Female Fertility Treatments
Before commencing any fertility treatments doctors at specialist reproductive will probably need to run a series of tests to discover the chances of the fertility treatment being able to work.
Doctors need to test for the ability of the endometrium to respond to oestrogen and progesterone in addition to test the ovaries for their ability to produce viable eggs.
Testing endometrium function:
Kallmann's or HH is usually first noticed in women by the absence of menstruation (amenorrhea).
In normal situations the endometrium is built up under the influence of progesterone and oestrogen combined. When progesterone levels fall to their lowest levels the endometrium is released from the lining of uterus.
Progesterone-induced withdrawal bleeding
A dose of progesterone is given over 5 days. After a week, menstruation should occur if the endometrium is functioning correctly under the influence of oestrogen.
Women with HH with no or very little oestrogen production will not produce menstruation under this test.
Progesterone / Oestrogen combined induced withdrawal bleeding
In this test both hormones are used to mimic the normal monthly supply of oestrogen and progesterone over the course of a month.
Oestrogen: - 28 days
Progesterone: - last 10 days of the month or cycle.
Menstruation should occur within 7 to 10 days after the last dose of progesterone.
It may take a couple of cycles, to produce the desired effect, especially if oestrogen has been absent for a long period of time.
Failure to produce menstruation may indicate other problems with the uterus which may need further investigations.
Ultrasound:
Ultrasound screening is sometimes used to visualize the presence of the ovaries and to test for the presence of 'streak ovaries'.
Regular testing is required throughout the course any fertility treatment to monitor the affect on the ovaries and uterus and to prevent the chances of any hyper-stimulation of the ovaries.
Anti-oestrogen hormones:
Anti-oestrogen drugs such as clomiphene are designed to stop the negative feedback effect of oestrogen on the hypothalamus and in doing so cause an increase in GnRH (or LHRH) production by the hypothalamus which in turn causes an increase in the production of LH and FSH by the pituitary.
The LH / FSH has a direct effect on ovaries to induce ovulation in some patients.
These drugs are unlikely to be effective in women with Kallmann's or HH but may be used as a first attempt, especially if HRT has been taken for a period of time.
Common trade names for clomiphene include: (Clomid (USA / UK), Clomifene (UK) Milophene (USA) and Serophene (USA).
Pituitary Hormones.
The anterior pituitary gland releases a range of hormones with various functions around the body.
Luteinising hormone (LH) and Follicle Stimulating Hormone (FSH) are known as gonadotrophins because they act on the gonads (testes or ovaries) to release the sex hormones. The term luteinising hormone and follicle stimulating hormone refers to their actions on the ovaries, but it is the same hormone that affects the testes in men.
The amounts of LH and FSH released by the pituitary are very small. However there is a another natural source of gonadotrophins, which have a very similar structure and almost identical chemical function as FSH and LH.
hCG ------- human chorionic gonadotrophin
hMG ------- human menopausal gonadotrophin
hCG is secreted by the placenta of pregnant women. It is an early form of LH and is used by the developing foetus. Excess LH is readily excreted into the urine. A highly purified form of hCG can then be obtained from the urine.
Common trade names of hCG include Choragon (UK), Pregnyl (USA / UK), Chorex (USA) and Choron (USA).
hMG is sometimes referred to as menotrophin. It is a mixture of LH and FSH in equal quantities and is produced from the urine of menopausal women.
Common trade names of hMG include Menopur (UK) and Menogon (UK).
Even though these hormones are obtained from females, they are not 'female' hormones and have the correct function in both males and females.
Follitropin is a recombinant form of FSH. This means it is not naturally derived like hMG or hCG but produced synthetically. This means it is more expensive than hMG and hCG, but there is a greater supply of it.
Common trade names of follitropin include Gonal-F (UK), Puregon (UK), Follistim (USA) and Fertinex (USA).
Hypothalamic hormones.
A less common approach, but one that can be effective is the use of the hypothalamic hormone GnRH - gonadotrophin releasing hormone (sometimes called LHRH - luteinising hormone releasing hormone instead).
GnRH is released by the pituitary and acts on the pituitary gland to release its own hormones - LH and FSH.
GnRH is released in a pulsatile manner by the hypothalamus throughout the day in order to stimulate the pituitary gland.
For GnRH treatment to be effective it has to be given in a manner that mimics its normal release as much as possible. In order to do this a pump is normally used that allows for timed release of a set dose of GnRH through out the day. The pump only works for short periods throughout the day, usually between 90 to 120 minute intervals, and can be removed for these periods. A very fine needle is inserted into the abdomen and attached to a pump which is worn for most of the day. The pump can be worn around the waist of leg.
Care is needed in changing the needle regularly and cleaning the injection site to prevent the risk of infection. Ampoules of GnRH are replaced in the pump every 10 days or so.
This may be not be the easiest method of delivery but it is one of the most effective and a high success rate has been achieved using this method, usually after 6 months. If effective it will induce normal ovulation and menstruation so conception can be achieved naturally. It is also an expensive method of treatment and may not be available everywhere.
A small percentage of HH patients will not respond to this treatment due a problem with the hypothalamus being able to recognise GnRH. Your doctor will probably carry out a very simple GnRH stimulation test first to tell if you are able to respond to this type of treatment.
GnRH comes in the form of a manufactured drug called gondorelin.
Common trade names of gondorelin include Gondorelin (UK), Factrel (USA) and Lutrepulse (USA).