MEDICAL MANAGEMENT OF MALE AND FEMALE FERTILTY

                                                                               

     
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.