INFERTILITY TREATMENT

Female Treatment Options

The choice of treatment will depend on the causes of the infertility, and on personal circumstances and preferences.

If infertility is associated with endocrinal factors the most common treatment that allows patients to ovulate and conceive is ovulation induction with clomiphene citrate or gonadotropins.

The treatment for tubal factor infertility is usually either tubal surgery to repair some of the damage or in vitro fertilization (IVF). The decision to have one of these therapies for tubal infertility should be based on several factors which your fertility specialist should discuss with you. The most significant issues are the degree of tubal damage, the age of the female, and whether other infertility factors (male or female) are present.

If you are found to have a uterine abnormality, such as fibroids, polyps, adhesions, or a congenital abnormality of the uterus, surgery can be done to correct this. If such surgery has proven to be unsuccessful you might consider IVF with surrogate mother.

If fertility problems are associated with endometriosis, the surgeries that are used to diagnose the disease are also used for treatment. The surgery is usually followed by medication therapy. The goal of surgery is to remove any ectopic endometrial lesions and/or adhesions. Pregnancy rates following surgery and medication therapy vary considerably depending on the severity and location of adhesions. Approximately 30-40 percent of women under 35 years of age with endometriosis will conceive within two to three years following corrective pelvic surgery. For women with endometriosis who are older than 35 years of age or for whom surgery and treatment with fertility agents have proven to be unsuccessful in vitro fertilization is the treatment of choice.

Intrauterine insemination may be recommended if you are found to have "hostile mucus" - that is, if the chemical composition of your cervical mucus will not support living sperm.

In cases of immune infertility immunosuppressive therapy is usually used.

For 5% of women the diagnosis is never discovered. Treatment with fertility injections plus artificial insemination by partner sperm has been found to help in many cases of "unexplained infertility". And, if this does not work, IVF is frequently successful for couples with unexplained infertility.

Sometimes, more than one infertility factor may be present, and a combination of therapies may be needed. Or, the appropriate therapy may be tried, but with no success. When "conventional therapy" fails, IVF is usually the only recourse.

Male Treatment Options

Hormonal causes of infertility are rare but treatment with the pituitary hormones, follicle stimulating hormone (FSH) and luteinising hormone (LH), is usually successful in improving sperm production. Low levels of these hormones in the body are associated with low sperm counts.

Surgery is the only treatment for torsion of the testis. This involves untwisting the blood vessels that supply the testis, replacing the testis to its normal position and anchoring the testis to the base of the scrotum with a small stitch. Without treatment, there is a significant risk that the testis will be permanently damaged.

The infertility problem caused by sperm antibodies can be managed in two ways, drug treatment or assisted reproductive technologies.

• Prednisolone, a cortisone-like drug, is a treatment used to lower the level of sperm antibodies in the body. Several research studies have shown that treatment with prednisolone can decrease sperm antibody concentrations and improve the chances of achieving a natural pregnancy.
  
  
• Assisted reproductive techniques using intracytoplasmic sperm injection (ICSI) is the most widely used option for the treatment of sperm antibodies. In this technique the sperm is placed directly in the egg, and therefore the problems caused by sperm antibodies, such as poor sperm movement and changes to interactions between the sperm and egg during fertilisation, are bypassed. The success rates of treatment using a combination of ICSI and in vitro fertilisation (IVF) have been shown to be between 20 and 35% for each attempt.

The treatment of varicocele is not a straightforward issue because there are many research reports showing different outcomes of treatment. Indeed, many argue that there is no good evidence that removing the varicocele will increase the chances of natural pregnancy. Others believe that semen quality is improved and that it is reasonable to expect that pregnancy prospects are also improved. These issues should be discussed with your doctor.

If treatment is advised, then there are two main treatments available:

• Surgery, which can remove the varicocele, but this requires a general anaesthetic and a period of hospitalisation of 2 to 3 days.
  
  
• Embolisation is a more simple procedure that does not require an anaesthetic and involves insertion of a very fine long needle or 'catheter' into a vein in the groin. This catheter is then guided through a network of veins and into the left testicular vein. A small coil or a plug of glue-likematerial is then passed through the catheter and placed in the vein of the testis to block the blood flow and stop the varicocele from forming.

A zero sperm count (referred to as azoospermia) can result from:

• Blockage of sperm transport
  
  When azoospermia is due to a blockage of sperm transport, the options for treatment are:
  • surgery to remove the blockage OR
    
    
  • collection of sperm from the testis or epididymis and the use of these sperm in assisted reproductive techniques

• Sperm production problems in the testis

When azoospermia is due to poor sperm production in the seminiferous tubules treatment options are more difficult. In the testis of some of these men, small areas of sperm production can still be found even though there are no sperm in the ejaculate. It is thought that these men make very small numbers of sperm but as these sperm passes down the tubes and through to the storage area in the epididymis, the majority of sperm are removed and none reach the ejaculate.

When an obstruction (or blockage) has been identified as the cause of male infertility, surgery may be required to repair or unblock the ducts so that sperm can be transported through the male reproductive tract and be ejaculated as normal. If surgery can not correct the blockage, sperm may be collected directly from the testis and be used for assisted reproductive technologies.

Testicular biopsy - Testicular biopsy performed as an in-office surgical procedure in which several small pieces of testicular tissue are removed and examined for sperm which can be used in fertility procedures.

Testicular sperm aspiration (TESA) - A TESA procedure involves a needle biopsy of the testicle in which a sample of tissue is taken directly from the testis and used to extract sperm for IVF or ICSI.

Percutaneous sperm aspiration (PESA) - PESA is a procedure involving a needle inserted into the epididymis in an effort to locate and aspirate a pocket of sperm.

Assisted reproductive technologies are now frequently used to treat male infertility. IVF does not treat the cause of male infertility but it may help to overcome the problem by achieving a pregnancy which, for many couples, is the outcome they most desire. When either needle or open testis biopsy is used for sperm recovery for ICSI in men with poor sperm production, sperm are found in about 50% of men, mostly in those with the pattern of hypospermatogenesis.

In others, the pattern of sperm production failure is more severe (so-called Sertoli-cell only syndrome or maturation arrest) and the chances of finding sperm at open biopsy is approximately 10%. In such cases, couples need to decide whether they would use donor sperm.

Many couples will decide that a 10% chance of finding sperm in an open biopsy is not acceptable and they may consider using donor sperm in the first instance without proceeding to ICSI/IVF. Others may wish to take every opportunity to have their own child and will proceed.