Assisted Reproduction

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Chapter 165 Assisted Reproduction

THE CHALLENGE

To use advanced reproductive technology to assist couples who experience difficulty conceiving through normal means.

Scope of the Problem: Ten percent to fifteen percent of couples who are infertile require or benefit from assisted reproductive technologies.

Objectives of Management: To achieve a successful pregnancy (carried to term) with minimal intervention. The treatment of an infertile couple is based on identifying the impediment to fertility and overcoming or bypassing it to achieve pregnancy. A number of techniques are available to accomplish this end. Most are less exotic than their acronyms suggest (see Table). Among infertile couples seeking treatment, 85% to 90% can be treated with conventional medical and surgical procedures and do not require assisted reproductive technologies such as in vitro fertilization.

TACTICS

Relevant Pathophysiology: The success of treatment depends to a great extent on the identified cause of infertility because some problems are more easily overcome than others. It must be recognized that success is also a function of the age of the woman. It is also true that the rate of spontaneous pregnancy loss increases rapidly after age 35, adversely affecting success.

ABBREVIATIONS FOR TECHNIQUES

Abbreviation	Technique
AID	Artificial insemination, donor (using donor sperm, occasionally referred to as TDI or therapeutic donor insemination)
AIH	Artificial insemination, homologous (using the partner’s sperm)
BT	Basal body temperature
GIFT	Gamete intrafallopian transfer (gametes placed in the fallopian tube for fertilization)
HSG	Hysterosalpingogram or uterine cavity radiograph
ICSI	Intracytoplasmic sperm injection
IUI	Intrauterine insemination (placement of either donor or husband sperm directly into the uterine cavity)
IVF/ET	In vitro fertilization with embryo transfer
PCT	Postcoital test or Huhner-Sims test
SPA	Sperm penetration assay (also known as a hamster egg test or zona-free egg penetration test)
ZIFT	Zygote intrafallopian transfer (fertilization takes place in vitro and the zygote is transferred to the fallopian tube to be transported into the uterine cavity)

Strategies: Often a good starting point in the treatment of infertility is a frank and open discussion about sexuality and the physiology of conception. When couples have intercourse four or more times per week, more than 80% achieve pregnancy in the first 6 months of trying. By contrast, only about 15% of couples conceive when intercourse happens less than once a week. Intercourse should be maintained on an every-other-day cycle for the period from 3 to 4 days before the presumed ovulation until 2 to 3 days after that time. When ovulation disorders are encountered, ovulation induction or control may be used to enhance the likelihood of pregnancy. Tubal factor infertility may be addressed by either surgical repair of the damage or by bypassing the tubes completely through in vitro fertilization and embryo transfer (IVF/ET). According to 2004 statistics, in vitro fertilization techniques account for only about 5% of infertility services and are associated with a roughly 32% live delivery rate per egg retrieval. Success rates for surgical repair, including the reversal of previous sterilization procedure, are highly variable. Technologies such as intracellular sperm injection may allow fertility with as few as one sperm per oocyte.

Patient Education: Reassurance; American College of Obstetricians and Gynecologists Patient Education Pamphlet AP136 (Evaluating Infertility), AP137 (Treating Infertility).

IMPLEMENTATION

Special Considerations: Patients experiencing infertility are usually extremely motivated, following to the letter any suggestion made by the health care team. For this reason, care must be taken that during the evaluation and treatment of infertility the couple’s relationship is not destroyed in the process. In the end, there is no guarantee that efforts will result in a conception, so the health care team must not damage what is present in the quest of something that may not be. Couples should be reminded that “If you miss having intercourse at the ‘right time’ in a given month, remember that ovulations are like commuter trains—there is probably another one on its way.” If the couple is in the mood for “making love,” in any of its myriad forms, they should not worry about what the temperature chart is doing. To do otherwise is the fodder of cinematic comedy and divorce lawyers. Because infertility does not threaten life or health, many insurance providers do not cover the cost of its evaluation or treatment. A frank and open discussion about the time and expense involved in infertility evaluation allows the couple to make informed choices and avoids unnecessary financial or emotional hardship in the future.

All types of assisted reproductive technologies involving ovarian stimulation are associated with an increased incidence of multiple gestations (40%): The majority of these pregnancies are twins (25%), and 5% are higher-order gestations.

American College of Obstetricians and Gynecologists. Management of infertility caused by ovulatory dysfunction. ACOG Practice Bulletin 34. Obstet Gynecol. 2002;99:347.

American College of Obstetricians and Gynecologists. Polycystic ovary syndrome. ACOG Practice Bulletin 41. Obstet Gynecol. 2002;100:1389.

American College of Obstetricians and Gynecologists. Perinatal risks associated with assisted reproductive technology. ACOG Committee Opinion 324. Obstet Gynecol. 2005;106:1143.

American College of Obstetricians and Gynecologists. Using preimplantation embryos for research. ACOG Committee Opinion 347. Obstet Gynecol. 2006;108:1305.

American College of Obstetricians and Gynecologists. Adoption. ACOG Committee Opinion 368. Obstet Gynecol. 2007;109:1507.

Braude P, Rowell P. Assisted conception. II—In vitro fertilisation and intracytoplasmic sperm injection. BMJ. 2003;327:852.

Braude P, Rowell P. Assisted conception. III—Problems with assisted conception. BMJ. 2003;327:920.

Lobo RA. Infertility. In: Katz VL, Lentz GM, Lobo RA, Gershenson DM, editors. Comprehensive Gynecology. 5th ed. Philadelphia: Mosby/Elsevier; 2007:1030.

Rowell P, Braude P. Assisted conception. I—General principles. BMJ. 2003;327:799.

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