Treatment Options for Infertility Association of Reproductive Health Professionals www.arhp.org

Learning Objectives State at least three infertility treatment options available for females. State at least three infertility treatment options available for males. List two available ovulation-inducing drugs.

Basic Services for Infertile Couples Talking Points This presentation is one in a series of four, based on these basic services that should be offered to couples facing the possibility of infertility. The goal is to help couples improve fertility, where possible, and to expedite further evaluation and treatment. Providers should begin with the first 4 items below and, where resources and training permit, include all of the following in their infertility services: Educate patients on infertility and its prevention. Gather pertinent historical information to establish a diagnosis. Offer information on diagnosis-dependent treatment alternatives. Provide a resource for reassurance, counseling, and emotional support, including referral as needed. Basic services begin with educating patients about the causes of infertility and the factors that may be within their control to improve their chances of conceiving. This curriculum focuses on treatment options available for infertility. Treatment options for infertility are diagnosis dependent. Reference Stewart GK. Impaired fertility. In Hatcher RA, Trussell J, Stewart F, et al., eds. Contraceptive Technology. 17th revised ed. New York, NY: Ardent Media; 1998. Basic Services for Infertile Couples 3. Offer information on treatment options 4. Provide resources for counseling and emotional support 1. Educate on infertility causes and prevention 2. Conduct appropriate diagnostic workup 2. Conduct appropriate diagnostic workup Stewart GK. 1998 Slide 3

Fertility Treatments Can Work Talking Points “With thorough evaluation and application of current treatments short of IVF, embryo transfer, or GIFT, 50–60% of infertility couples will conceive.” Reference Meldrum DR. Infertility. In Hacker NF, Moore JG, eds. Essentials of Obstetrics and Gynecology. 3rd ed. Philadelphia, PA: WB Saunders; 1998. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Fertility Treatments Can Work ‘ ‘ “…With thorough evaluation and application of current treatments short of IVF, embryo transfer, or GIFT, 50–60% of infertility couples will conceive.” Meldrum DR 1998 Meldrum DR. 1998. Slide 4

Causes & Treatments for Male Infertility Talking Points Treatment for men who have azospermia (no sperm) with inadequate gonadotropin levels includes injections of FSH and LH. Men who have undergone surgical sterilization can have a vasectomy reversal. Repairing a varicocele can treat oligospermia or abnormalities of sperm form or motility. Reference Nelson AL, Marshall JR. Impaired fertility. In Hatcher R, Trussell J, Stewart F, et al. (Eds.) Contraceptive Technology. 18th Revised Ed. New York, NY: Ardent Media, Inc.; 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Causes & Treatments for Male Infertility Azospermia Inject FSH and LH Surgical sterilization Reverse vasectomy Impaired sperm motility Repair varicocele Nelson AL, Marshall JR. 2004. Slide 5

Main Causes of Female Infertility Talking Points Treatment for female infertility will also depend on the identified cause. The main causes of female infertility include: Ovulation disorders Tubal abnormalities Endometriosis Other causes of female infertility include cervical or uterine factors or remain unexplained. Reference Nelson AL, Marshall JR. Impaired fertility. In Hatcher R, Trussell J, Stewart F, et al. (Eds.) Contraceptive Technology. 18th Revised Ed. New York, NY: Ardent Media, Inc.; 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Main Causes of Female Infertility Ovulation disorders Tubal abnormalities Endometriosis Nelson AL, Marshall JR. 2004. Slide 6

Treatments for Female Infertility Talking Points Treatment for female infertility due to ovulation disorders can include the following: Maintenance of normal body weight. Being severely overweight or underweight can contribute to infertility problems Clomiphene for women who have withdrawal bleeding with progestin challenge Metformin for women with PCOS, to lower testosterone levels Gonadotropin therapies for women with low estrogen levels who do not have withdrawal bleeding with progestin challenge Laparoscopic ovarian drillling for PCOS patients who do not respond to clomiphene Reference Nelson AL, Marshall JR. Impaired fertility. In Hatcher R, Trussell J, Stewart F, et al. (Eds.) Contraceptive Technology. 18th Revised Ed. New York, NY: Ardent Media, Inc.; 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Treatments for Female Infertility Maintain normal body weight Clomiphene Metformin Gonadotropin therapies Laparoscopic ovarian drilling Ovulation disorders Tubal abnormalities Endometriosis more… Nelson AL, Marshall JR. 2004. Slide 7

Treatments for Female Infertility (continued) Talking Points Treatment for female infertility due to tubal abnormalities can include the following: In vitro fertilization (IVF) to bypass the tubal abnormality altogether IVF is combined with salpingectomy when tubal abnormality is due to PID or endometriosis. Tuboplasty for tubal ligation reversal Reference Nelson AL, Marshall JR. Impaired fertility. In Hatcher R, Trussell J, Stewart F, et al. (Eds.) Contraceptive Technology. 18th Revised Ed. New York, NY: Ardent Media, Inc.; 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Treatments for Female Infertility (continued) In vitro fertilization With or without salpingectomy Tuboplasty (tubal ligation reversal) Tubal abnormalities Tubal abnormalities Endometriosis more… Nelson AL, Marshall JR. 2004. Slide 8

Treatments for Female Infertility (continued) Talking Points Treatment for female infertility due to endometriosis can include the following: Laparoscopic ablation of endometriosis implants followed by intrauterine insemination with controlled hyperstimulation In-vitro fertilization if simpler therapy isn’t successful Reference Nelson AL, Marshall JR. Impaired fertility. In Hatcher R, Trussell J, Stewart F, et al. (Eds.) Contraceptive Technology. 18th Revised Ed. New York, NY: Ardent Media, Inc.; 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Treatments for Female Infertility (continued) Laparoscopic ablation Intrauterine insemination with controlled hyperstimulation In vitro fertilization Endometriosis Tubal abnormalities Endometriosis Nelson AL, Marshall JR. 2004. Slide 9

Ovulation-Inducing Drugs: Clomiphene Talking Points Ovulation-Inducing Drugs: Clomiphene Chemically stimulates the pituitary gland to produce hormones that trigger ovulation process Usually 50mg/day for 5 days. A physician may increase the dose in increments in future cycles if ovulation does not occur; maximum does is usually 200mg daily. Numerous side effects, including: Nausea, vomiting, visual problems, headache, insomnia, hot flashes, breast tenderness, heightened emotional sensitivity, painful ovulation, decreased menstrual flow 10% chance of twins Reference Harkness C. The Infertility Book. Berkeley, CA: Celestial Arts; 1992. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Ovulation-Inducing Drugs: Clomiphene Chemically stimulates pituitary gland to produce hormones that trigger ovulation process Usual dosage: 50 mg/day for 5 days Numerous side effects May not be appropriate for patients with: Large fibroid tumors Ovarian cysts Liver problems more… Harkness C. The Infertility Book. 1992. Slide 10

Ovulation-Inducing Drugs: Bromocriptine Talking Points Ovulation-Inducing Drugs: Bromocriptine Reduces pituitary’s production of prolactin hormone May not be appropriate for patients with pituitary tumors larger than 1 cm 2.5mg 1-3 times/day; however, this dosage is reached slowly and patients generally start at one-half a tablet (1.25 mg)/day Side effects: Nausea, nasal stuffiness, dizziness, low blood pressure, headache Reference Harkness C. The Infertility Book. Berkeley, CA: Celestial Arts; 1992. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Ovulation-Inducing Drugs: Bromocriptine Reduces production of prolactin hormone Dosage: 2.5 mg 1–3 times/day Some side effects May not be appropriate for patients with pituitary tumors >1 cm Harkness C. The Infertility Book. 1992. Slide 11

Ovulation-Inducing Drugs Talking Points Ovulation-Inducing Drugs: hMG, FSH Stimulates ovary to develop follicles; injection of human chorionic gonadotropin required Controlled doses are given in ampules of 75–150 IU per day, given by injection There is a 20-40% possibility of multiple births with these medications, as well as a small risk of hyperstimulation syndrome. May not be appropriate in cases of pituitary tumor or ovarian cysts Reference Harkness C. The Infertility Book. Berkeley, CA: Celestial Arts; 1992. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Ovulation-Inducing Drugs Human Menopausal Gonadotropins (hMG) Follicle-Stimulating Hormone (FSH) Stimulate ovary to develop follicles 75–150 IU/day (with hCG) 20–40% possibility of multiple births May not be appropriate in cases of pituitary tumor, ovarian cysts more… Harkness C. The Infertility Book. 1992. Slide 12

Ovulation-Inducing Drugs (continued) Talking Points Ovulation-Inducing Drugs: GnRH Triggers normal pituitary hormonal activity so ovulation can occur Effective in women with hypothalamic amenorrhea Ovulation pump administers injections every 90 minutes User has to carry pump attached IV tubing for 1-2 weeks or until ovulation occurs No known physical side effects Reference Harkness C. The Infertility Book. Berkeley, CA: Celestial Arts; 1992. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Ovulation-Inducing Drugs (continued) Gonadotropin-Releasing Hormone (GnRH) Triggers normal pituitary hormonal activity so ovulation can occur Effective in women with hypothalamic amenorrhea No known physical side effects Ovulation pump administers injections every 90 minutes User must carry pump with attached IV tubing for 1–2 weeks or until ovulation occurs Harkness C. The Infertility Book. 1992. Slide 13

Endometriosis: Treatment with Surgery Talking Points Endometriosis: Pregnancy rates after surgical treatment 45–75% after Stage 1 or 2 endometriosis, if no impairment of the ovaries or tubes is present Up to 60% for Stage 3 disease 35–48% for Stage 4 disease References Jennings VH, Lamprecht VM, Kowal D. Fertility awareness methods. In Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive Technology, 17th Ed. New York, NY: Ardent Media, Inc.; 1998. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Endometriosis: Treatment with Surgery Pregnancy rates after surgery 45–75% ≤60% 35–48% After Stage 1 or 2 Stage 3 Stage 4 Jennings VH, et al. 1998. Slide 14

Endometriosis: Drug Therapies Talking Points Endometriosis: treatment with drug therapies Gonadotropin-releasing hormone (GnRH) agonists Birth control pills Danazol, but it has largely been replaced by GnRH therapy Reference Jennings VH, Lamprecht VM, Kowal D. Fertility awareness methods. In Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive Technology, 17th Ed. New York, NY: Ardent Media, Inc.; 1998. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Endometriosis: Drug Therapies GnRH agonists Birth control pills Jennings VH, et al. 1998. Slide 15

Polycystic Ovarian Disease: Treatment Talking Points Polycystic ovarian disease: Treatment Ovulation induction Clomiphene HMG, FSH, GnRH Insulin sensitizers (e.g. metformin, rosiglitazone) Medical treatment if pregnancy is not desired Low dose oral contraceptives Reference Jennings VH, Lamprecht VM, Kowal D. Fertility awareness methods. In Hatcher RA, Trussell J, Stewart F, et al, eds. Contraceptive Technology, 17th Ed. New York, NY: Ardent Media, Inc.; 1998. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Polycystic Ovarian Disease: Treatment Ovulation induction Clomiphene HMG, FSH, GnRH Insulin sensitizers (e.g. metformin, rosiglitazone) Jennings VH, et al. 1998. Slide 16

ART Treatments for Infertility Talking Points A variety of ART have been developed to treat infertility that has not been successfully addressed using traditional treatments. ART treatments include the following: IVF with embryo transfer: The egg and sperm are retrieved from the couple or donors or some combination of both and are then combined in a Petri dish and incubated for 2 to 5 days. If fertilization and cleavage occurs, the embryo is transferred through a catheter to the uterus for the embryo to implant in the uterus. This treatment is best for fallopian tube disorders, unexplained infertility, peritoneal and male factors. Gamete intrafallopian transfer (GIFT): Oocytes are retrieved via laparoscopy, and oocytes and sperm are placed in the same catheter and injected directly into the fallopian tube via laparoscopy. The embryo travels through the fallopian tube to the uterus for implantation. Zygote intrafallopian transfer (ZIFT): Combines the techniques used in IVF and GIFT. The ova are placed in a Petri dish with sperm, and if fertilization occurs, the zygote is injected into the fallopian tube, travels through the tube to the uterus, and implants in the uterus. Cryopreservation: Sperm or embryos are preserved by freezing for replacement in subsequent cycles. Intracytoplasmic sperm injection (ICSI): A single sperm is injected directly into the cytoplasm of the oocyte. This procedure increases the probability of fertilization when there are abnormalities in the number, function, or quality of sperm. References American Society for Reproductive Medicine. Assisted Reproductive Technologies: A Guide for Patients. Birmingham, AL: American Society for Reproductive Medicine; 2003. Available at http://www.asrm.org/Patients/patientbooklets/ART.pdf. Accessed June 18, 2007. American Society for Reproductive Medicine. Patient’s Fact Sheet: Intracytoplasmic Sperm Injection (ICSI). Birmingham, AL: American Society for Reproductive Medicine; 2001. Available at http://www.asrm.org/Patients/FactSheets/ICSI-Fact.pdf. Accessed June 18, 2007. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. ART Treatments for Infertility IVF with embryo transfer A Gamete intrafallopian transfer (GIFT) R Zygote intrafallopian transfer (ZIFT) Cryopreservation T Intracytoplasmic sperm injection (ICSI) American Society for Reproductive Medicine. 2003. American Society for Reproductive Medicine. 2001. Slide 17

IVF with Embryo Transfer Talking Points IVF with embryo transfer: The egg and sperm are retrieved from the couple or donors or some combination of both and are then combined in a Petri dish and incubated for 2 to 5 days. If fertilization and cleavage occurs, the embryo is transferred through a catheter to the uterus for the embryo to implant in the uterus. This treatment is best for fallopian tube disorders, unexplained infertility, peritoneal and male factors. Reference Clapp DN. Assisted Reproductive Technology. Fact Sheet 33. Somerville, MA: RESOLVE: The National Infertility Association; 2002. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. IVF with Embryo Transfer 1 Egg and sperm are retrieved from couple, donor(s), or both 2 Combined in a petri dish, incubated for 2–5 days If fertilization and cleavage occurs, embryo is transferred through a catheter to uterus 3 Clapp DN. 2002. Slide 18

Gamete Intrafallopian Transfer (GIFT) Talking Points Gamete intrafallopian transfer (GIFT): Oocytes are retrieved via laparoscopy Oocytes and sperm are placed in the same catheter and injected directly into the fallopian tube via laparoscopy The embryo travels through the fallopian tube to the uterus for implantation Reference Clapp DN. Assisted Reproductive Technology. Fact Sheet 33. Somerville, MA: RESOLVE: The National Infertility Association; 2002. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Gamete Intrafallopian Transfer (GIFT) Oocytes retrieved via laparoscopy Oocytes and sperm placed in same catheter Injected directly into the fallopian tube via laparoscopy Embryo travels through the fallopian tube to the uterus for implantation Clapp DN. 2002. Slide 19

Zygote Intrafallopian Transfer (ZIFT) Talking Points Zygote intrafallopian transfer (ZIFT): Combines the techniques used in IVF and GIFT The ova are placed in a Petri dish with sperm If fertilization occurs: the zygote is injected into the fallopian tube, travels through the tube to the uterus, and implants in the uterus Reference Clapp DN. Assisted Reproductive Technology. Fact Sheet 33. Somerville, MA: RESOLVE: The National Infertility Association; 2002. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Zygote Intrafallopian Transfer (ZIFT) Combines techniques used in IVF and GIFT 1 Ova are placed in a petri dish with sperm 2 If fertilization occurs, the zygote: Is injected into fallopian tube Travels through tube to uterus Implants in uterus Clapp DN. 2002. Slide 20

Talking Point Cryopreservation: Sperm or embryos are preserved by freezing for replacement in subsequent cycles. Reference Clapp DN. Assisted Reproductive Technology. Fact Sheet 33. Somerville, MA: RESOLVE: The National Infertility Association; 2002. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Cryopreservation Sperm or embryos are preserved by freezing for replacement in subsequent cycles Clapp DN. 2002. Photo source: http://www.dcmsonline.org Slide 21

Intracytoplasmic Sperm Injection (ICSI) Talking Points Intracytoplasmic sperm injection (ICSI): A single sperm is injected directly into the cytoplasm of the oocyte This procedure increases the probability of fertilization when there are abnormalities in the number, function, or quality of sperm. Reference American Society for Reproductive Medicine. Patient’s Fact Sheet: Intracytoplasmic Sperm Injection (ICSI). Birmingham, AL: American Society for Reproductive Medicine; August 2001. Available at http://www.asrm.org/Patients/FactSheets/ICSI-Fact.pdf. Accessed June 28, 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. Intracytoplasmic Sperm Injection (ICSI) A single sperm is injected directly into the cytoplasm of the oocyte Increases probability of fertilization American Society for Reproductive Medicine. 2004. Photo source: www.fertilitycentre.ca Slide 22

ART Options for Same-Sex Couples Talking Points Although ART was developed to treat infertility, it has also offered new options in parenthood for same-sex couples. For decades, single women, gays, and lesbians have made special arrangements to become parents and have created new forms of parental relationships with their children. ART has made these options more attractive, private, and feasible for many. Same-sex couples may use a combination of their own and donor sperm and eggs through IVF and may also choose surrogacy. ART has allowed single women and same-sex couples to parent biological children and in some cases to experience pregnancy and childbirth. Reference Bateman S. When reproductive freedom encounters medical responsibility: changing conceptions of reproductive choice. In: Vayena E, Rowe PJ, Griffin PD, eds. Current Practices and Controversies in Assisted Reproduction: Report of a meeting on “Medical, Ethical and Social Aspects of Assisted Reproduction.” Geneva, Switzerland: World Health Organization, September 17–21, 2001. Available at http://www.who.int/reproductive-health/infertility/report_content.htm. Accessed January 16, 2004. - - - Original content for this slide taken from the Reproductive Health Model Curriculum, 2nd Edition [March 2004]. Original funding received from the John Merck Fund, the Mary Wohlford Foundation, the Naomi and Nehemiah Cohen Foundation, the William and Flora Hewlett Foundation, and Marjorie Braude, MD. Funding for the 2008 update received from Ferring Pharmaceuticals. Last reviewed/updated by Carolyn Coulam, MD, Elizabeth Grill, PsyD, and Karen Hammond, MSN, CRNP, in May 2008. This slide is available at www.arhp.org/core. ART Options for Same-Sex Couples Combination of their own and donor sperm and eggs through IVF Surrogacy Can parent biological children Bateman S. 2004. Slide 23