The treatment of infertility is complex and often requires advanced technology. The specific type of treatment depends on the cause of the problem, if it can be identified. Many infertile couples have normal test results for ovulation , sperm production and fallopian tube patency.
PHARMACOLOGIC
THERAPY
Pharmacologically induced ovulation is undertaken when women do not
ovulate on their own or ovulate irregularly. Women older than 37 years are less
likely to be fertile. These couples are often treated with clomiphene to
stimulate ovulation. Gonadotropn treatment may also be used if conception does
not occur. Various other medications are used, depending on the primary cause
of infertility.
Blood
tests and ultrasounds are used to monitor ovulation. Multiple pregnancies (i.e,
twins, triplets or more) may occur with use of these medications. Ovarian
hperstimulation syndrome (OHSS) may also occur. This condition is characterized
by enlarged multicystic ovaries and is complicated by a shift of fluid from the
intravascular space into theabdominal cavity. The fluid shift can result in
ascites, pleual effusion, and edema; hypovolemia may also occur. Risk factors
include younger age, history of polycystic ovarian syndrome, high serum
estradiol levels, a larger number of follicles and pregnancy.
ARTIFICIAL
INSEMINATION
Artificial insemination is the deposit of semen into the female genital
tract by artificial means. If sperm cannot penetrate the cervical canal
normally, artificial insemination using
partner’s or husband’s semen or that of a donor may be considered. When
the sperm of the woman’s partner is
defective or absent (azoospermia) or when there is a risk of transmitting a
genetic disease, donor sperm may be used. Safeguards are put in place to
address legal, ethical, emotional, and religious issues.Written consent is
obtained to protects all paties involved, including the woman, the donor and
the resulting child. The donor’s semen is frozen, and the donor is evaluated to
ensure that he is free of genetic disorders and STDs, including HIV infection.
Certain
conditions must be met before semen is transferred to the vaginal or uterus.
The woman must have no abnormalities of the genital system, the fallopian tubes
must be patent, and oval must be available. In the male, sperm need to be
normal in shape, amount, motility, and endurance. The time of ovulation should
be determined as accurately as possible so that the two or three days of which
fertilization is possible each month can be targeted for treatment.
Ultrasonography and blood studies of varying hormone levels are used to
pinpoint the best time for insemination and to monitor for OHSS. Fertilization
seldom occurs from a single insemination. Usually, insemination is attempted
between days 10 and 17 of the cycle; three different attempts may be made
during one cycle. The woman may have received clomiphene or other medications
to stimulate ovulation before insemination. The recipient is placed in
lithotomy position on the examination table, a speculum is inserted, and the
vaginal and cervix are swabbed with cotton-tipped applicator to remove any
excess secretions. The sperm are washed before insertion to remove biochemical and
to select the most active sperm. Semen is drawn into a sterile syringe, and a
cannula is attached. The semen is then directed to the external os. In IUI,
semen is placed into the uterine cavity.
IN
VITRO FERTILIZATION
In vitro
fertilization (IVF) involves ovarian stimulation, egg retrieval, fertilization,
and embryo transfer. This procedure is accomplished by first stimulating the
ovary to produce multiple eggs or ova, usually with medications, because success
rates are greater with more than one embryo. Many different protocols exist for
inducing ovulation with one or more agents. Patients are carefully selected and
evaluated, and cycles are carefully monitored using ultrasound and monitoring
hormone levels. At the appropriate time, the ova are recovered by transvaginal
retrieval. Sperm and eggs are coincubated for up to36 hours, and the embryos
are transferred about 48 hours after retrieval. Implantation should occur in 3
to 5 days.
GAMETE
INTRAFALLOPIAN TRANSFER
Gamete intrafallopian
transfer (GIFT), a variation of IVF, is the treatment of choice for patients
with ovarian failure. GIFT is considered in unexplained infertility and when
there is religion-based discomfort with IVF. The most common indications for
IVF and GIFT are irreparable tubal damage, endometriosis, unexplained
infertility, inadequate sperm, and exposure to DES. Success rates for GIFT vary
from 20% to 30%.
OTHER
ASSISTED REPRODUCTIVE TECHNOLOGIES
In
intracytoplasmic sperm injection (ICSI), an ovum is collected as explained before, and one sperm is introduced through
the egg membrane, through the zona pellucida, and into the cytoplasm of the oocyte. The egg fertilized is transferred back to donor. ICSI treatment is of choice in severe
male factor infertility.
Women who
cannot produce their eggs (ie, premature ovarian failure) have option of using
the eggs of a donor after stimulation of the donor;s ovaries. The recipient
also receives hormones in preparation for these procedures. Couples may also
choose this modality if the female partner has a genetic disorder that may be
passed on to children.
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