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REVIEW ARTICLE
Year : 2013  |  Volume : 4  |  Issue : 2  |  Page : 107-110

Traditional management of infertility in the era of in vitro fertilization


Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Mangalore, Karnataka, India

Date of Web Publication16-Sep-2013

Correspondence Address:
Arun A Rao
Department of Obstetrics and Gynecology, Kasturba Medical College, Manipal University, Mangalore - 575 001, Karnataka
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0975-9727.118239

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  Abstract 

Purpose: The efficacy of assisted reproductive technology has improved significantly over the past decade. Due to lifestyle changes and sociological factors couples are delaying childbirth and resorting to the treatment of assisted reproductive technology. In spite of the success of IVF, traditional management of infertility has still a role to play. Recent findings: Expectant management and treatment with clomiphene should be the first line of management in couples with unexplained infertility where the cause for infertility cannot be detected. IUI with superovulation has been successful in some couples, but the risk of multiple pregnancies should be kept in mind. WHO guidance for semen analysis is still the method of choice to investigate male infertility. Hysterosalpingographyor sonohysterography can replace diagnostic hysteroscopy and diagnostic laparoscopy as a diagnostic tool in majority of patients with infertility. Operative hysteroroscopic procedures like myomectomy, polypectomy, metroplasty, and dissection of intrauterine adhesions can be performed when intrauterine pathology is detected. Tubal surgeries like tubal anastomosis, salpigostomy, and fimbrioplasty have a definite role to play in addition to other surgeries done to enhance the in vitro fertilization outcome. Endometriomas >4 cm need to be operated and a higher pregnancy rate has been found with laparoscopic excision rather than the popular methods of laparoscopic stripping, ablation or fenestration. The surgical mode of treatment for endometriosis has a limited place, like in conditions of chronic pelvic pain and whenever there is difficulty in follicular aspiration due to dense adhesions in IVF treatment. Inadvertent excision of healthy ovarian tissue is the most common complication of surgeries for ovarian endometriomas. Conclusion: In the present era of IVF there is still place for expectant management, ovulation inducing drugs, and limited place for laparoscopy and hysteroscopy surgeries before subjecting the infertile patients for IVF treatment.

Keywords: Endometrioma, intracytoplasmic sperm injection, intrauterine insemination, in vitro fertilization, tubal surgery, unexplained infertility


How to cite this article:
Rao AA. Traditional management of infertility in the era of in vitro fertilization. Muller J Med Sci Res 2013;4:107-10

How to cite this URL:
Rao AA. Traditional management of infertility in the era of in vitro fertilization. Muller J Med Sci Res [serial online] 2013 [cited 2021 Dec 4];4:107-10. Available from: https://www.mjmsr.net/text.asp?2013/4/2/107/118239


  Introduction Top


The main character in the 19 th century Leo Tolstoy's "Family Happiness" comments "children perhaps - what can more the heart of man desire?" This sentiment seems to apply to both kinds of gender. A human reproduction is inefficient, with average cycle fecundity around 20%. [1] Due to lifestyle changes and different sociological factors, couples in modern societies are increasingly delaying childbearing with an overall reduction in fertility rates. [2] Although in some developed countries concern regarding the declining fertility rates has been raised, forecasting agencies like U.N. and Eurostat predict that the total fertility rate in most countries will rise in the decades ahead. [3]

Advances in artificial reproductive technology cannot compensate for the age-related decline in infertility. [4] In vitro fertilization is the most successful treatment of both male and female infertility. First IVF child Louise Brown was born in 1978. [5] More than 4 million children have been born since then. In some countries 1-4% of all children born annually are born as a result of IVF. Pregnancy rates of 35-40% have been achieved as newer techniques are constantly being introduced. [6]

Definition

Infertility is defined as inability to conceive within a year of unprotected intercourse. [7]

Causes of Infertility

  1. Male factor - 35% [8]
  2. Tubal and pelvic pathology - 35%
  3. Ovulatory dysfunction - 15%
  4. Unexplained infertility - 10%
  5. Unusual problems - 5%.
Essential Work-up for Infertile Couple

  1. Semen analysis [9]
  2. Assessment of ovulation
  3. Tubal patency tests.
Assessment of Male Factor for Infertility

Semen analysis remains the main diagnostic test. It is carried out according to the methods suggested by WHO - 2010. [10]

Although many newer tests are available for sperm function, they are not yet established due to the lack of randomized controlled trials.

Treatment of Male Factor Infertility

Smoking cessation and antioxidant supplementation can be proposed. [11] In cases of moderate to mild male-factor subfertility intrauterine insemination should precede IVF. [12] Fine-needle aspiration of the motile spermatozoa can be done from testis or epididymis for intracytoplasmic sperm injection (ICSI) in cases of nonobstructive or obstructive azoospermia. [13]

Management of Ovulatory Infertility

Optimization of body weight is the first line of treatment in underweight and in obese patients. [14]

WHO Classification of Ovarian Disorders

  1. WHO group 1 - hypogonadotrophic hypogonadism
  2. WHO group 2 - normogonadotrophic normogonadic ovarian dysfunction
  3. WHO group 3 - hypogonadotrophic hypogonadism
If the cause of hypogonadotrophic hypgonadism can be found it should be treated - for example, surgery for intracranial tumors, otherwise women with hypogonadotrophic anovulation can be treated with pulsatile GnRH therapy. Gonadotrophin preparations containing both FSH and LH can also be used.

Clomiphene citrate should be the first choice of treatment for normogonadotrophic anovulation.

Dosage can be gradually increased monthly from 50 mg/day to 150 mg/day for 5 days. Treatment is generally for 6 months but can be extended to 12 months on individual basis until pregnancy occurs. Tamoxifen or letrazole can also be used as alternatives.

In women with polycystic ovary syndrome who are resistant to clomiphene, cotreatment with metformin can be an alternative option. But routine use of metformin is of limited efficacy. A chronic low-dose step-up approach with gonadotropins is recommended for women with PCO who fail to conceive with the above treatment. Laparoscopic ovarian drilling can be an alternate to gonadotrophins. [15] Treatment with donor oocyte is the only option for women with ovarian failure-hyper gonadotrophic hypogonadism

For WHO - group 3, dopamine agonist is the treatment of choice for anovulation due to hyperprolactinemia. It can be combined with antiestrogens or gonadotropins in women who still fail to ovulate.

Surgery in the Era of IVF

Reproductive surgery can be

  1. Surgery as a primary treatment of infertility
  2. Surgery to enhance IVF.
Surgery as a Primary Treatment of Infertility

Laparotomy has been replaced by laparoscopy and hysterectomy. Peritoneal and tubal factors can be investigated by transvaginal ultrasound. Suspected endometriomas can be diagnosed by MRI although it is not cost-effective. Diagnostic laparoscopy is not useful as a routine procedure for infertility work-up. But on the other hand, laparoscopy for the surgical procedure for treatment of infertility is quite useful. [16]

A normal uterine cavity is a prerequisite for implantation. Hysterosalpingography and hysterosonography are useful to evaluate the uterine cavity besides giving information regarding the tubal patency. There is no place for routine hysteroscopy in the investigation of infertility except when intrauterine lesion is suspected.

Common Laparoscopic Surgeries for Infertility

  1. Laparoscopic tubal surgeries like salpingostomy, fimbrioplasty, and end-to-end anastomosis of the  Fallopian tube More Details
  2. Laparoscopic treatment of ovarian endometriomas
  3. Role of laparoscopic ablation of stage 1 and 2 endometriosis is limited as it does not contribute in increasing the pregnancy rate significantly.
Hysteroscopic surgeries for infertility could be hysteroscopy - polypectomy, myomectomy, metroplasty, and hysteroscopiclysis of intrauterine adhesions. [17]

Treatment of Ovarian Endometriomas

Endometriomas cause damage to ovarian reserve and function. Endometriomas less than 4 cm need no surgery. The stripping technique through laparoscopy is the common surgical procedure.

Fenestration and ablation are the other techniques used. But excision of the endometrioticcyst >4 cm gives a higher pregnancy rate and lower recurrence rate. Irrespective of the type of procedure used there appears to be consequences on the ovarian reserve and menstrual function. [18]

Sparing the surgical procedure and going directly to IVF reduce the time to achieve pregnancy. The surgical procedure should be reserved for patients with pelvic pain and when it is difficult to access follicles for IVF. [19]

Unexplained Infertility

Unexplained infertility is an inability on part of clinicians to identify a definite barrier to conception. The incidence of unexplained infertility is about 22-28%. Expected management has an important role to play in couples with unexplained infertility of short duration. Recent trials have questioned the effectiveness of empirical treatment with clomiphene citrate and IUI in the treatment of unexplained infertility. [20] Superovulation plus IUI is a more effective treatment but is associated with higher rates of multiple pregnancy. [21] For long-standing unexplained infertility, IVF is a better option. [22]


  Conclusion Top


Lifestyle changes and different sociological factors like delay in childbearing seem to contribute to the rate of declining fertility especially in developed countries. Hence there is an increasing demand for assisted reproductive technology. Due to newer more effective technologies, pregnancy rates of 35-40% have been achieved by IVF.

Expectant management and ovulation induction with clomiphene citrate should be the first line of treatment in couples with infertility.

Superovulation with IUI is a better option than IUI alone.

Women with polycystic ovaries can be treated with clomiphene citrate initially. Gonadotrophins or laparoscopic ovarian drilling, if clomiphene citrate fails. Routine use of metformin treatment has limited place, but it can be used as a cotreatment with clomiphene citrate as a second option.

The role of hysteroscopy and laparoscopy has a limited place in diagnostic procedures in infertility.

They are useful in fertility enhancing surgical procedures like hysteroscopicpolypectomy, myomectomy, metroplasty, intrauterine adhesiolysis, and laparoscopy can be used for tubal anastomosis, salpingectomy, and fimbrioplasty.

Ovarian endometriomas >4 cm should be operated. Laparoscopic surgical excision of endometriomas has a pregnancy rate of 50-66.7%.

Laparoscopic surgery for endometriosis is mainly limited to the treatment of pelvic pain.

For 22-28% of patients with unexplained infertility, if IUI with superovulation fails, IVF is the treatment of choice.

 
  References Top

1.Wilcox AJ, Weinberg CR, Baird DD. Timing of sexual intercourse in relation to ovulation. Effects on the probability of conception, survival of the pregnancy, and sex of the baby. N Eng J Med 1995;333:1517-21.  Back to cited text no. 1
    
2.Balasch J, Gratacos E. Delayed childbearing effects on fertility and the outcome of pregnancy. Fetal Dign Ther 2011;29:263-73.  Back to cited text no. 2
    
3.Eurostat. Available from: http://epp-eurostat-ec-europaeu/portal/page/population/data/main_tables. [Last accessed on 2013 Apr 06].  Back to cited text no. 3
    
4.Marinakis G, Nikolaoun D. What is the role of assisted reproduction technology in the management of age related infertility? Human Fertil (Camb) 2011;14:8-15.  Back to cited text no. 4
    
5.Steptoe PC, Edwards RG. Birth after the implantation of a human embryo. Lancet 1978;2:366.  Back to cited text no. 5
    
6.de Mouzon J, Goossens V, Bhattacharya S, Castilla JA, Ferraretti AP, Korsak V, et al. The European IVF - monitoring Consortium for the European Society of Human Reproduction and Embryology-ESHRE. Assisted reproductive technology in Europe, 2006: Results generated from European registers by ESHRE. Human Reprod 2010;25:1851-62.  Back to cited text no. 6
    
7.Gurunath S, Pandian Z, Anderson RA, Bhattacharya S. Defining infertility: A systematic review of prevalence studies. Human Reprod Update 2011;17:575-88.  Back to cited text no. 7
    
8.Miller JH, Weinberg RK, Carino NL, Klein NA, Soules MR. Pattern of infertility diagnoses in women of advanced reproductive age. Am J Obstet Gynecol 1999;181:952-7.  Back to cited text no. 8
    
9.National Institute for Health and Clinical Excellince Fertility: Assessment and treatment for people with fertility problems. London: NICE Clinical Guidelines; 2004.  Back to cited text no. 9
    
10.WHO. WHO manual for the standardized investigation, diagnosis and management of the infertile male. Cambridge: Cambridge Univ Press; 2000.  Back to cited text no. 10
    
11.Showell MG, Brown J, Yazadani A, Stankiewicz MT, Hart RJ. Antioxidants for male subfertility. Cochrane Database Syst Rev 2011;19:CD007411  Back to cited text no. 11
    
12.Cholen BJ, te Velde ER, van Kooje RJ, Looman CW, Habbema JD. Controlled ovarian hyperstimulation and IUI for treating male subfertility: A controlled study. Hum Reprod 1998;13:1553-8.  Back to cited text no. 12
    
13.Tournaye H. Update on surgical sperm recovery-European view. Hum Feril (Camb) 2010;13:242-6.  Back to cited text no. 13
    
14.The ESHRE Capri Workshop Group. Nutrition and reproduction in women. Hum Reprod 2003;9:359-72.  Back to cited text no. 14
    
15.The Thessaloniki ESHRE/ASRM-Sponsored PCOS Consensus Workshop Group. Consensus on infertility treatment related to polycystic ovary syndrome. Hum Reprod 2008;23:462-77.  Back to cited text no. 15
    
16.Marcus S, Maheux R, Berube′S. Laparoscopic surgery in infertile women with minimal or mild endometriosis. N Eng J Med 1997;337:217-22.  Back to cited text no. 16
    
17.Prits EA, Parker WH, Olive DL. Fibroids and infertility: An updated systematic review of the evidence. Fertil Steril 2009;91:1215-23.  Back to cited text no. 17
    
18.Bretta P, Franchi M, Ghezzi F, Busacca M, Zupi E, Bolis P. Randomized clinical trial of treatment of endometriomas. Fertil Steril 1998;70:1176-80.  Back to cited text no. 18
    
19.Tsoumpou I, Kyrgiou M, Gelbaya TA, Nardo LG. The effect of surgical treatment for endometrioma on in vitro fertilization outcomes: A systematic review and meta-analysis. Fertil Steril 2009;92:75-87.  Back to cited text no. 19
[PUBMED]    
20.Hughes E, Brown J, Collins JJ, Vanderkerchove P. Clomiphene citrate in unexplained subfertility in women. Cochrane Database Syst Rev 2010;1:CD000057.  Back to cited text no. 20
[PUBMED]    
21.Veltman-Verhulst SM, Cohlen BJ, Hughes E, Heineman MJ. Intra-uterine insemination for unexplained infertility. Cochrane Database Syst Rev 2012;9:CD001838.  Back to cited text no. 21
[PUBMED]    
22.Pandian Z, Bhattacharya S, Vale L, Templeton A. In vitro fertilization for unexplained sub fertility. Cochrane Database Syst 2005;2:CD003357.  Back to cited text no. 22
    




 

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