Infertility Treatments Need Not Be Expensive
Infertility treatment does not have to be prohibitively expensive. Many infertility clinics offer technology-assisted reproduction, such as in-vitro fertilization (IVF), to help couples conceive. While these technologies are effective, they are expensive, costing tens of thousands of dollars and often an emotional toll.
In reality, many couples with infertility problems often can achieve pregnancy merely with proper information and guidance, simple medical treatments, and possibly minimally invasive surgery. From an efficiency, cost, and convenience standpoint, an infertile couple should start with the basic infertility work-up to see if some of the simpler measures can help achieve pregnancy before going through the high cost technology-assisted reproduction process.
Infertility Work-Up: The Basics
Most gynecologists can offer basic infertility information and order infertility screening tests, such as sperm count, hormone blood levels, and hysterosalpingogram (HSG), which helps to evaluate the patency of the fallopian tubes. These are good starting points.
Dr. Lau, being a reproductive surgeon, has been doing infertility surgeries for over 25 years. From his years of experience in microscopic tubal surgeries to treat tubal occlusion and pelvic adhesions, Dr. Lau has evolved in using mostly minimally invasive laparoscopic surgeries for infertility. Using high definition optical systems and laser, Dr. Lau has been successful in treating distal tubal occlusion/ hydrosalpinx, pelvic adhesions, and pelvic endometriosis using laser laparoscopy. For patients with fibroid tumors that might adversely affect pregnancy, laparoscopic or hysteroscopic myomectomy (removal of fibroids) can be performed non-invasively. Of course, infertility surgery is recommended only if it is deemed necessary after a thorough infertility work-up.
Dr. Lau has set up an infertility work-up system by which the couple will be evaluated systematically for sperm quality, ovarian function and reserve, hormonal status, cervical factors, immune factors, and tubal imaging. Often the causes of the infertility problem can be readily detected, and simple medical treatments, such as fertility drugs as guided by ultrasound follicle studies which Dr. Lau performs personally, can help to achieve pregnancy. Another example would be in the case of hostile cervical factors that are preventing the sperm from passing the cervix to enter the uterus. Intrauterine insemination (IUI) can be performed economically as an office procedure.
Occasionally there are infertile couples that have gone through the basic fertility work-up and medical fertility treatments and still cannot conceive. Many times their fertility problem would be labeled as “infertility of unknown cause.” However, these infertile couples might have silent endometriosis adhesions of the tubes and ovaries causing infertility that the hysterosalpingogram (HSG) cannot detect. Using laser laparoscopy to diagnose and treat the endometriosis and adhesions would be a logical step to take to correct the basic cause of the infertility and help the couple to achieve pregnancy, not just for one time only, as in the case of IVF, but also for future pregnancies. There is definitely a role that minimally invasive infertility surgery should play in treating infertility. Only when there is a clear indication for infertility surgery from the initial investigation would the minimally invasive surgery be recommended.
Surgery for Infertility/Fertility in Seattle
Indications for Infertility Surgery
In order to conceive, the egg released from the ovary needs to travel into the fallopian tube to meet the sperm towards the far end of the tube. The fallopian tube basically has to capture the egg using the finger like fimbria tissue at the end of the fallopian tube and usher the egg into the tube. One can imagine if there were adhesions (scar tissue) that would bind down the fimbria tissue or limit the mobility of the tube, it would be difficult for the egg to migrate into the tube. In some cases, the far end of the tube is actually blocked by filmy adhesions that prevent the egg from entering the tube. Also, the adhesions could completely wrap around the ovary and trap the egg so it cannot go anywhere. The worst case scenario would involve the blockage of the tube by adhesions, causing the tube to fill up with fluid like a sausage, forming a hydrosalpinx. This can lead to permanent damage of the tubal lining, causing infertility and/or the increased risk of tubal pregnancy.
The causes of the pelvic adhesions and infertility most commonly are:
- Pelvic Infection: Pelvic Inflammatory Disease (PID) caused by chlamydia or gonorrhea can damage the fallopian tubes and cause the formation of adhesions. Frequently, chlamydia infection can be silent, without the patient realizing that she has pelvic inflammation, but yet the adhesions and damage to the tubes would occur. Appendicitis, especially a ruptured appendix, can cause similar problems of adhesions.
- Pelvic Endometriosis: The abnormally located endometrial tissue outside of the uterus can cause local inflammation and adhesion formation around the tubes, ovaries and pelvic side wall. Sometimes the adhesions can be very dense.
- Pelvic and Abdominal Surgery: Any surgery in the pelvic and abdominal area, especially those associated with infection, can cause adhesion formation around the tubes and ovaries.
Surgical Treatment for Pelvic Endometriosis and Adhesions Causing Infertility
In order to fix the cause of infertility due to adhesions and/or endometriosis, one would need surgery to physically remove the adhesions or endometriosis. Since it is a structural problem, no medication would work and infertility surgery is needed.
It is unfortunate, but often the infertile couple would go through months of medical infertility treatment without success, but with much frustration, and then find out that the woman actually has a physical cause for infertility, such as pelvic adhesions. Hysterosalpingogram (HSG) can show that the tubes are open but it can miss adhesions around the tubes and ovaries unless there are fluid pockets caused by adhesions showing up with the contrast medium. Ultrasound studies cannot detect endometriosis or adhesions, except in the most advanced stages. The only way to confirm endometriosis and/or adhesions is by laparoscopy. Dr. Lau has over 25 years of experience in performing laser laparoscopy in Seattle. With laser laparoscopy, he can diagnosis and treat endometriosis and adhesions in the same surgical setting to help restore fertility.
Using a laparoscope, which is a thin tube telescope that can be inserted through a tiny incision in the abdomen, and a fine laser beam, pelvic endometriosis and pelvic adhesions can be vaporized or removed. The laparoscope actually magnifies the pelvic structures, especially when used in conjunction with a high definition imaging system, so it can function as an operating microscope with zooming capabilities. Essentially, we can use minimally invasive laparoscopy to do most of the procedures that used to be done using an operating microscope with open abdominal surgery.
Using a fine laser beam, the endometriosis deposits in the pelvis can be precisely vaporized or dissected off. Elimination of these endometriosis deposits often reduces the factors contributing to infertility and pain. Adhesions around the fallopian tubes and ovaries, often caused by pelvic infection, prior pelvic surgery or endometriosis, can impair the transport of the eggs from the ovaries to the fallopian tubes, causing infertility. Laser laparoscopy often can lyse off those adhesions and restore the normal relationships and function between the tubes and ovaries and enhance the egg transport mechanism.
Blockage of the distal (far end) of the fallopian tubes, often by adhesions caused by pelvic infections, obviously causes infertility since the eggs cannot get into the tubes from the distal (fimbriae) end. Often such blockage causes the tubes to balloon up with fluid, causing hydrosalpinx. By using laser laparoscopy, the blocked distal end of the tubes, inducing hydrosalpinx, can be opened up and expose the fimbriae, enhancing the chance of fertility. Of course, there is increased risk of future ectopic tubal pregnancies after such fallopian tube repair. Occasionally, the hydrosalpinx is so severe that the tubes cannot be repaired and should be removed, and the patient would be advised to have IVF to conceive.
Dr. Lau pioneered the use of laser laparoscopy in Seattle. With a background in physics, Dr. Lau recognized the potential of using laser in reproductive surgery. Having been trained to use laser in vaginal and cervical surgery at Henry Ford Hospital – one of the first institutions in the U.S. that developed laser application for medicine – Dr. Lau developed the laser laparoscopy program in Seattle in the early 1980s. He has performed over 2,000 cases of laser laparoscopy, including many complex cases involving extensive pelvic adhesions and endometriosis. He has also transitioned infertility surgery from open microscopic surgery to the use of minimally invasive laser laparoscopy to correct tubal infertility problems. The patient can recover in just a few days and can start trying to conceive in a matter of weeks.
Myomectomy — the Removal of Uterine Fibroids
Fibroid tumors are benign tumors of the uterus. They can distort the uterine cavity, causing infertility or early pregnancy loss (miscarriage). Uterine fibroids can be classified into several categories:
- Intracavitory, pedunculated: all inside the uterine cavity, attached to the uterus by a stalk
- Submucosal: under the lining of the uterine cavity, the endometrium, causing obvious distortion of the uterine cavity
The above two categories of fibroids can cause infertility and abnormal menses.
- Intramural: fibroids mainly in the muscle wall of the uterus
- Subserosal: fibroids mainly under the outer lining (serosa) of the uterus, which can be pedunculated — connected to the uterus by a stalk
The intracavitory-pedunculated fibroids and submucosal fibroids can be resected and removed through a hysteroscope, a thin telescope inserted through the cervix. Myomectomy (removal of fibroid tumors) can help improve fertility and decrease abnormal menses. The subserosal and intramural fibroids often do not cause infertility if they do not encroach or distort the uterine cavity. Their removal is usually performed by laparoscopic myomectomy, if indicated.
Cost of Infertility Surgery
If the surgery is done solely for the indication of infertility and not covered by insurance, Dr. Lau has negotiated with Swedish Edmonds Hospital to have a special cash discount rate to have surgery performed there. If the minimally invasive surgery is done to correct a medically indicated problem, such as painful endometriosis that contributes to infertility, medical insurance might cover the surgery as defined by the insurance benefits of the patient.
Causes of Infertility that Can Be Treated without Surgery
Most of the causes of infertility do not require reproductive surgery to correct. A brief summary of these causes and treatment are listed as follows:
Male Factors: Abnormally low sperm count, mobility, and normal form can all cause infertility. Usually the male is referred to a urologist to seek the diagnosis and treatment of such problems. If appropriate, intrauterine insemination (IUI) can be used to concentrate the sperm and improve the chance of conception by directly depositing the washed sperm into the uterine cavity.
Ovulation Deficiency: Some women may not ovulate regularly or optimally, most commonly seen in patients with polycystic ovary syndrome (PCO). Medical treatment, such as with the fertility drug Clomid, can help to enhance ovulation and improve fertility. Ovulation induction can be done rather inexpensively, monitored by ultrasound follicle studies, with a total cost of less than $200 per cycle. Occasionally for resistant cases, injectable fertility drugs may be needed with increased cost.
Fallopian tube factors: Besides pelvic-tubal adhesions described previously, which are treated by reproductive surgery, the fallopian tubes can be blocked at the first narrow portion. In this situation, cannulation, using a surgical wire to open up the tube through the cervix and uterus as guided by radiologic imaging, can occasionally restore fertility.
Cervical factors: The female cervix can produce abnormal mucus that is hostile to the sperm, causing infertility. Medication, such as antibiotics and/or estrogen can be used, to help improve the cervical factors. Intrauterine insemination (IUI) can be an effective treatment to overcome infertility caused by cervical factors.
Intrauterine insemination (IUI) – by using a sterile technique, the semen from the male partner can be washed with a specialized solution and concentrated into a small volume of tissue nutrient solution. The washed sperm then is injected into the uterine cavity through a small tube that passes through the cervix, thus bypassing the hostile cervical mucus. The deposit of millions of active sperm into the uterine cavity, without the hurdle of passing the cervix, can at times improve fertility for couples with male factors or those with unknown infertility factors. The cost of IUI is around $205, certainly much less than IVF. The combination of Clomid therapy and IUI can be tried for three cycles before considering surgical treatment, if indicated, or IVF.