Subfertility in the era of assisted reproduction: changes and consequences

Tubal disease: towards a classification

Tubal disease is a major cause of infertility. The amount of damage can vary greatly in extent, anatomical location and nature. For women with infertility due to tubal disease, prognostication for pregnancy often remains unclear and there is no universally accepted classification. A classification system that reliably distinguishes infertile patients with tubal disease into favourable and unfavourable groups would be useful if subsequent management could depend on this assessment, especially if the classification is able to define which group of patients would benefit most from interventions such as surgery. The progress of IVF questions the contribution of the Fallopian tube to the successful achievement of pregnancy in infertile women. Nonetheless, several studies reveal that severity is the key factor in the determining outcome, and the classifications reviewed in this paper imply that women with tubal disease could be categorized into prognostic groups using a simple classification system based on severity. However, prospective trials are needed to validate and assert the usefulness of any particular classification.

Psychogenic infertility--myths and facts

PURPOSE

The hypothesis of this review is that the role of psychological factors as the sole cause of infertility is generally overrated.

METHODS

A review is given of studies concerning the influence of psychological factors on the development of infertility.

RESULT

A prevalence of psychogenic infertility of 10-15 per cent must be discussed critically. A value of approximately 5 per cent is more realistic. Equating unexplained infertility with psychogenic infertility is not justified. A definition of psychogenic infertility according to the German guidelines Psychosomatics in Reproductive Medicine is presented. Spontaneous pregnancies following adoption or the decision to remain childless are the absolute exception. The association of stress and infertility in humans is still unclear. For many women the effect of infertility and notably of medical therapy is a considerable emotional stress. This may make psychosocial counseling necessary in certain cases.

CONCLUSIONS

An exclusive psychological/psychodynamical point of view on the complexity of infertility is as inadequate as a strictly somatic point of view. Infertility should always be treated as a psychosomatic entirety.

Spontaneous conception after the birth of infants conceived through in vitro fertilization treatment

OBJECTIVE

To investigate the incidence of spontaneous conception after the birth of infants conceived through IVF in couples with subfertility caused by endometriosis, a mild male factor, or unexplained factors, and to identify clinical conditions related to the occurrence of spontaneous conception.

DESIGN

Retrospective analysis.

SETTING

Department of Obstetrics and Gynecology, Akita University School of Medicine, Akita, Japan.

PATIENT(S)

One hundred forty-two women who conceived through IVF and 25 of the 142 women who subsequently conceived spontaneously.

INTERVENTION(S)

Patient characteristics and IVF data were obtained from hospital records, and follow-up data were collected through telephone interviews.

MAIN OUTCOME MEASURE(S)

Cumulative conception rate.

RESULT(S)

The cumulative conception rate at 60 months after the delivery of infants conceived through IVF was 18%, with most conceptions occurring within 2 years of delivery. Proportional hazard analysis indicated that patient age was the most important clinical variable related to the occurrence of spontaneous conception.

CONCLUSION(S)

This study provides information that will be useful in counseling subfertile couples who have conceived through the use of IVF.

Clinical review 100: Evaluation and treatment of the infertile couple

Infertility by itself does not threaten physical health but has a strong impact on the psychological and social well-being of couples. In the last two decades, progress in caring for the infertile couple, in particular progress in the field of assisted reproduction and micromanipulation, has provided significant hope for many couples for whom hope could not have been offered in the past. This is especially true for bilateral tubal disease and for male factor infertility, as nearly all couples with male factor infertility can now undergo either one (or more) IVF or ICSI attempt(s). For couples with other causes of infertility, however, the differences in pregnancy rates often do not reach statistical significance. We must also remember that the total cost incurred for successful delivery for couples with a better chance of successful IVF (i.e. those with tubal disease) increases from approximately $55,000 in American dollars for the first cycle to $73,000 by the sixth cycle. Because of these high costs, many insurers in the United States and many public health systems in Europe do not cover or only partially cover these procedures. Consequently, the availability of IVF and related therapies frequently depends on the couple's ability to pay. Therefore, after having established the correct diagnosis, appropriate treatment should be counseled to the infertile couple keeping in mind the following points: 1) in subfertile couples expectant management should be reasonably counselled if the age of the woman is less than 30 yr and the duration of infertility is less than 36 months, even if oligozoospermia is present; 2) superovulation and timed intercourse seems also to be a reasonable approach in couples with anovulatory, mild/moderate endometriosis, and unexplained infertility; 3) in unexplained infertility, ovarian stimulation (with clomiphene or gonadotropin) and IUI seem to offer some advantage over ovarian stimulation and timed intercourse; 4) IVF can be a firstline approach in tubal sterility and when IUI or IPI cannot be performed because the number of motile sperm is insufficient, but is usually also the final treatment attempt when other methods have failed. The outcome of IVF is negatively influenced mainly by the woman's age; however, the number of deliveries is also generally lower in couples with male factor; 5) ICSI is a further option, which should be limited to couples: a) with very poor semen parameters; b) previous failed fertilization; c) presence of obstructive or nonobstructive azoospermia in which ICSI is combined with sperm extraction from the epididymis or the testis; 6) international register studies demonstrate that the risk of malformation after conventional IVF is not increased; 7) some reports suggest that incidence of congenital major and minor malformations is not increased in children born after ICSI. However, the rate of sex chromosome anomalies in ICSI fetuses has been reported to be approximately 1% in 585 prenatal diagnoses, a frequency increased by a factor of 4 if compared with naturally conceived live-born babies. ICSI bypasses the physiological selection of spermatozoa that occurs at the level of the testis and epididymis, and in the female reproductive tract as well as at the sperm-oocyte interface. As genetic abnormalities are present in a significant percentage of infertile males with impaired spermatogenesis, karyotyping and analysis of the Y chromosome for microdeletions should be carried out in all potential ICSI fathers. Screening for cystic fibrosis gene mutations should also be performed in azoospermia caused by congenital absence of the vas deferens and seminal vesicles. Appropriate genetic counseling should be made available to all ICSI couples whenever a gene or chromosomal anomaly has been identified. With most ARTs the average delivery rate per cycle is approximately 15% and the cumulative delivery rate after several cycles is about 50%. (ABSTRACT TRUNCATED)

Outcome of IVF in patients with endometriosis in comparison with tubal-factor infertility

PURPOSE

The aim of this retrospective study was to compare the outcome of in vitro fertilization and embryo transfer in women with endometriosis and a control group with tubal-factor infertility.

METHODS

Forty-eight patients with endometriosis underwent 65 cycles of in vitro fertilization and embryo transfer at Huddinge University Hospital. The matched control group with tubal-factor infertility consisted of 98 cycles in 98 patients. These groups were retrospectively analyzed regarding stimulation, fertilization, embryo development, implantation, and pregnancy outcome.

RESULTS

The fertilization rate was significantly lower in women with endometriosis, but the cleavage, implantation, and pregnancy rates did not differ.

CONCLUSIONS

Our results show that women with endometriosis have a lower fertilization rate compared with women with tubal-factor infertility. However, once the oocyte is fertilized, it seems that the preembryo has a normal chance of implantation, leading to similar pregnancy rates.

Profiling assisted reproductive technology: outcomes and quality of infertility management

OBJECTIVE

To critically appraise the content of the American Society for Reproductive Medicine (ASRM)/Society for Reproductive Technology (SART) Registry.

DESIGN

English-language literature review.

PATIENT(S)

Women undergoing treatment with assisted reproductive technology (ART).

INTERVENTION(S)

Current ART treatments, including IVF, GIFT, zygote intrafollopian transfer (ZIFT), oocyte micromanipulation, and cryopreserved embryo transfers.

MAIN OUTCOME MEASURE(S)

Compliance with clinical practice guidelines, and casemix-adjusted rates of live delivery, clinical pregnancy, ectopic pregnancy, miscarriage, birth defects, implantation, fertilization, and retrieval.

RESULT(S)

Outcomes should be adjusted for variation in patient characteristics known to affect prognosis, including maternal age, the duration of infertility, the presumed cause(s) of infertility, the patient's prior history of treatment for infertility, and diethylstilbestrol exposure. Outcome rates should be reported using the patient as the denominator, as well as cycle, retrieval, and transfer. The statistical significance of observed differences in events rates should be indicated. Because widely accepted clinical practice guidelines related to performance of ART procedures are not available, compliance with practice guidelines cannot currently be assessed.

CONCLUSION(S)

Reports based on ASRM/SART Registry data can be enhanced by refined casemix adjustment, assessing outcome rates per patient, as well as per component of ART procedure, and by providing an indication of the statistical significance of observed differences in event rates. In addition, a critical appraisal of available evidence related to particular aspects of infertility management would help clarify the areas in which there is an evidentiary basis for formulation of practice guidelines, as well as topics requiring additional clinical research.

Preembryo research: medical aspects and ethical considerations

Recent advances in the field of reproduction have made it possible to obtain preembryos and to use them in many research applications. These include research into improving methods of IVF treatment, contraceptive research, preimplantation diagnosis, gene therapy, the study of malignant disease, and others. The benefits, academic and scientific, are enormous, but many moral and ethical issues and reservations exist. Potential sources from which the preembryos may originate may also lead to controversy. Pressure groups in various societies seek to hasten governments into legislation or other means of control. We conducted a MEDLINE search of all pertinent literature since 1980, and these findings have been reviewed.

Scavenging effect of N-acetyl-L-cysteine against reactive oxygen species in human semen: a possible therapeutic modality for male factor infertility?

A new approach to reduce the level of reactive oxygen species (ROS) in human semen by using N-acetyl-L-cysteine (NAC) was evaluated. Semen samples were incubated with or without NAC (1.0 mg ml-1) at room temperature. The chemiluminescent signal of the oxidation of luminol was detected by means of an MTP reader after 0, 20, 40, 60 and 120 min, respectively, using 200 microM luminol. In addition, the dose-dependent action of NAC (0.1, 1.0 and 5.0 mg ml-1) and the influence of NAC on functional sperm parameters (motility and acrosome reaction) were studied. ROS levels decreased significantly after 20 min incubation with NAC. This reduction was greater in the high ROS group (> 30000 counts/10(7) viable sperm at t = 0) than in the low ROS group (< 30000). In addition, a marked dose-dependence of NAC was observed. Concerning sperm function, total sperm motility improved after incubation with NAC, but no significant change was observed with respect to the acrosome reaction. NAC (at concentrations of 1.0 mg ml-1) significantly reduced ROS in human semen and showed the possibility of improving impaired sperm function. After further testing NAC might be useful for the treatment of male infertility patients.

The impact of hydrosalpinx on successful pregnancy in tubal factor infertility treated by in vitro fertilization

OBJECTIVE

To determine the impact of hydrosalpinx on pregnancy rates in patients undergoing IVF for infertility caused by tubal disease.

DESIGN

Review of the records of all patients who had undergone IVF for tubal factor infertility at our institution between May 1988 and October 1994.

SETTING

A university-sponsored, hospital-based IVF facility.

PATIENT(S)

Two hundred fifty patients were identified with infertility due to tubal disease; 67 of these had at least one documented hydrosalpinx whereas the remaining 183 did not.

MAIN OUTCOME MEASURE(S)

Numbers of oocytes retrieved and fertilized, the number of embryos transferred and implanting, and resulting pregnancy rates.

RESULT(S)

The groups were similar in age and cycle cancellation rates. The patients with hydrosalpinx had greater numbers of oocytes retrieved per cycle (15.0 versus 11.6) and embryos transferred per cycle then those without hydrosalpinges (4.21 versus 3.98). The hydrosalpinx group also undertook more cycles per patient (2.31 versus 1.96). Fertilization rates between the two groups were similar, but implantation rates were decreased in those with hydrosalpinx (8.5% versus 11.2%).

CONCLUSION(S)

Hydrosalpinx did not result in impaired ovarian stimulation or decreased oocyte fertilization. It did, however, interfere with implantation and reduce to some degree the success of IVF in achieving an ongoing pregnancy. The validity of routine salpingectomy for hydrosalpinx is debatable, but its use in selected individuals may well be appropriate.

Is assisted reproduction the optimal treatment for varicocele-associated male infertility? A cost-effectiveness analysis

OBJECTIVES

To evaluate the cost-effectiveness of assisted reproduction using in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI) as a primary treatment for varicocele-associated infertility.

METHODS

Analysis of cost per delivery using published and contemporary results for treatment with ICSI in the United States for male factor infertility was compared with cost per delivery after surgical varicocelectomy. Only results from controlled trials of varicocelectomy were used for evaluation of pregnancy and delivery rates. Cost estimates were based on prevailing nationwide charges for services in 1994.

RESULTS

The cost per delivery with ICSI was found to be $89,091 (95% confidence interval $78,720 to $99,462), whereas the cost per delivery after varicocelectomy was only $26,268 (95% confidence interval $19,138 to $44,656). Assuming the highest possible published success rate for ICSI resulted in a cost estimate as low as $62,263. The average published U.S. delivery rate after one attempt of ICSI was only 28%. whereas a 30% delivery rate was obtained after varicocelectomy.

CONCLUSIONS

Specific treatment of varicocele-associated male factor infertility with surgical varicocelectomy is more cost-effective than primary treatment with assisted reproduction. Continued evaluation and treatment of the man with infertility is warranted. Despite the apparent success of ICSI for the most severe cases of male factor infertility, application of assisted reproduction for all cases of male factor infertility also does not necessarily provide as high a delivery rate as specific treatment of the cause of male factor infertility.

Benefit of in vitro fertilization treatment for endometriosis-associated infertility

OBJECTIVE

To evaluate the effectiveness of IVF treatment in endometriosis-associated infertility.

DESIGN

Nonrandom retrospective study.

SETTING

Department of Gynecology and Obstetrics, Akita University School of Medicine.

MAIN OUTCOME MEASURE(S)

Cumulative pregnancy rate.

PATIENT(S)

One hundred eighteen infertile patients in whom diagnosis of endometriosis was established by laparoscopic examination.

INTERVENTION(S)

The prognoses of 60 patients (IVF group) who started IVF treatment within 6 months after laparoscopy were compared with those of 58 patients who were managed expectantly without IVF treatment during the same period.

RESULT(S)

The cumulative conception rates at 36 months after laparoscopy were 62% in the IVF group and 43% in the control group, and the difference was not significant (a log-rank test). For patients > or = 32 years of age, the conception rates were significantly higher in the IVF group (59% versus 29%). A relatively large but nonsignificant difference in the conception rate between the two groups was observed in patients with endometriosis at stages III or IV (52% versus 27%).

CONCLUSION(S)

In vitro fertilization treatment provides better prognosis in patients > or = 32 years of age and is recommended for such patients. The benefits of treatment appear to be greater in patients with more advanced stages of endometriosis.

Recanalization of obstructed fallopian tube by selective salpingography and transvaginal bougie dilatation: outcome and cost analysis

OBJECTIVE

To investigate effectiveness and cost of transcervical salpingography and recanalization in the management of infertility caused by tubal occlusion.

DESIGN

Retrospective analysis of patients investigated with transcervical selective salpingography and, in some instances, treated by transcervical recanalization.

SETTING

Four hundred patients with hysterosalpingography diagnosis of obstructed fallopian tubes (clinical environment) are investigated. A repeat hysterosalpingogram after administration of a prostaglandin antagonist demonstrated patency of the tubes in 82 patients and selective transcervical salpingography demonstrated patency in an additional 131 patients.

INTERVENTION

Transcervical tubal recanalization. Of the remaining 187 patients, recanalization by transcervical technique was successful in 145 patients. The underlying etiology for tubal obstruction was salpingitis isthmica nodosa in 62, salpingitis and perisalpingitis in 71, endometriosis in 8, failed surgical anastomosis in 43, and undeterminate cause in 3 patients. Pregnancy was attained in 24 patients, there were 10 minor and 1 major complication.

OUTCOME MEASURE

Attained and maintained patency of tubes, pregnancy, attendant complications.

CONCLUSION

A pregnancy rate of 12.8% was attained after transcervical recanalization of obstructed tubes. An attendant increased rate of pregnancy in patients proven patent after selective salpingography, valuable detailed information about proximal and distal tubes after recanalization of the obstructed proximal tube segment, the low rate of complications, and low cost are factors recommending the use of this technique. Moreover, tubal surgery or IVF treatment are not influenced adversely by prior transcervical tubal recanalization and remain an option for patients who failed to attain pregnancy.