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Treatment and Management of Infertility

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The prevalence of infertility over the last 30 years has been more or less the same. However, the number of people seeking treatment and management of infertility has increased substantially during this time. This increase is due to better patient awareness and access to services, and advances and improvements in fertility treatments.

Treatment of male factor:
Any abnormality in sperm count or study must be confirmed by a repeat analysis. Sometimes, illness and environmental factors can affect sperm temporarily. A repeat semen analysis after 4 weeks will therefore give a better picture of the situation.

* If results remain abnormal, the patient must be evaluated for genetic, anatomic, hormonal, or infectious causes and treated accordingly.

* If the semen volume is low an analysis of the urine must also be done to check for any retrograde  ejaculation.
In cases where the sperm concentration is less than 20 million/mL, intrauterine inseminations (IUI) where the sperm is implanted directly into the uterus, could be the treatment of choice.
If sperm counts are extremely low or if motility is poor, in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) may be required.

Treatment of ovulatory dysfunction in females: 
1. If there is obesity and chronic lack of ovulation, polycystic ovarian syndrome (PCOS) or Cushing disease, then it must be evaluated and treated accordingly.

2. If there is hirsutism, the patient must be further tested for any elevated androgen levels or hyperinsulinemia.

3. In a patient with low body weight and low hormone levels, better nutrition, weight gain and decreased exercise may improve fertility.

4. If oligomenorrhea remains, or if there are no physical findings, ovulation induction is the next treatment to consider. It can be achieved with external hormones.

5. Clomiphene citrate (CC) treatment regimens are often used for ovulation induction in patients with idiopathic ovulatory dysfunction or PCOS.

In hyperinsulinemia with elevated androgens - Metformin and/or clomiphene citrate can be tried.

The goal of therapy is to achieve 3 ovulatory cycles.  40-50% of women should become pregnant in this timeframe in the absence of any other abnormalities.
If conception has not occurred after 3 clomiphene citrate cycles, the doctor must investigate other causes of infertility. No more than 6 consecutive cycles should be tried.
Ovulation induction can also be initiated with exogenous FSH. 

Treatment of tubal disease:
When there is significant tubal blockage then IVF offers the best chance for conception in patients with significant tubal disease. Often, if only 1 tube is affected, ovarian stimulation with hormones can be tried to produce mature eggs in the ovary near the open tube.

In patients with minimal or moderate tubal disease, laparoscopic lysis of adhesions and procedures may be performed to open up the tube so that it can function normally. Care must be taken to prevent future adhesions.

In patients with an irreparable hydro-salpinx, in genital tuberculosis, removing the tube or disconnecting it from the uterus may be done. This will reduce the risk of a tubal pregnancy and enhance embryo implantation if the patient requires IVF.

Laparoscopic lysis of adhesions offers an opportunity to conceive either naturally or with minimal types of therapy.
If the tubal occlusion is close to the uterus, the obstruction can be fixed with a balloon tuboplasty. This is done under fluoroscopic guidance similar to the common angioplastic procedure in cardiology.

Treatment of cervical factor:
The presence of antisperm antibodies in the cervix of the female often prevents conception. Such cases warrant direct intrauterine inseminations bypassing the cervix.  IUIs offer a reasonable option for treatment in such cases.
If the antibodies are on the sperm itself, washing the sperm with a chymotrypsin/galactose preparation may improve sperm motility.

Treatment of uterine factor:
An operative hysteroscopy is usually required to lyse adhesions or remove endometrial polyps or submucosal fibroids.
Fibroids in the uterus may also be removed by laparotomy, traditional laparoscopy or robotically assisted laparoscopy.

Treatment of endocrine abnormalities:
Any endocrine abnormality that is detected must be normalised prior to attempts at conception.

Treatment of unexplained infertility:
The choice of treatment depends on how aggressive the couple wants to be with their efforts to conceive. Most doctors start with either clomiphene citrate or gonadotropins in conjunction with IUIs.

Patients should completely understand the success rates and the risks of multiple pregnancy with any treatment protocol before they embark on any treatment or procedure.

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