therapy are discussed in detail elsewhere. (See "Overview of ovulation induction", section on 'Gonadotropin therapy'.)

Other agents

Metformin — Insulin resistance is commonly observed in women with PCOS. Correction of hyperinsulinemia with metformin has a beneficial effect in anovulatory women with PCOS because this leads to an increase in menstrual cyclicity and enhanced spontaneous ovulation. However, live birth rates are not as high as those achieved with clomiphene [26]. A consensus group has recommended against the routine use of metformin for ovulation induction except in women with glucose intolerance [27]. However, the addition of metformin in this setting may help facilitate weight loss and ovulation. In addition, metformin may provide additional metabolic effects that are beneficial for pregnancy. (See "Metformin for treatment of the polycystic ovary syndrome", section on 'Anovulatory infertility'.)

Laparoscopic surgery — Laparoscopic ovarian drilling by diathermy or laser is a surgical treatment to induce ovulation in anovulatory PCOS patients. For subfertile anovulatory patients with PCOS, a Cochrane review of six randomized trials found similar cumulative ongoing pregnancy rates 6 to 12 months after laparoscopic ovarian drilling and after three to six cycles of ovulation induction with gonadotropins as a primary treatment [28]. However, the rate of multiple pregnancy was considerably lower in women who conceived after ovarian drilling.

As laparoscopic ovarian diathermy is invasive and carries more risk for the patient than medical therapy, we reserve its use for patients who fail to conceive with alternative treatments and after other fertility factors have been thoroughly investigated and corrected. This technique is discussed in detail separately. (See "Treatment of polycystic ovary syndrome in adults", section on 'Laparoscopic surgery'.)

Dopamine agonists — Dopamine agonists, such as bromocriptine, are the treatment of choice for women with hyperprolactinemic anovulation. (See "Clinical manifestations and evaluation of hyperprolactinemia" and "Management of hyperprolactinemia" and "Overview of ovulation induction", section on 'Dopamine agonists'.)

Assisted reproductive technologies — Oligoovulatory women who do not conceive with other fertility treatments may be considered for IVF. (See "In vitro fertilization: Overview of clinical issues and questions".)

WHO class 3 patients or women with premature ovarian failure may require oocyte donation by a known or anonymous donor who undergoes controlled ovarian hyperstimulation and oocyte retrieval. (See "In vitro fertilization: Overview of clinical issues and questions", section on 'When are donor oocytes used?'.)

TUBAL FACTOR INFERTILITY AND ADHESIONS — For patients with access to in vitro fertilization (IVF) services, IVF is first-line treatment for tubal factor infertility due to bilateral tubal obstruction. For women who cannot access or decline IVF, we offer surgical reconstruction to young patients with bilateral distal or proximal tubal obstruction. Counseling is provided regarding the success rates of different methods of repair compared with those using the assisted reproductive technologies and on the high risk of ectopic pregnancy. If surgery is successful, this approach has the advantages that additional treatment is not required for each attempt at conception, and it allows natural conception. However, reocclusion rates are high.

For women with severe tubal disease (bilateral hydrosalpinx, both proximal and distal occlusion, extensive adhesions) and for older women, we recommend IVF as the initial approach because tubal surgery is unlikely to be successful in these patients. Hydrosalpinges should be removed prior to IVF to optimize outcomes. These treatments are discussed briefly below.

It is important to make a definitive diagnosis of bilateral proximal tubal occlusion, as HSG may yield false positive results due to tubal spasm. This contrasts with distal tubal occlusion, where findings from HSG and laparoscopic tubal lavage typically are concordant.

(See "Female infertility: Evaluation", section on 'Hysterosalpingogram'.)

(See "Hysterosalpingography".)

Unilateral proximal tubal occlusion can be treated medically initially with controlled ovarian hyperstimulation. A retrospective case-controlled study found that controlled ovarian hyperstimulation with intrauterine insemination (IUI) in women with unilateral proximal tubal occlusion resulted in pregnancy rates statistically similar to those in patients with unexplained infertility (31 versus 43 percent), while patients with unilateral mid-distal or distal tubal occlusion had significantly lower pregnancy rates (19 versus 43 percent) [29].

Procedures for improving tubal patency

Distal obstruction — Surgery for the treatment of tubal factor infertility is most successful in women with distal tubal obstruction. Fimbrioplasty, the lysis of fimbrial adhesions or dilatation of fimbrial strictures, and neosalpingostomy, the creation of a new tubal opening in a distally occluded tube, may be performed via laparotomy or laparoscopy. (See "Female infertility: Reproductive surgery", section on 'Treatment of distal tubal occlusion'.)

Proximal tubal occlusion — Reconstructive surgery for bilateral proximal tubal occlusion is not very effective, and the risk of subsequent ectopic pregnancy is high (as high as 20 percent) [30]. Therefore, IVF is preferable, if available. When IVF is not available or not acceptable, proximal tubal occlusion may be treated with hysteroscopic or fluoroscopic tubal catheterization or with tubocornual anastomosis by laparotomy (a laparoscopic approach is possible but requires significant expertise). An advantage of the minimally invasive hysteroscopic approach over fluoroscopy-directed selective salpingography is the capability to perform concomitant laparoscopy with tubal lavage, allowing the clinician both to confirm the diagnosis of proximal occlusion and to treat any coexisting tubal adhesions prior to performing hysteroscopic cannulation [30].

Tubal catheterization is accomplished with a coaxial catheter system where the outer catheter is directed at the tubal ostium and used to perform a selective salpingogram. If tubal occlusion is observed, the inner catheter is advanced along a guide wire to gently overcome the blockage. In bilateral proximal occlusion, the procedure is successful in 85 percent of tubes and 50 percent of patients conceive, but one third of the tubes re-occlude [30,31]. The procedure should be terminated if gentle pressure does not open the tube as over 90 percent of unsuccessful cases are due to true anatomic occlusion from salpingitis isthmica nodosa, chronic salpingitis, or obliterative fibrosis [32].

For women with unilateral proximal tubal obstruction, at least one study reported similar pregnancy rates for these women undergoing controlled ovarian hyperstimulation and intrauterine insemination (COH-IUI) compared with women with bilaterally patent tubes and unexplained infertility also undergoing COH-IUI [33]. Thus, for women with unilateral tubal occlusion for whom IVF is not an option, COH-IUI appears to be a reasonable alternative. (See "Female infertility: Reproductive surgery", section on 'Treatment of proximal tubal occlusion' and "Female infertility: Reproductive surgery", section on 'Tubal reanastomosis'.)

In vitro fertilization — IVF is a proven method of treatment of tubal factor infertility and has the following advantages and disadvantages compared with tubal reconstruction. (See "In vitro fertilization: Overview of clinical issues and questions".)

Advantages [34]:

Better per-cycle success rate than other fertility treatments

Less surgically invasive than tubal surgery

Can overcome other subfertility factors, if present (eg, male factor, cervical factor, decreased ovarian reserve)

Site and extent of tubal damage are not important to outcome

Disadvantages:

High per cycle cost and possible need for multiple cycles

Need for IVF each time a pregnancy is desired

Requires frequent injections and monitoring

Increases risk of multiple gestation

Increases risk of ovarian hyperstimulation syndrome

Possibly slightly higher absolute risk of some adverse perinatal outcome than natural conception

Salpingectomy for hydrosalpinx — There is evidence from randomized trials that laparoscopic salpingectomy in women with hydrosalpinges improves the outcomes of IVF treatment compared with no surgical intervention [35]. The improvement in pregnancy and live birth rates is likely due to the removal of a source of embryotoxic substances or fluid into the uterus disrupting implantation. It has been hypothesized that the surgical removal of hydrosalpinges might decrease blood supply to the ovaries and compromise ovarian reserve, but this has not been studied. In a meta-analysis of seven trials, proximal tubal occlusion and salpingectomy each resulted in increased rates of ongoing pregnancy following IVF in women with hydrosalpinges (tubal occlusion risk ratio 3.22, 95% CI 1.27-8.14 and salpingectomy risk ratio 2.24, 95% CI 1.27-3.95) [36]. Although tubal occlusion resulted in more ongoing pregnancies compared with salpingectomy, the small number of trials and procedures limits the ability to determine procedure superiority. Further investigation is required to assess whether alternative surgical treatments for hydrosalpinx removal (salpingostomy, tubal occlusion, needle drainage of hydrosalpinx at oocyte retrieval) are more effective than salpingectomy. (See "Female infertility: Reproductive surgery".)

ENDOMETRIOSIS — Treatment of subfertility in women with endometriosis is approached by identifying and treating reversible causes of infertility followed by sequential application of various therapies: surgical resection of endometriosis, ovulation induction plus intrauterine insemination, and assisted reproductive technologies. We generally use this stepwise approach, except in the setting of multiple infertility factors (eg, significant male factor component, decreased ovarian reserve, pelvic factors) because the presence of multiple factors has a large negative effect on conservative therapy. For these cases, we would probably go straight to in vitro fertilization rather than apply less resource-intensive approaches. In addition, moving directly to in vitro fertilization in patients with high-stage endometriosis seems prudent. A treatment algorithm for infertile patients with early and advanced stage endometriosis is provided separately. (See "Endometriosis: Treatment of infertility in females".)

UTERINE FACTOR INFERTILITY — The finding of a uterine abnormality is not in and of itself an indication for surgical intervention because there is no uterine abnormality that is always associated with poor reproductive performance [37]. However, when a submucous fibroid, endometrial polyp, septate uterus, or uterine synechiae are discovered in the setting of failure to conceive or recurrent pregnancy loss, surgical correction should be considered since there may be a causal association.

Fibroids (leiomyoma) — The relationship between fibroids and infertility is controversial and removal of fibroids is not clearly associated with improved fertility treatment outcomes [38,39]. Couples should complete a full infertility evaluation before addressing the role of fibroids in their infertility. In general, the best candidates for myomectomy are women with a submucosal fibroid or an intramural fibroid that deforms the uterine cavity.

Synechiae, septa, congenital anomalies — Intrauterine synechiae and septa may be uterine causes of infertility (particularly recurrent pregnancy loss) that may be surgically correctable by hysteroscopic resection. While there is no randomized controlled trial comparing pregnancy outcomes between treated and untreated patients, two retrospective series showed a marked reduction in pregnancy loss after resection of a uterine septum or lysis of adhesions [37,40]. (See "Congenital uterine anomalies: Clinical manifestations and diagnosis" and "Intrauterine adhesions: Clinical manifestation and diagnosis".)

Women with severe irreparable uterine defects may require a gestational carrier. (See "Gestational carrier pregnancy".)

Endometrial polyps — Polypectomy can improve fertility in subfertile women with asymptomatic endometrial polyps. This was illustrated in a trial that randomly assigned subfertile women with an endometrial polyp to hysteroscopic polypectomy before intrauterine insemination (IUI) or IUI alone and found removal of the polyp significantly improved the pregnancy rate (pregnancy rate 63 percent after polypectomy versus 28 percent with IUI alone) [41]. Based on this trial, and other data from observational studies, we remove endometrial polyps in infertile women, even in the absence of abnormal bleeding. (See "Endometrial polyps".)

Luteal phase defect — There is no consensus on the scientific definition of luteal phase defect. In the past, it has been defined as a lag in endometrial epithelial maturation as determined by histological analysis of a timed luteal endometrial biopsy. However, there is good evidence that this is not a valid concept because fertile women have a higher prevalence of abnormal endometrial maturation than infertile women [42], thus calling into question the association between luteal phase defect and infertility. A 2015 committee opinion by the American Society of Reproductive Medicine concluded that luteal phase defect as an independent entity that results in infertility has not been proven [43]. (See "Recurrent pregnancy loss: Definition and etiology", section on 'Luteal phase defect'.)

Clinicians should avoid making the diagnosis of luteal phase defect until the definition and diagnosis are clarified through further research.

CERVICAL FACTOR INFERTILITY — Cervical factor infertility is best treated by intrauterine insemination (IUI) to bypass cervical factors (eg, scanty or abnormal mucus that might impair fertility). In vitro fertilization is the next option for patients with cervical factor infertility who fail to conceive with IUI. (See "Procedure for intrauterine insemination (IUI) using processed sperm" and "In vitro fertilization: Overview of clinical issues and questions".)

There is no strong evidence to support IUI in the absence of ovulation induction agents. A Cochrane review of randomized and controlled trials found IUI was no more effective than timed intercourse for treatment of subfertility attributed to abnormal cervical mucus [44]. Subfertility was defined as failure to conceive within one year and cervical mucus abnormality was based upon postcoital testing. The lack of benefit of IUI may be related, at least in part, to the poor prognostic value of postcoital tests for identifying women with abnormal cervical factors. (See "Female infertility: Evaluation", section on 'Postcoital test'.)

UNEXPLAINED INFERTILITY — Couples with unexplained infertility have no identifiable etiology of their infertility after comprehensive evaluation; therefore, treatment strategies are empiric.

Therapy with clomiphene or letrozole with intrauterine insemination (IUI) may be employed as initial treatment due to the low cost and low risk of side effects. If the patient does not conceive after clomiphene or letrozole with IUI, gonadotropin injections with IUI or assisted reproductive technologies may be employed. (See "Unexplained infertility".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Female infertility".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Female infertility (The Basics)" and "Patient education: Infertility in couples (The Basics)")

Beyond the Basics topics (see "Patient education: Ovulation induction with clomiphene or letrozole (Beyond the Basics)" and "Patient education: Infertility treatment with gonadotropins (Beyond the Basics)" and "Patient education: Evaluation of infertility in couples (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

Treatment approach – Once the cause of infertility is identified, therapy is aimed at correcting reversible etiologies and overcoming irreversible factors. The couple is also counseled on lifestyle modifications to improve fertility, such as smoking cessation, reducing excessive caffeine and alcohol consumption, and appropriate frequency of coitus (table 1). (See 'Introduction' above.)

Ovulatory dysfunction – The treatment of ovulatory dysfunction is based upon the underlying cause of anovulation (WHO class 1, 2, or 3 or hyperprolactinemia), and the efficacy, costs, risks, and potential complications associated with each method as they apply to the individual woman. Oligoovulation unrelated to ovarian failure can usually be treated successfully with ovulation induction. (See 'Ovulatory disorders' above.)

Tubal occlusion – We offer surgical reconstruction to young patients with bilateral proximal or distal tubal obstruction and limited access to in vitro fertilization (IVF), with counseling on the success rates of different methods of repair and on the high risk of reocclusion and ectopic pregnancy. IVF is preferable to surgery in women with severe tubal disease (bilateral hydrosalpinx, both proximal and distal occlusion, extensive adhesions) and for older women, given the proven success of IVF in these patients. Hydrosalpinges should be removed prior to IVF to optimize outcomes. (See "Female infertility: Reproductive surgery".)

Subfertility related to endometriosis – Treatment of subfertility in women with endometriosis is generally approached by identifying and treating reversible causes of infertility followed by a sequential series of steps: surgical resection of endometriosis, ovulation induction plus intrauterine insemination (IUI), and assisted reproductive technologies. High-stage endometriosis may be an indication for moving directly to IVF. (See 'Endometriosis' above.)

Targeted surgical treatment – Surgical treatment of submucous fibroids, endometrial polyps, septate uterus, or uterine synechiae in the setting of failure to conceive or recurrent pregnancy loss appears to improve ongoing pregnancy rates. (See 'Uterine factor infertility' above.)

Cervical factor – Cervical factor infertility is best treated by bypassing abnormal cervical factors using IUI, generally with ovulation induction agents. (See 'Cervical factor infertility' above.)

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Topic 5448 Version 39.0

References

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