Onm-5: Patient Management

Infertility is defined as failure to conceive after 1 year of unprotected intercourse(6 months for women over 35). The prevalence of infertility appears to be increasing; many women are postponing childbearing for social, professional, financial, or psychological reasons. The current evidence indicates a 9% prevalence of infertility (of 12 months) with 56% of couples seeking medical care. 80% of all women desiring children conceive within 1 year of marriage and another 10% within the second year. In the late 20th century, medical science has made great advances in understanding each stage of the reproductive process and in identifying the problems that can occur at each step. In an increasing number of cases these barriers can be corrected or worked around in order to achieve fertility for about 65% of couples who seek the help of fertility specialists. Despite public worryand discussion, the actual incidence of infertility has remained fairly stable over the years. One American couple out of 5 or 6 currently experiences infertility. Infertility grows more common with increasing age; about 33% of couples in their late 30s are infertile. The age factor has taken on new importance as many people in the United States and similar industrialized countries have put off marriage and children until certain educational or career goals are reached. Increased awareness and availability of modern treatments that assist couples to conceive and the decreased supply of infants for adoption have led more couples to seek infertility therapy. While the inability to conceive distresses many couples, they differ in their willingness to undergo intensive investigation and treatment for infertility. All women should be aware of certain information before trying to conceive. It is also important to counsel women about smoking cessation, weight control. Natural fertility declines with age. The main causes of infertility are related to ovulatory dysfunction; blocked or damaged fallopian tubes; and abnormalities of sperm number, motility, or morphology. Questions should focus on four main areas: ovulatory dysfunction, risk factors for tubal infertility,sexual factors, and male or sperm factors. Physical examination of women includes assessment of body mass index, thyroid, breasts, and signs of hyperandrogenism. A Pap smear should be done if indicated, along with a bimanual examination to search for signs of endometriosis or pelvic adhesions, such as a fixed retroverted uterus, adnexal masses or tenderness, and uterosacral ligament thickening, nodules, or tenderness. Infertility investigations aim to assess three main areas: ovulation, tubal damage or dysfunction, and male factors. First-line investigations generally include a semen analysis and assessment of tubal patency, usually by HSG. Semen analysis is readily available in most communities. The need for blood tests is determined by the history; a battery of tests is rarely required. Routine random measurement of FSH, TSH, and prolactin. A woman with a suspicion of chronic anovulation most probably due to polycystic ovary (PCO) syndrome, as there is a long history of irregular cycles and clinical presentation with hirsutism, her serum levels of testosterone hormone, SHBG, DHEA, DHEAS and prolactin should be evaluated to prove the provisional diagnosis and to detect the source of excess androgens. Semen analysis is best performed after 72 hours of abstinence. A longer period of abstinence results in increased sperm count, but reduced motility.There are three main types of fertility treatment: medical treatment (such as ovulation induction therapy); surgical treatment (such as laparoscopy and hysteroscopy); and the different assisted reproduction techniques (ART) such as IUI, IVF, ICSI, IVM, Choice of infertility treatment often related to issues of efficacy, cost, ease of use or administration, and its side effects. Legal, cultural and religious inquiries have limited the available choices in some countries, such as the use of donor sperms or oocytes.Treatment options available for any particular infertile couple will depend also on the duration of their infertility, which partner is affected, the age of the female partner. It is customary to transfer more than one embryo to the uterus to increase the chance of at least one embryo implanting; the risk of multiple pregnancies must be balanced with the chance of achieving a pregnancy at all .It is not appropriate to replace more than two embryos in women under the age of 37. High multiple pregnancies are much more likely to be the result of inappropriate ovulation induction in polycystic ovarian syndrome than they are of in vitro fertilization and embryo transfer. Fertility clinics should address the psycho-social and emotional needs of infertile couples as well as their medical needs. The content of counseling may differ depending on the concerned couple and the existing treatment options. It usually involves treatment implication counseling, emotional support counseling, and therapeutic counseling.Infertility by itself does not threaten the life, but it has devastating psycho-social consequences on infertile couples. It remains a worldwide problem challenge. Management of infertility has been and still a difficult medical task not only because of the difficulty in the diagnosis and treatment of the reproductive disorders in each partner, or the poorly unstated interaction between the partners' fertility potentials, but also because of the fact that success of treatment is clearly identifiable entity; the achievement of pregnancy. The treating doctor who is counseling the couple regarding their infertility must be familiar with the causes, investigations and the treatment options available. The couple needs to be given realistic information about their chances of having a live birth, as well as, the risks and costs of the management plan and its alternatives.