Treatments for Infertility

What is infertility?

It is common: roughly 1 in 6 couples needs some help. The cause may lie with the woman, the man, both, or may remain unexplained. Think of the pathway from gamete to implantation: anything that blocks a step can cause infertility.

Stimulating ovulation

If the cause is a lack of regular ovulation, the first treatment is hormonal. Recall the menstrual cycle: FSH from the pituitary gland stimulates follicles to grow, and a surge of LH triggers ovulation.

Fertility drugs mimic these natural hormones. One group is gonadotrophins (injections that act like FSH, sometimes with LH), which make the ovaries develop follicles. Another is clomifene, a tablet that blocks oestrogen feedback so the pituitary releases more FSH and LH. The result is that one or more follicles mature and release eggs.

Timing is checked by ultrasound scans and blood hormone tests, so that intercourse or insemination can be timed with ovulation.

Artificial insemination, IVF and ICSI

These three techniques are called assisted human reproduction. They differ in where fertilisation happens and what problem they overcome.

The steps of IVF

Success, risks and strategies

Success rate is usually the percentage of cycles that end in a live birth:

Why success falls with age. Egg quality drops (more chromosome errors), fewer eggs remain in the ovaries, and miscarriage becomes more likely. Fewer follicles respond to FSH.

Risks of ovarian stimulation. Drugs raise FSH activity, and often LH, so several follicles mature. This can cause:

• ovarian hyperstimulation syndrome (OHSS): swollen, painful ovaries and fluid build-up in the abdomen;

• multiple births, if several embryos implant.

Multiple pregnancies carry higher risk of premature birth, low birth weight, pre-eclampsia and gestational diabetes for the mother, and complications for babies.

Strategies to reduce the risks:

• single embryo transfer (the main strategy), with spare embryos frozen for later;

• careful, lower drug doses guided by scans and hormone tests;

• cancelling a cycle or "freezing all" embryos if too many follicles develop;

• using milder protocols or an LH-like trigger that carries less OHSS risk.

Trade-off: single transfer lowers the chance of twins but may mean more cycles to succeed, with more cost and stress.

Choosing a technique

Match the technique to the cause by asking: what is failing, and does the technique bypass it?

Ethical, social and legal issues

Assisted reproduction raises questions that science alone cannot answer. For a "discuss" question, give points on both sides and a reasoned conclusion.

• Surplus embryos. Extra embryos are frozen. Should they be stored indefinitely, donated to other couples or to research, or destroyed? The answer depends on whether you think an embryo has the moral status of a person.

• Donor gametes. Donor eggs or sperm help those who cannot use their own, but raise issues of consent, payment and the genetic link of the parents to the child.

• The child's right to know. A donor-conceived person may want to know their genetic origins and medical history. Against this, donors may have expected anonymity. Irish law now provides for a register so donor-conceived people can access information.

• Access and funding in Ireland. Some treatments are publicly funded through the HSE (for example, certain cycles of IVF and IUI), but waiting lists are long and private treatment is expensive, so access is unequal.

• Other concerns. Risk of multiple births, treatment for older women, same-sex couples and single parents, and the emotional strain on families.

Back to the start: Aoife and Conor would first have tests. If the cause is irregular ovulation, drugs; if Conor's sperm are slightly weak or ejaculation is a problem, insemination; if Aoife's tubes are blocked, IVF; if Conor's count is very low, ICSI.

Summary