Because a diagnostic answer is usually not possible, couples should be grouped into two broad categories: potentially fertile and probably infertile. To be potentially fertile, there should be a normal male component, the possibility of normal ovulation and at least one open Fallopian tube and a negative antichlamydia antibody level. Those in the potentially fertile group will be treated in such a way that would tend to increase their fertility by creating more eggs and placing the sperm in dose proximity in order to facilitate the more mechanical aspects of the fertilization process. Initially, Clomid is used to cause the production of extra eggs, and at the appropriate time, intrauterine insemination (IUI) is performed. This treatment protocol is followed for a maximum of three cycles, as long as the patient responds well to Clomid. Since, the probability of pregnancy occurring is best during the first three months of treatment, if pregnancy does not occur during this period of time, it is time to change treatment. Approximately 25% if couples will conceive during the first treatment level.

For those patients who do not conceive, controlled ovarian hyperstimulation with injectable gonadotropoins (Metrodin, Fertinex) is combined with Intrauterine (IUI) or Intraperitoneal (IPI) inseminations. Multiple eggs and sperm are put near each other and, if all other factors are functioning normally, pregnancy should occur within the first three treatment cycles. Twenty to thirty percent of couples will conceive during this treatment phase. For those couples who do not conceive with the above two treatment strategies, the existence of any one of a number of possible defects in the body is preventing conception from occurring. However, in the cases of women aged 34-40 who produce only 2-3 follicles with controlled ovarian stimulation using gonadotropins, the problem usually relates to the depletion of eggs in the ovary. if pregnancy does not occur with this low level of egg production, this patient is usually not a good candidate for continued treatment.

Couples in whom a tubal or male factor is suspected should proceed direly to an IVF cycle. Of course, IVF is also the final logical step for couples not conceiving despite adequately hyperstimulated cycles and insemination.

An IVF cycle should be considered as both a diagnostic and a therapeutic modality. In couples with unexplained or unresolved infertility, a patient's response during an IVF cycle can suggest the general area in which conception falls. Oocyte abnormalities and fertilization failure are readily demonstrable. if fertilization occurs normally In vitro, the probable defect in vivo was either nonfunctional Fallopian tubes, or a toxic factor blocking fertilization

If fertilization failure is observed In vitro, the cause may be an egg defect (zona pellucida too thick) or a sperm problem (failure to bind or improper acrosome function). Although, in many cases it is impossible to tell if the defect resides in the sperm or egg, the treatment remains the same: the injection of a sperm directly into the egg (ICSI). Again, the diagnosis is not important, since the treatment is identical for both problems.

For patients in whom a male factor is suspected or fertilization failure is anticipated, the initial IVF procedure should include ICSI in order to maximize the chance for a successful cycle. In borderline cases or in patients with long-standing unexplained infertility, the use of ICSI should be considered with one half of the mature eggs.

If there is complete failure of fertilization the cause of infertility is diagnostically uncovered, but is nevertheless heartbreaking for the patients. When an unanticipated fertilization failure occurs, we will attempt to do ICSI on the second day. Although fertilization can usually be obtained, pregnancy rates are much lower than for normally timed fertilization. Some clinics will not do second day ICSI, but I feel that the 5% pregnancy rate with 2nd day ICSI is worth the effort.

Criticism could be expressed for the overzealous use of ICSI. However, its potential benefits may out weigh its downside, which is its extra expense. Performing ICSI adds $1000-$2500 to the cost of an IVF cycle. However, in borderline cases, performing ICSI is an insurance policy against losing the complete cycle. Moreover, in performing ICSI, the oocytes are stripped of their surrounding cells, which enables the quality and maturity of the eggs to be more accurately assessed. In many cases, eggs which appear to be Metaphase II prior to Stripping, are really in Metaphase I and are not ready to be fertilized. Some eggs never do progress to maturity. This oocyte abnormality cannot be determined with the routine fertilization process. The use of ICSI now allows almost every woman who produces mature eggs to have an embryo transfer. In reality, ICSI is probably the only valid treatment for male infertility.