After ovulatory dysfunction is established, treatment should begin. Some specialists recommend the use of simple means of inducing ovulation (e.g., clomiphene citrate) for 3 to 4 months before the completion of the infertility evaluation in an effort to save the couple effort and expense. However, because of the high incidence of multiple causes for infertility and the paradoxical potential of clomiphene to induce other causes of infertility (e.g., hostile cervical mucus, endometrial abnormalities, detrimental effects on oocyte maturation), the rationality of such an approach is unclear40 (see Chap. 97).

Patients who ovulate with therapy but do not conceive should be reevaluated periodically to determine whether any other cause for the infertility exists. Individuals who become anovulatory after an initially favorable response also should be evaluated to exclude incipient thyroid disease and ovarian failure.

Significant uterine and tubal abnormalities usually necessitate surgical intervention. Many patients with uterine abnormalities such as fibroids and müllerian anomalies do not require surgery, and such surgery more often is considered for patients who have multiple pregnancy losses. The decision to proceed with tubal surgery is predicated on information obtained from a comprehensive infertility evaluation. Success rates for tubal patency range from 0% to 70%, depending on the location and the extent of disease and the presence of other infertility factors. For the
most common form of tubal factor infertility, distal tubal damage, the chance of successful pregnancy after surgery is 20% to 30%. For this reason, many patients now elect to proceed with in vitro fertilization, which yields a higher pregnancy rate (30% to 50%), rather than undergo tubal surgery. Significant predictive information usually can be obtained at diagnostic laparoscopy, and after this procedure, a more accurate appraisal of the prognosis and risks can be presented to the patient.

Significant improvements in atraumatic surgical technique, including the use of magnification, nonreactive suture material, and adhesion-inhibiting substances, have enhanced fertility potential compared with the macrosurgical methods used before 1970. However, many patients with extensive tubal destruction cannot be helped by reparative pelvic surgery. The advent of in vitro fertilization has been beneficial to these individuals.

ART includes techniques in which the ovaries are stimulated with fertility drugs and at the time of ovulation the sperm is introduced into the uterine cavity through a small catheter. This technique is called superovulation with intrauterine insemination (IUI) or therapeutic donor insemination (TDI) when donor sperm is used. More advanced reproductive techniques include those in which the oocytes are surgically aspirated from the ovary through a needle directed by transvaginal ultrasonography or at laparoscopy. These techniques include in vitro fertilization (IVF), gamete intrafallopian transfer (GIFT), and zygote intrafallopian transfer (ZIFT) (Table 103-2). The techniques have not been compared in a prospective, randomized fashion. Success rates with the different techniques vary widely among institutions.41 IVF and embryo transfer (ET) technology has spawned several innovative approaches to the treatment of infertility. IVF and ET are the most successful ARTs, with pregnancy rates around 50% to 60% per cycle, and are most appropriate for patients with irreparable tubal damage, infertility attributed to the male factor, endometriosis, refractory ovulatory dysfunction, and idiopathic infertility.