Treatments designed to address infertility include:
- Non-Assisted Reproductive Technology (ART) therapies such as medications to induce or stimulate ovulation (e.g., clomiphene tablets, gonadotrophin injections or metformin) or, in some cases, progesterone supplements for women and trans and gender diverse people at risk of miscarriage
- Assisted Reproductive Technology (ART) treatments including Intrauterine Insemination (IU), In-Vitro Fertilization (IVF), Intracytoplasmic Sperm Injection (ICSI), and IVF ‘add-ons’ – extra treatments that lack a strong evidence base
- Surgical treatments to treat underlying conditions (e.g., endometriosis, uterine fibroids, blocked uterine (fallopian) tubes or intrauterine adhesions).
To learn more, please see Further Information at the end of this page.
In the first film below, you can hear about people’s experiences of ovulation induction, ovulation stimulation, and progesterone supplements. These are non-ART (Assisted Reproductive Technology) therapies.
The second film features experiences of ART – Intra-uterine Insemination (IUI), IVF and Intracytoplasmic Sperm Injection (ICSI). IVF add-ons are also covered on this film. While add-ons lack good evidence and their use is contested, they are commonly offered as part of IVF treatment, usually after a few unsuccessful cycles. ICSI is considered an add-on when it is offered without a medical reason such as problems with sperm quality.
The third film covers experiences of fertility-related surgery.
Non-Assisted Reproductive Technology (ART) therapies
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After having blood hormone tests and trying ovulation tracking, Georgia still was not conceiving. She sought a second opinion, learned that she was not ovulating regularly, and was advised to start ovulation induction.
So I went back to the GP again, and I said, “Look, it’s not happening. We’ve been trying for about a year now, and I’m just wondering if there’s anything else that I can do.” So she sent me to have a blood test done through every cycle. So I had the blood tests starting from day five, and then they would let me know when to come back, and do all that sort of stuff. Then they would phone me to say, “You’re going to ovulate or you’re just about to ovulate; come back in seven days and we will check your progesterone.”
So that was fine. I did that for three or four months, I think; and thought, “Okay, things still aren’t progressing. I know that I’m ovulating.” We’d try and get the right times. “What’s going on?” basically. So I went back to my GP, who didn’t really have any answers for me. She just said, “Look, these things happen.”
So I ended up contacting a previous employer of mine who is actually an obstetrician gynaecologist, and she works at a fertility clinic. So I went to her, and I said, “Look, I’m just really confused. I need some answers.” I said, “I’ve been having the calls to say, “You’re about to ovulate today, your progesterone is great. So why isn’t this happening?”
So within five minutes, clicking through all of my different results, said, “You’re not close to ovulating, and your progesterone isn’t where it should be.” So that was a bit of a kick to the stomach, to think that I’ve been doing this for so long, and things really weren’t the way that they should be, even though I was being told differently. So she said, “I don’t have any concerns whatsoever that you are completely infertile; I don’t think that at all. But we should get some tests done, just in case.”
So my husband got his sperm count done; I had a HyCoSy [Hysterosalpingo Contrast Sonography] performed, and then she said, “I think the best option is going to be to go forward and do ovulation induction.” And that’s where I am at the moment, basically; waiting to start that.
So what they’ve explained to me is that I come in, and I have scans done to check that follicles are sort of… At least one is maturing; then I give myself injections, and I come in every day for a scan and check that it is just one follicle that is maturing, and not multiple, because that can make an issue in itself. Then, yeah, I’ll just be injecting myself. They said that it could be tablets or injections; but for myself, it will be injections.
Megan underwent three cycles of ovulation stimulation using clomifene citrate [CLOMID] tablets, on the advice of her fertility specialist and after seeking a second opinion from her GP.
So, after six months of trying naturally after the [endometriosis] surgery, we went back to the fertility specialist, to review where things were at; and at that point, he recommended an ovulation induction cycle, where I would take CLOMID [clomifene citrate] for a few days at the start of the cycle, and they would monitor me with scans, and then we would time intercourse exactly when we knew I would be likely to be ovulating.
I remember when he recommended that, it was strange at first, and we didn’t do it for a couple of months; just because I wasn’t sure if I was ready. I remember I went back to the GP to just ask her about CLOMID, and should I be concerned about it. I had read things online that sort of talk about the various side effects of being on the drug, and I was a bit worried about that. And she assured me that it would be a very low dose, that I’d be monitored the whole time, that probably the stories I was reading online were people who were prescribed CLOMID by a GP and then left to take it unmonitored for weeks or months, which apparently sometimes happens, but is not necessarily what is recommended; and that in my case, I would be monitored closely and that it would all be managed really carefully.
So once I had spoken to her about it and she put my mind at ease, we decided to start the first cycle. I think we did two ovulation induction cycles pretty close together, probably two months back-to-back, but then had a little break before we tried for a third one. Then we had another break again, before we moved up to IUIs.
Chelsey and her husband conceived their first baby via ICSI and their second baby ‘naturally’. After then having three miscarriages in two years, Chelsey took progesterone supplements during her final pregnancy, which went to term.
I was very lucky and did fall pregnant naturally with my second child, which was a great shock, and I felt like he really wanted to be here for a reason, to show me that there was light at the end of the tunnel.
After the 12 months with him, like after he was born for the first 12 months, I didn’t go on contraception. I really felt deep inside my family wasn’t complete and I really wanted to go for a third child, so I just looked after myself, just thought well if I could get pregnant with my second child I’ll see how I go with a third. So off we went, and I ended up having three miscarriages in the space of about two years. Each of those miscarriages was devastating.
So then from there I felt like all was lost. I was now reaching closer to 40 and didn’t particularly want to get much older, so I felt a lot of pressure, time was against me, and struggling to come to terms with maybe this is it, maybe I will continue my life feeling that my family was incomplete. Luckily enough though, I did fall pregnant and I rushed to a doctor and asked for some progesterone suppositories to help with the HCG levels, because I felt that maybe that was part of the problem previously, and given my age, and I had talked to a doctor about it, whether or not I should start on a low dose of aspirin, which she had also agreed to1.
And luckily enough, at the seven week mark, I went and had a scan and I was pregnant with twins, which was fantastic news, and my pregnancy continued, although like the other two, I was very nervous, I was anxious all the time until I had these little bubs in my arms, and luckily that’s what happened.
1 Progesterone supplements are not usually given during a spontaneous pregnancy.
Assisted Reproductive Technology (ART) treatments
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Tallace and her ex-partner, a trans man, tried IUI using donor sperm for 12 months before moving to IVF. She describes her experience of the process.
Tallace: I think that IUI is sort of the closest that the medical system can approximate natural conception. So they just time your ovulation with the procedure, with the… I guess with the insemination. So they just defrost the sperm, and it isn’t… I believe it’s washed sperm, so they actually thread it straight into your uterus. So they give it a bit of a head start, I think, by trying to insert it a bit higher than if you had just had intercourse. But it’s not a particularly complex procedure; it’s just a trigger injection, and then you come into the hospital, and they thread a very fine tube into your cervix, and inject the defrosted sperm.
So, with IUI and IVF, you quickly become accustomed to this terminology, where you ring up your patient liaison officer and say, “It’s day one”, and day one means, “I just got my period.” And so that’s pretty much the key date that they time your cycle off. I think that they trigger your ovulation probably a little bit before you would have naturally ovulated, so that they don’t miss it.
Interviewer: Do they supply you with everything that you need for the injection?
Tallace: Yeah, you have to… A lot of it has to be refrigerated, so you have to turn up and have arrangements to keep your medication cold until you get home and pop it in the fridge. So that’s sort of, a bit of a logistical challenge. But, yeah, you just do that. They tell you when to do the injection, and one of your initial appointments with a nurse is to be shown how to do the injections, and then you do that on your own at home.
So, they’re all… I think you call it a subcutaneous injection, so you just need to find a little bit of fat, generally on your stomach, and inject into that. It’s a very fine needle; sort of just a bit of a sting. It’s pretty tender afterwards, and you do end up with sort of these blotchy bruises across your stomach.
Interviewer: You then need to go into the clinic a certain number of hours later, is that correct?
Tallace: It’s usually the next day, I think. For IUI. I think something about my cycle often meant that it fell over a weekend, so I’d be going up to the hospital, where they had another site for weekends. All up, it might be an hour that you would be there. The actual procedure is maybe five minutes.
Sarah, a single mother by choice, conceived her first baby via IUI and her second baby via IVF (second cycle). She describes her experience of IVF.
Interviewer: How did you find the IVF, compared to the IUI – to go through it physically and emotionally?
Sarah: Obviously it was a lot more complicated. I had to get all of my needles, so it was a needle a day for a while, and then I had to do two needles a day. Going in for the blood test and things like that, that was all the same; going in for my scans. But it was just more doing those needles every day. After a while I did get used to them, but at first it was not fun, injecting myself every day, in my stomach. Gave myself quite a few bruises trying to work out the best way to do it.
And also then obviously having egg collection. It involved going under general [anaesthetic]. My mum had to take the day off to be able to come and pick me up and collect me, and egg collection was not very pleasant afterwards. It was a bit painful, bit of cramping.
Then also the emotional toll of waiting to see how many eggs you got, and then waiting to see how many embryos it made, and then waiting to see if any made it to day three, and then to day five. So, it was definitely a lot more of an involved process; a physical toll on your body, and also emotional toll. So just waiting for those calls from the clinic, and from the scientist, to see what your chances are.
So, the first egg collection, they only got three eggs, and that obviously wasn’t an ideal result. Then out of those three eggs, only one made it to a day three embryo, and they just put it back, because they didn’t even know if it would make it to day five. So I was already very realistic about that cycle; I’m like, “I don’t think this cycle is going to work”, but you just never know.
But obviously that cycle didn’t work, and the second cycle, they upped my stimulation, because obviously I only got three eggs the first time, so they upped my stimulation the second time, and I got 10 eggs the second time; and out of those 10, I think three or four made it to day three, and then I actually didn’t know how many made it to day five until I went in for my transfer, and they told me that, “This is the only one that’s made it. None of the others made it to day five.”
Interviewer: Did they give you any explanation about why the others didn’t make it?
Sarah: No. No, I don’t think they did. The first cycle, I know after, they said I wasn’t stimulated enough, and so I obviously didn’t get many eggs; so that already reduced my chance of first of all having embryos, and then them making it to day five. The second time, I think if that cycle had failed, we would have gone through more around that; but because that cycle worked, I didn’t really investigate after that, because obviously it worked. So I was happy with that.
Because of problems with Chelsey’s husband’s sperm, Intracytoplasmic Sperm Injection (ICSI) was recommended as part of their IVF procedure.
So with IVF they put the eggs and the sperm in a petri dish and they just let things do it on their own. With ICSI they get each egg and they actually inject the sperm into the egg, so they help fertilise the egg.
So they harvest the eggs from me, like they would in IVF, but instead of, say they might get ten eggs, they might put all the eggs in the petri dish and then put the sperm in there and they let the sperm fertilise whichever egg they manage to do, whereas with me, they were picking the healthiest looking sperm and the one with the most motility, and injecting that. So they were sort of picking which sperm was the healthiest and using that.
And then after 24 hours – 48 hours, you then go back into the clinic and they have the embryos, and then they inject the embryos into the womb, which is exactly the same what they do with IVF. It’s just that it’s an added procedure basically, with the ICSI that they have to then inject the sperm.
And it’s more to do with the sperm health as well. They’d probably do it for, say if a man has had cancer of the testes and he’s perhaps taken a sample and they’ve frozen it on ice until he’s ready, or even, it’s more to do with the sperm health that if the sperm can’t penetrate into an egg, that’s when they need to start using it.
Whereas with IVF, the man’s sperm is fine, so they collect the women’s – it’s more about the woman being able to – for some reason, my sister-in-law, they had unexplained infertility. My brother’s swimmers were fine, but for some reason her eggs wouldn’t fertilise basically, or if she fertilised them – I mean, because she had polycystic ovary. When they did hers, when they harvested her eggs, she had 15 eggs, so she went the other way where you hyperovulate, and her eggs and his sperm were just put in the petri dish and they just let them choose their own destiny.
Jacinta explains how after a few unsuccessful IVF cycles she and her husband were more willing to consider IVF add-ons, even though her specialist was ‘really upfront’ that the treatments were ‘experimental’.
Jacinta: I guess the official diagnosis was unexplained infertility. There was no really obvious reason as to why it wasn’t working and I think that’s why we stuck with the CLOMID [clomiphene citrate] and the letrozole for so long because everything was working fine. I was ovulating really fine. I was producing really great quality follicles. Everything was working fine. The sperm analysis came back fine. It just wasn’t ever sticking. By the time we got to that last cycle of IVF when we did the CLEXANE [enoxaparin sodium] and the prednisolone it was kind of everything but the kitchen sink method. We’d done scratching of the
Interviewer: Of the endometrial lining?
Jacinta: Yes. Yes. We’d done a few of those. I had done – we’d used Filgrastim which is a uterine wash which is super expensive. It’s $400 a dose and you have two of them in a cycle so we did that a couple of times. Because once you keep going you just keep going and every intervention that you might have said at the start you would never do becomes something that you might do the next time when nothing else has worked. So we did everything. We were well aware that a lot of the things that we were doing didn’t have a huge evidence base. Our doctor was really upfront about that that a lot of this is kind of experimental.
But when you’re reaching that point of desperation you’re just really happy to be doing something and trying something new. I don’t know. For me I will always wonder if perhaps the immune suppression stuff is what did the trick and certainly that was the cycle that we got our daughter from and whether it’s now kicked my body into gear to realise that these things are not foreign and we don’t need to fight them off we’ll never know that.
Surgical treatment of infertility
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When Kate was not getting pregnant, she thought endometriosis might be a factor. A laparoscopy not only confirmed her suspicions but possibly also helped her conceive a few months later.
So when my husband and I got married, that was 2012. I came off the pill just before we got married because we knew we wanted to start a family pretty soon after. So we started trying straight away and I also started tracking my cycle and things like that. But we were having no luck. So months were going by and nothing was happening. As time went on I started to suspect that maybe I might have a little bit of endometriosis, just based on some of my symptoms. There was not much prior to that to give me that indication but I guess the pill kind of masks those sort of things.
So being in my 30s I knew time was precious. So went to see a hormone specialist who ran some tests and nothing major came up. Low progesterone I think came up but nothing that was really indicating why we were having trouble. Checked out my husband, everything came back fine there. So eventually he referred us on to a fertility specialist. So we started working with a fertility specialist.
He decided we would try CLOMID [clomifene citrate] and see how we went. And we still weren’t getting any results. No pregnancies at all. So then eventually he said, “It’s time to do a laparoscopy and investigate what’s going on.”
And by this point I had started to suspect endometriosis. So we went on the waitlist. I think I only had to wait about three months – three or four months. And then had the surgery. I remember waking up from the anaesthetic and saying to the nurse straight away, “Do I have endometriosis?” And she said, “Yeah you do.” She said, “It was all over your bowel and your bladder.”
The fertility specialist didn’t seem concerned. I think the general consensus was that when you have a laparoscopy it’s a bit like a clean out and they do a D&C [dilation and curettage] and they flush your tubes and that’s often enough. There wasn’t much discussion around the endometriosis. And because I went through the public system I never met the surgeon or anyone that was involved in the surgery. They just gave me an A4 piece of paper with a diagram on it that the nurses had drawn to show me that there had been endometriosis on the bowel and the bladder and that there had been “thick adhesions” they’d written.
And then when I went for that six-week post-op checkup the doctor I saw was a different fertility specialist who just I think works one day in the public system. And she was quite forceful when she just looked at it – so I’d never met her – she just looked over the notes, “How are you feeling? I see you’ve got endometriosis here.” And she said to me, “You need to go straight to IVF. This endo grows like a weed. It’s really problematic. Don’t waste time.”
When I went back to my own fertility specialist with that advice he felt that we were maybe acting too quickly and he wanted me to wait a little bit longer. But by that point I’d burst into tears and was like, “Yeah I’m done. I just want to move straight to IVF.” Which we attempted to but then fell pregnant. So it must have been about the third month after the laparoscopy I think that we fell pregnant.
I know there’s lots of evidence to support that a laparoscopy can be helpful, even for women who don’t have endometriosis. But it would have been good to have got more insight into the endo because it really reared its ugly head after having the boys. Then it was really problematic. Like I said it was affecting my ability to function daily. And then became really expensive to seek out a specialist.
Hannah describes how two back-to-back dilation and curettage (D&C] procedures led to scarring in her uterus, a blocked uterine tube and a diagnosis of Asherman syndrome. She needed further surgery to remove the adhesions in her uterus before commencing IVF.
So, fell pregnant naturally, for the first time, at age 37, after many years of not being able to fall pregnant. Unfortunately, that ended in the spontaneous miscarriage at nine weeks.
Unfortunately, with that miscarriage, when I was 37, it wasn’t completed properly at the local hospital, where I was advised to go by my GP, and there was a bit of tissue still left in the uterus, so I had to go back in the next month and have, back-to-back, another D&C [dilation and curettage], at the same hospital. The hormone levels were not back to zero after six weeks, so there was retained products in the uterus. I think that could have been because – it didn’t help the fact, at that point, I had a subseptate uterus, which means that it was a heart-shaped uterus, so the little bit of tissue stuck, which was hard to get to. So, that was a big ordeal, mentally, to have that physical operation, that operation, and physically, it was quite difficult. That led to scarring and adhesions inside the uterus, because there was a lot of – how do you say, damage, and it’s quite harsh on that area.
So, then, we were about – so, that was in June of that year, two D&Cs, back-to-back. Then, we were still looking at seeing a fertility specialist, but we were about to relocate and move to Asia, so we thought there’s not much point, if we’re moving overseas. However, we did see an obstetrician gynaecologist, who did more testing, and he said everything was pretty much ready to go, and referred us to a family planning specialist. But the worst thing was that my uterus – so, when I moved to Asia, six months after the two D&Cs, I arrived in Asia and my uterus was stuck together with the scarring, and the internal – the adhesions inside the uterus caused substantial damage, and there’s no way you can fall pregnant when everything is stuck together.
It was unfortunate that no ultrasound was performed in Australia, during that six months, after those two D&Cs, so therefore, it wasn’t picked up, the uterus issue, with the scarring, and I arrived in Asia and had to have a big operation to have that fixed. But after tests in Asia, with the hysteroscopy, it was actually diagnosed as Asherman’s Syndrome, and I had removal of intrauterine adhesions. So, after the adhesions were removed, there was still scarring, and the right-hand side fallopian [uterine] tube was blocked, and not working properly.
After that, after the adhesions were removed, and one fallopian [uterine] tube was working, we had – we started our IVF overseas, because we were living overseas at that point.
When Andrea and her husband wanted to have a baby, her fertility specialist performed several surgeries to try to remove uterine fibroids to improve her chances of IVF.
So, our first appointment, he talked us through what my condition was, in more detail, and what it can actually mean, in terms of your fertility. He also talked about, sort of the pathways to having a child, about IVF being one of those pathways.
Then, because of my reluctance around the IVF, I was like, “Okay, can you explain this?” With the condition, to get pregnant, what was explained to us, to get pregnant, you need to have a really healthy lining in your uterus, for embryos to attach to. So, I said to him, “Well, what’s the solution? How does it work, then, given my lining issues?”
He also talked about surgery, and the surgery I’d had to date was more about taking off the top. So, you’ve got a fibroid that’s embedded in your uterus, so by taking off the top, that’s not necessarily giving you the clean lining that I need for a healthy environment. So, I was trying to understand how all of that actually works. So, then, he was talking about different surgical procedures that you can do, and using different techniques. That kind of encouraged me, that he had knowledge, that he will help us find a way, and he’s got the techniques to get us to where we want to be, which is to have a family. That was a good meeting. He did say, though, the first step was to get my body into optimal shape, because there’s no point trying to even – through IVF or naturally – put an embryo into that environment, if it’s not likely to succeed.
It started with a surgery again, with him. So, once he’d actually gone in and had his first go at removing the fibroids, we had, then, another conversation. He described the lining full of some that were of a certain size that he could get in and remove, and he had removed as much as he could, and I can’t remember the number of how many there were, but I remember there being a lot. He said, there were some that were so small, he said, effectively, you’d end up kind of getting rid of all of the lining, if you were trying to get rid of every single one of them. So, he said, that wasn’t realistic.
He did talk about the fact that it was going to take a couple of surgeries to get the lining as clean as it needs to be, before we can proceed with anything else, but he also then started to break down what sort of success rates looked like, based on our condition. Success rates, for example, for us trying on our own, versus us trying with some assistance through IVF, and either way, the odds weren’t brilliant.
Fertility Treatment Explained – VARTA
Explore Fertility Treatments – Human Reproduction and Embryology Authority (HFEA), UK
Progesterone support of the luteal phase and in the first trimester – RANZCOG Guidance (2018)