DIAGNOSIS AS ESSENTIAL AS MEDICINE

 MANKIND’S QUEST for knowledge is the fundamental story of human progress and civilization. The history of civilization reveals how the thirst for knowledge leads to genuine progress and scientific advances. The treatment of infertility by assisted reproduction is one of the most progressive areas of modern medicine and the progress made in the last 25 years in understanding human reproduction has been truly awesome. Despite this progress, we have still a long way to go before every infertile couple could be assured a successful outcome.

On a practical front, the use of sophisticated technology, medications and investigations, often makes treatment prohibitively expensive, and out of reach of couples that need it the most.

This however does not dissuade many a couple from clinging to the dream of having a baby and the extent to which they go to raise the treatment cost is amazing. Unfortunately, even the best available treatment is not always successful and often these vulnerable couples are subjected to expensive treatments of unproven efficacy. Failure to conceive after treatment is understandably more disappointing.

Understanding the treatment proposed and anticipated risks and benefits make it easier to cope with failure. Often in a busy clinic, or individual practice the patient may not get the time to discuss this with her doctor, and therefore assumes that treatment invariably means successful conception.

Probing the cause

The choice of treatment will depend on the cause, and in only about 20% of cases, although no cause has been identified treatment would still offer a chance of success. Both the male and female are just as likely responsible for infertility in a couple, and often it is a combination of both.

Infertility in the male is often a result of one of the following reasons.

* Inability to deposit sperm – common causes are impotence, inability to ejaculate, retrograde ejaculate or congenital defects in genitals

* None or Low sperm count/ abnormal sperm: resulting from either blockage of ducts or damage to testes.

* Antibodies to sperm – previous injury/ surgery / vasectomy

Precautions

By and large all men are encouraged to lead a healthy lifestyle and avoid alcohol and certainly stop smoking if a smoker. Abstinence from sex or programmed sex is totally unnecessary and unrewarding, and only adds to an already stressful situation. Medications for other systemic illness may have an influence on sexual potency and semen quality and it is important to inform your doctor of any medication you may be taking.

The temperature at which the testes are maintained in a large way affect the sperm in numbers and quality. Hot baths, tight and restricting underwear and unacceptably high ambient temperature adversely affect sperm quality and conceptive potential. Loose, air permeable underwear improves the circulation around the testes enhancing sperm mobility and counts although the relationship is by no means one of linear progression!!

Medications and potions offering quick cures and superhuman virility are the realm of the gullible. Hormonal treatments unless indicated, (which is the case in only a minority) do more harm than good.

A thorough discussion with your specialist about the rationale, the risks and benefits of the proposed treatment, is recommended. Given the wide choice of treatment options now available, it is difficult to describe in brief all the available treatment for male factor infertility. The table below  is a rough guide to the investigations, and treatments available for some common conditions and the outcomes expected.

Treatment for Women

Infertility in women may arise from one or more of the following conditions

* Inability or difficulty in producing eggs- caused by advancing age, damage to the ovaries, hormonal imbalance, disease of the ovary and some genetic conditions.

* Inability of the sperm in meeting the egg - caused by excessively thick mucous, damage or blockage of fallopian tubes (most often caused by previous genital infections, endometriosis, and surgery especially D&C)

* Excessive destruction of sperm as result of vaginal infections, or sperm antibodies.

* Inability of the fertilized egg to implant into the womb as a result of abnormalities or disease of the womb such as polyps and fibroids

It would certainly mean that in the investigation of infertility, a woman has tests done to confirm the appropriate and timely release of eggs, the establishment of the health and potency of the tubes and confirmation of the normality of the uterus. Tests should be performed systematically and on an as needed basis. Expensive hormonal tests are not required as a routine as they should be done only when needed.

All women seeking treatment should take folic acid supplementation as this has been shown to reduce the incidence of birth defects.

Ovulation

Disorders of Ovulation (formation and release of the egg) are corrected by means of medications and there is now a wide spectrum of these available. The choice of the drug is made on an individual basis, and hence what is good for one may not be right for the other. Although very successful these drugs carry serious side effects (deaths have been reported) and should never be self prescribed or taken without a doctor’s supervision. As this treatment tends to stimulate more than one egg, the risk of multiple births i.e. twins and triplets are common with these medications. Damage to the tubes could be treated by an attempt to repair the tubes, which is now commonly done through keyhole surgery (Laparoscopy). In situations where the damage is significant and repair unlikely to be successful IVF (In Vitro Fertilization or test tube baby) may be the treatment adopted.

Abnormalities of the uterus are corrected by surgery only after other causes of infertility are ruled out. These operations give the best results when done by modern keyhole techniques as there is less damage done to the womb. Fibroids (benign tumors of the womb) are often associated with infertility, but may not be the cause, removal of small fibroids is often unnecessary, and rarely remedies the situation. If you are unsure of the need for an operation, discuss this with your doctor and request a second opinion

In about 20% of couples even the most diligent of investigations will reveal no abnormality. If the period of infertility is more than three years these couples are best treated with super ovulation (More than one egg stimulated) and Intra Uterine Insemination (IUI - washed sperm put in the womb directly), and if unsuccessful after six cycles IVF.

If the period of infertility is less than three years observation is probably best as the chance of spontaneous conception is just about the same as with treatment.

Because around four in five couples undergoing a single cycle of treatment do not have a baby it is easy to talk about failure. But the truth is that the overall success rates of assisted conceptions (when treatments are appropriately selected) are as good as nature and maybe even better. It is important to bear in mind though that the statistical chance of success in every cycle is the same, after six cycles cumulative conception rates are low. There is strong scientific evidence to suggest that conception is less likely in women over the age of 40, and in men with significant sperm abnormality, for the other couples the chance of a live birth is as good as for a fertile couple if they persist with treatment.

Dr. Eugene D’ Silva is a Consultant Obstetrician and Gynecologist.

GUIDE TO TREATMENT FOR INFERTILE MEN

GUIDE TO TREATMENT FOR INFERTILE WOMEN

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