Exploring Fertility Treatments and Understanding Access Barriers

Lifestyle Changes

Addressing infertility may be as simple as making lifestyle changes. For example, those with a history of disordered eating or overexercising, which can cause ovulatory disorders, may be advised to make dietary or exercise changes to increase their BMI and caloric intake. Conversely, those with a BMI indicating obesity may be advised to make nutritional changes and increase physical activity to regulate ovulation or increase sperm count.

The Imperial College in London recently concluded a study to assess the effects of weight loss on seminal quality and male infertility. The study has not updated its results; however, the theory is that weight loss in obese patients with male reproductive anatomy will improve seminal quality and restore fertility.

Weight loss recommendations are standard for individuals dealing with infertility; however, a 2022 study in PLOS Medicine suggests that habits like exercise may be more important than weight loss. This randomized control trial divided obese individuals who struggled with female infertility into two groups: an intensive weight loss group and a standard increased physical activity group.

The researchers in the publication concluded, “A preconception-intensive lifestyle intervention for weight loss did not improve fertility or birth outcomes compared to an exercise intervention without targeted weight loss. Improvement in metabolic health may not translate into improved female fecundity.” This study implies a need for additional research on the correlation between weight and infertility.

Beyond weight management lifestyle changes, providers will also recommend that patients reduce tobacco and alcohol exposures, as they can reduce fertility.

Fertility Drugs

While lifestyle changes are often recommended first, the following line of infertility treatment is fertility drugs and medications. There are many options for fertility drugs; however, providers must consider the patient history and cause of infertility when determining the appropriate medication.

Estrogen Receptor Blockers

One of the most common classes of fertility medications is estrogen receptor blockers, including clomiphene citrate (CC). CC is a widely used fertility drug that may address both male and female infertility.

For people with male reproductive organs, estrogen blockers cause the pituitary gland to release follicle-stimulating hormones (FSH) and luteinizing hormones (LH), improving sperm count and motility.

In individuals with female reproductive organs, CC can address issues of anovulation, such as PCOS. According to GoodRx, clomiphene is attached to estrogen receptors, causing the body to perceive low estrogen levels, which triggers the body to release more FSH to help create estrogen. This increase in FSH levels allows eggs to develop. Ovulation is then activated by the release of LH in the presence of a mature egg.

Providers often prescribe 50 mg of CC daily for five days, starting on the second, third, fourth, or fifth day of the menstrual cycle. Those hoping to get pregnant through intercourse are advised to start intercourse daily for one week, five days after the partner with female reproductive anatomy has finished taking CC.

Additionally, letrozole functions similarly to increase LH and trigger ovulation. Currently, letrozole is not approved for infertility. Instead, it is approved for breast cancer treatment but has implications for fertility treatments.

“One study of people with PCOS found that people taking letrozole had higher ovulation and live-birth rates than those taking clomiphene. This study found that about 28% of people taking letrozole got pregnant and gave birth. Only about 19% of those taking clomiphene had the same success,” says GoodRx in its article.

Nasal Testosterone

According to a StatPearls textbook, nasal testosterone gel may be a reasonable option for male infertility patients. Unlike standard testosterone replacement, which can cause the body to detect an excess of testosterone and cease making it, nasal testosterone gel is a low-dose hormone that can improve testosterone levels and fertility.

Gonadotropin Therapy

The American Society of Reproductive Medicine (ASRM) notes that gonadotropin therapy is the injection of FSH or combined LH and FSH. As previously mentioned, increased rates of these hormones can help trigger ovulation for those with female reproductive anatomy. Gonadotropin therapy can also help address any underlying endocrine disorders that may contribute to infertility in those with male reproductive anatomy.

Surgical Interventions

In some cases, surgical interventions may help correct structural problems contributing to infertility. This may mean removing uterine fibroids or any fallopian tube blockage in female reproductive organs. For patients with endometriosis, surgery nearly doubles the chance of pregnancy.

Structural issues in male reproductive organs, such as sperm duct blockage or varicocele, may be corrected through surgical interventions, restoring fertility.

ART

Assisted reproductive therapy (ART) often is the last option for addressing infertility issues. These procedures may be done in patients who have already tried medication, lifestyle changes, and surgical interventions. Beyond treating infertility, these fertility treatments allow non-cis-gendered and heterosexual couples and single individuals to reproduce.

The Mayo Clinic defines ART as “any fertility treatment in which the egg and sperm are handled.” ART may include intrauterine insemination (IUI), in vitro fertilization (IVF), and intracytoplasmic sperm injection (ICSI).

Intrauterine Insemination

Planned Parenthood notes that IUI, sometimes called artificial insemination, is when a provider places sperm directly into the uterus using a flexible tube with an attached syringe that passes through the cervix. This process is done during ovulation, and the male sperm is extracted from semen after a sperm-washing procedure to procure concentrated sperm.

In Vitro Fertilization

IVF is the most commonly discussed form of ART, involving the implantation of a fertilized embryo into the uterus. The process can be divided into four stages: ovulation induction, egg extraction, fertilization, and embryo implantation.

The ovulation induction phase often involves using fertility drugs to stimulate ovulation. The egg is then extracted and fertilized.

The Mayo Clinic notes, “transvaginal ultrasound aspiration is the usual retrieval method. An ultrasound probe is inserted into your vagina to identify follicles. Then a thin needle is inserted into an ultrasound guide to go through the vagina and into the follicles to retrieve the eggs.”

Once fertilized, the embryo is implanted in the person carrying the pregnancy.

The Advanced Fertility Center of Chicago notes that this IVF is a favorable procedure for those with blocked fallopian tubes, pelvic adhesions, multiple failed cycles of ovarian stimulation with IUI, females over 38, those with severe endometriosis, and couples who may have concerns about male infertility.

Intracytoplasmic Sperm Injection

ICSI requires a direct injection of sperm into a mature egg. The University of California San Francisco (UCSF) Health notes that mature eggs are extracted from the ovaries following ovarian stimulation, and a single live sperm is injected directly into the egg.

This treatment option is often used for those who have male infertility or have undergone multiple cycles of IVF without success.

Combined Treatments

Fertility treatments are not one size fits all. Providers and patients must assess which treatments or combination of treatments to use for conception based on the reason for fertility treatment. Many couples or individuals trying to conceive may use a combination of medications, lifestyle changes, and ART.

Different fertility strategies can be used alongside ART, assisted hatching, donor eggs or sperm, and gestational carriers.

Risks of Fertility Treatment

Fertility treatment for childbearing individuals may cause many complications, including multiple gestations, ectopic pregnancy, and ovarian hyperstimulation syndrome. The statistical probability of having a twin birth after ART is nearly ten times higher than the probability of unassisted conception.

Additionally, some procedures may trigger ovarian hyperstimulation syndrome, caused by swollen ovaries and characterized by abdominal pain, bloating, nausea, rapid weight gain, or shortness of breath.

Ectopic pregnancy is 2–3 times more likely in patients who have undergone fertility treatments. Additionally, invasive procedures can carry a risk of bleeding.

Beyond the risk to the person undergoing treatment, there may be risks to offspring produced through fertility treatment. Fertility medicine is a relatively new field with little longitudinal data available. While many babies have been born healthy with the assistance of fertility treatment, the long-term impacts require more research.

Access to Treatment

Without treatments, some couples with infertility, 1.3–3.8%, may be able to conceive; however, the odds improve with other treatment types. IUI has a 4% success rate, while CC has a 5.6% success rate. Combined, the two treatments have an 8.3% success rate. IVF has the highest success rate among all fertility treatments, 20.7%; however, it is arguably the least accessible treatment option.

Despite the many available fertility treatments, many individuals who could benefit from or would like fertility treatments cannot access them for several reasons. The ASRM revealed that a 2009 estimation found that only 24% of ART needs are being met in the United States, leaving the number of ART births in the US nearly 50% lower than in Europe. Beyond that, the organization notes that countries that publicly fund ART have even higher rates of ART birth.

Financial Barriers

One of the most considerable barriers to IVF is the financial investment required for the treatment. Many insurance companies do not cover IVF or other fertility treatments, leaving an extraordinary financial burden on the families hoping to undergo treatment. A survey conducted in 2015 determined that 83% of the patients undergoing fertility treatment were concerned about the cost.

The Advanced Fertility Center of Chicago estimates that the average cost of one cycle of IVF — without eligibility testing, embryo storage, pregnancy testing, prenatal care, and physician consultation — is $12,000.

According to the ASRM, “a single cycle may represent 50% of an average person’s annual disposable income, whereas a full course of treatment, i.e., 2+ IVF cycles, may cost significantly more.” Roughly 70% of IVF patients went into debt.

Beyond the burden for those who undergo treatment and the delays it can cause, approximately one-third of patients report discontinued therapy due to the costs.

Societal Factors

Other barriers to accessing fertility treatments may include the societal pressures many face to be fertile. Additional burdens include having the time necessary to undergo treatment. The cycle is vicious as patients need time off from work to go to doctor’s appointments and get treatment; however, time off work may compromise them financially, making them unable to pay for treatment.

Additionally, some facilities may not offer or allow ART or other fertility treatments due to societal discrimination. The ASRM states, “Patients may be denied access to effective care if the institution at which they seek treatment does not inform them of treatment options, such as IVF, because they conflict with the religious affiliation of the institution. Fair access also is impaired by providers who refuse to treat unpartnered individuals and same-sex couples, a practice that this Committee rejects.”

Geographical Barriers

Location may present an additional barrier to accessing care. Like many other forms of healthcare, there are areas of the world that lack the necessary resources and workforce to provide care. According to a 2017 analysis, 13 states have less than 5 accredited reproductive endocrinologists, and approximately 18 million people with female reproductive organs do not live near an ART clinic.

Research Gaps

A significant knowledge gap in understanding IVF outcomes for Black, Asian, and Hispanic women may be an additional barrier to successful fertility treatments. The ASRM explains that minority women are less likely to have successful IVF experiences; however, little research has been done to explain the phenomenon. While an unsurprising disparity considering outcomes in other healthcare sectors, this problem needs further investigation.

The WHO notes, “A wide variety of people, including heterosexual couples, same-sex partners, older persons, individuals who are not in sexual relationships and those with certain medical conditions, such as some HIV serodiscordant couples and cancer survivors, may require infertility management and fertility care services. Inequities and disparities in access to fertility care services adversely affect the poor, unmarried, uneducated, unemployed, and other marginalized populations.”