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In most cases, couples struggling with infertility will have options that may increase the odds of becoming pregnant.

In 85 to 90 percent of all cases, infertility is treated with either medication or surgery, according to the American Society for Reproductive Medicine. Less than 5 percent of infertility treatments involve in-vitro fertilization or other kinds of assisted reproductive technologies (ART), in which a laboratory is used to try to help a couple become pregnant.

Fertility drugs are usually the first option for couples. Up to 90 percent of women who seek fertility treatment will use medications at some point,  according to the National Women’s Health Resource Center (NWHRC). These drugs are intended to correct hormonal imbalances and to stimulate the production of mature eggs. They include:

• Clomiphene citrate. Causes the pituitary gland to release more FSH and LH, which stimulate the growth of an ovarian follicle containing an egg. About 60 percent of women who use this drug will ovulate following treatment, and 40 percent of these women will go on to become pregnant, according to the NWHRC. The drug is taken in pill form and is easy to use. It tends to be more effective in women who experience abnormal ovulation cycles than in those who regularly ovulate. It can cause side effects such as swelling of the ovaries, multiple pregnancies, hot flashes, mood swings, weight gain, water retention, depression and irritability.
  
  
• Gonadotropins. These drugs can correct many ovulation problems except ovarian failure and generally have a higher rate of success than clomiphene citrate. Pregnancy rates can reach 100 percent for some ovulation problems, according to the NWHRC. However, gonadotropins are much more likely to cause multiple births. In rare cases, they may also cause severe medical complications. Examples of gonadotropins include:
  
  
• • Human menopausal gonadotropin (hMG). This drug is used for women who do not menstruate because of the failure of the pituitary gland to stimulate ovulation. Unlike clomiphene, hMG is an injected prescription medication that directly stimulates the ovaries instead of stimulating the pituitary gland. This drug contains both FSH and LH.
    
    
  • Human chorionic gonadotropin (hCG). Used in combination with clomiphene, hMG and FSH, this drug stimulates the follicle to ovulate.
    
    
  • Gonadotrophin-releasing hormone (GnRH) analogs. A treatment used in women with irregular ovulatory cycles or who ovulate prematurely during hMG treatment. GnRH analogs deliver constant GnRH to the pituitary gland, which alters hormone production. This allows a physician to induce follicle growth with FSH.
    
    
• Follicle-stimulating hormone (FSH). This drug is essentially hMG without the LH. Like hMG, it also works to stimulate the ovaries to mature egg follicles.
  
  
• Letrozole. Sometimes prescribes for women who do not ovulate on their own and who do not respond to clomiphene citrate treatment. The drug is normally used in treatment of advanced breast cancer.
  
  
• Metformin. May be used to boost ovulation when insulin resistance is known or suspected.
  
  
• Bromocriptine. Used when high levels of prolactin – the hormone that stimulates milk production in new mothers – causes irregular ovulation cycles. This drug lowers prolactin production.

Fertility drugs work for many women but the use of fertility drugs raises the risk of having multiple births. In addition, there is some speculation that using these drugs may increase the risk of developing ovarian cancer. This link has not been conclusively established.

If medications fail to help a woman become pregnant, other options remain. Most involve implantation of the fertilized egg into the woman’s uterus. Such techniques are known as ART.

Several factors can reduce the odds of successful fertilization using ART. These include advanced maternal age, presence of large submucous fibroids or polyps, abnormal endometrial development and the presence of a hydrosalpinx (collection of watery fluid in the fallopian tube). 

To ensure a woman is a good candidate for ART, she may receive several tests, including:

• Hysterosalpingogram (HSG). Uses radio-opaque dye during fluoroscopy (x-ray) of the abdomen and pelvic region. This procedure allows the physician to examine the uterine cavity and to note whether the fallopian tubes are blocked (tubal patency).
  
  
• Saline-infusion sonogram (SIS). Sterile saline is inserted into the uterus to allow the physician to evaluate the contour of the uterus during an ultrasound. It differs from HSG in that it does not expose the patient to radiation, but it does not provide as clear a picture of tubal function and patency as HSG.
  
  
• Transvaginal ultrasound. Reveals the thickness of the endometrium and uterine blood flow in relation to the ability of an egg to implant. Blood flow should rise during implantation, and some research has indicated that high uterine blood flow rates are associated with high implantation rates.

Implantation techniques include:

• In-vitro fertilization (IVF). The patient receives fertility drugs that ensure that enough eggs are available to be removed for the IVF procedure. The eggs are removed from the ovary through the vagina using an ultrasound-guided aspiration technique. The procedure is usually performed in a physician’s office using a local anesthetic. The eggs are then combined with sperm in a Petri dish that is placed in an incubator. Once fertilization occurs, the resulting embryos are either frozen for later use or placed in the uterus in a separate procedure.  
  
  
• Gamete intrafallopian transfer (GIFT). Uses the same stimulation process as IVF except that the eggs and sperm are combined and immediately transferred into the fallopian tube. This allows fertilization to take place in the body. The procedure can be performed only on women who have normal fallopian tube function. GIFT is usually performed using general anesthesia.
  
  
• Zygote intrafallopian transfer (ZIFT). This procedure is a combination of IVF and GIFT and has a similar success rate to those procedures. Eggs are retrieved from the ovaries via a laparoscope and combined with sperm in a Petri dish. The fertilized egg is then placed in the fallopian tube 24 hours later. As with GIFT, general anesthesia is used and a woman’s fallopian tubes must be functional for the procedure to work.
  
  
• Intracytoplasmic sperm injection (ICSI). Used when sperm function or number of sperm are inadequate for fertilization. It can also be used when a fertilization defect is discovered when attempting IVF. In this procedure, sperm is injected into the cytoplasm (cell matter, excluding the nucleus) of a single egg. ICSI is a highly specialized process that may not be available in all areas.
  
  
• Donor egg. Women who cannot produce their own eggs or who have poor-quality eggs may use an egg donated by another woman as part of an IVF process. In this method, the woman gives biological birth to the child, but the child does not share the woman’s genetic makeup. The procedure is successful between 30 and 60 percent of the time, according to the NWHRC.
  
  
• Donor sperm. If the father’s sperm is inadequate – or if the mother does not have a male partner to father her baby – donor sperm can be used to fertilize the woman’s egg.
  
  
• Gestational hosting. Some women cannot carry a pregnancy. In such circumstances, a couple’s egg and sperm may be placed in another woman’s uterus. The woman who gives birth to the baby does not share her genetic makeup with the child. In a variation on this procedure, the surrogate mother may also donate her egg. In such instances, the woman who gives birth to the child also shares her genetic makeup with the child. Laws about surrogate parenting vary from state to state.

In some IVF or combination IVF/ICSI procedures, a technique known as assisted hatching can be used to improve implantation rates. Once the embryo has formed, the outer covering (zona pellucida) is thinned with a special harmless solution. This helps in the hatching process, allowing the cells of the embryo to emerge from the outer shell and implant in the uterus. The method is most likely to be used in women over age 35 or women who have experienced repeated failure of IVF attempts.

Similar to fertility drugs, ART techniques come with some risks. These include higher incidences of:

• Multiple births
• Enlarged ovaries (ovarian hyperstimulation syndrome)
• Bleeding or infection
• Low birth weight
• Birth defects

Many couples are unprepared for some of the obstacles that accompany fertility treatments. Treatments can be costly – for example, in-vitro fertilization may cost between $5,000 and $15,000 per procedure. Many times it requires multiple procedures for a successful pregnancy. Treatments often can be emotionally draining and may cause significant mood swings in women. In addition, patients may find that the physical and emotional toll of treatment impacts their professional and social lives.

All that effort is often rewarded in the birth of a child. More than 70,000 babies have been born in the United States using assisted reproductive technologies, including 45,000 born as a result of in-vitro fertilization, according to the National Women’s Health Resource Center.

However, in other cases treatments may fail. It is not unusual for couples to find that the stress of treatments has a negative impact on their relationship. At some point, couples may find themselves having to accept that conception is not going to occur, and that it is time to stop treatments and choose another option, such as adoption or child-free living. Good communication and mutual support can help couples get through this trying time.