Medical treatment of male infertility

Although male factors contribute to approximately half of all cases of infertility, no specific cause can be found to explain the majority of abnormalities found in semen parameters. Specific and effective medical treatment is restricted to rare endocrine disorders. As a consequence, various empirical medical treatments are often used to treat idiopathic male infertility, with limited success. This review focuses on the rationale and current evidence on the efficacy of medical treatment of male infertility. Unless new studies provide high quality evidence in favour of medical treatment, assisted reproductive technologies will remain the mainstay of treatment of male infertility.     

Medical treatment of male infertility

Although male factors contribute to approximately half of all cases of infertility, no specific cause can be found to explain the majority of abnormalities found in semen parameters. Specific and effective medical treatment is restricted to rare endocrine disorders. As a consequence, various empirical medical treatments are often used to treat idiopathic male infertility, with limited success. This review focuses on the rationale and current evidence on the efficacy of medical treatment of male infertility. Unless new studies provide high quality evidence in favour of medical treatment, assisted reproductive technologies will remain the mainstay of treatment of male infertility.     

PCOS: diagnosis and management of related infertility

Polycystic ovarian syndrome (PCOS) is one of the most common endocrine disorders in women of reproductive age. It is characterised by a combination of hyperandrogenism (either clinical or biochemical), chronic oligo/anovulation, and polycystic ovaries. It is frequently associated with insulin resistance and obesity. PCOS receives considerable attention because of its high prevalence and possible reproductive, metabolic, and cardiovascular consequences. It is the most common cause of anovulatory infertility. Ovulation induction with an aromatase inhibitor or anti-oestrogen is the first-line medical treatment. The aim of ovulation induction is monofollicular growth to avoid multiple pregnancy. The second-line treatments include gonadotrophins and laparoscopic ovarian drilling. The role and benefit of metformin in ovulation induction is uncertain. Woman with PCOS undergoing IVF are at significant risk of ovarian hyperstimulation syndrome. Women with PCOS are also at an increased risk of developing gestational diabetes, pregnancy-induced hypertension, and pre-eclampsia.     

Therapie der Endometriose unter Berücksichtigung der Aktivitätsgrade

Active proliferating implants in endometriosis cause pain by inducing biochemical and mechanical mechanisms. Medical and/or surgical treatment is indicated. Regressive and inactive foci induce no mechanisms which cause pain, therefore therapy is not necessary. In contrast, even in inactive endometriosis surgery can be beneficial when fibrosis and scars secondary to the disease cause pain mechanically. Severe stages of endometriosis cause sterility by mechanical disturbance of the reproductive organs. Endoscopic surgery is an effective treatment. Some data in the literature demonstrate that treatment of mild endometriosis – surgically or medically – does not improve infertility. The data of this paper indicate that the conflicting findings in the literature can be explained by the fact that inactive endometriosis does not cause infertility. On the other hand active disease reduces fertility and medical or surgical therapy will lead to earlier achievement of pregnancy and higher pregnancy rates.     

Valuing live births from assisted reproduction: A health economics viewpoint

Infertility is a medical condition that can be overcome, thanks to advances in medically assisted reproductive (MAR) therapies. Despite the ultimate measure of MAR efficacy being the birth of a new human being, there are ethical and methodological questions as to which outcome best translates the value of MAR in cost-effectiveness analyses. Many authors favour cost per life birth outcomes instead of more traditional cost per quality-adjusted life years (QALYs), which raises generalizability issues for decision-makers. Nonetheless, infertility and infertility treatments substantially differ from other health conditions and health treatments, particularly in the way they affect the quality of life of the infertile couple. Collecting quality of life measures in infertility and pregnancy is also surrounded by challenges not easily overcome. We reflect on cost-effectiveness methods applied to MAR technologies, on ethical considerations for valuing a MAR-generated life, and on its broader societal value for consideration by decision-makers.     

Tubal pregnancy and the risk of subsequent infertility

One hundred forty-one women with tubal infertility, all of whom had been pregnant at least once before, were interviewed concerning their reproductive, contraceptive, medical, and sexual histories. Their responses were compared with those of a control group of 467 fertile women. A higher percentage of cases (13%) than controls (1%) had had a tubal pregnancy. From these percentages, we estimate that 92% of tubal infertility in women who have had a tubal pregnancy results from tubal pregnancy itself or factors that predisposed to its occurrence. We also estimate that approximately one-fifth of women who suffer a tubal pregnancy will subsequently be infertile because of a tubal abnormality. After controlling for the joint effects of several known risk factors for tubal pregnancy that independently predispose to infertility (eg, a history of pelvic inflammatory disease), the relative risk of tubal infertility associated with tubal pregnancy was 15.0 (95% confidence interval 5.2-43.6). However, because we had no sensitive indicator of antecedent tubal disease, we were extremely limited in our attempt to determine the extent to which this association was actually due to the consequences of the tubal pregnancy itself.     

Salpingitis isthmica nodosa in female infertility and ectopic tubal pregnancy

Salpingitis isthmica nodosa has been studied in relation to female infertility and tubal ectopic pregnancy. The incidence of this lesion in a control Caucasian population was 0.6%, as compared with incidences of 2.86% in an ectopic group and 50% in a small infertility group undergoing tuboplasty. It is suggested that salpingitis isthmica nodosa should be considered as an etiologic factor in these reproductive disorders. Chronic tubal spasm is suggested as the underlying process.     

Coeliac disease and problems associated with reproduction

Coeliac patients taking a normal diet have a shortened reproductive period with delayed menarche and early menopause. Many studies have shown that coeliac women are susceptible to reproductive difficulties such as infertility and miscarriages. The disease is also associated with low birth weight in babies and short duration of breast feeding. Folic acid deficiency is present in the majority of patients with untreated disease and it might be a maternal risk factor for neural tube defects and orofacial clefts. Coeliac men may have reversible infertility, and as in women, if gastrointestinal symptoms are mild or absent the diagnosis may be missed. It is important to make diagnosis because the giving of gluten free diet may result in conception and favourable outcome of pregnancy.     

子宫内膜异位症对妊娠结局影响的研究进展

子宫内膜异位症（EMs）是一种妇科常见疾病,常发生于育龄期妇女,以盆腔疼痛和不孕为主要表现,严重困扰育龄期妇女的身心健康。近年研究发现EMs不仅可以引起不孕,还可以导致不良的妊娠结局。研究显示EMs患者在妊娠早期发生流产、异位妊娠的风险增加,在妊娠中晚期发生早产、前置胎盘、妊娠期高血压疾病-子痫前期以及小于胎龄儿的风险增加,剖宫产分娩率增加。EMs与上述不良妊娠结局有关,其导致不孕以及不良妊娠结局的机制复杂,涉及EMs发生、发展过程中的病理生理改变,阐明其发生机制对EMs患者不良妊娠结局的防治具有重要意义。     

Thyroid disease and reproductive dysfunction: a review

Thyroid disorders are often ubiquitous and insidious in their presentation. They have been implicated in a broad spectrum of reproductive disorders ranging from abnormal sexual development to menstrual irregularities and infertility. If pregnancy occurs in a patient with thyroid disease, the physician must ensure that therapeutic measures instituted to restore the health of the mother do not adversely affect the developing fetus. This review examines the role of thyroid disease in disorders confronting the obstetrician/gynecologist and provides a theoretical framework upon which to base practical management decisions.     

Successful pregnancy in a liver transplant recipient following controlled ovarian hyperstimulation and intracytoplasmic sperm injection

As the demand for assisted reproductive technologies (ART) increases, infertility treatments are increasingly being sought by patients with serious health problems that were once regarded as leading to infertility. Moreover, since pregnancy may worsen their underlying health conditions, these women have been advised to remain infertile. We describe here a liver transplant recipient who underwent ART for male factor infertility. Assisted fertilization was achieved using intracytoplasmic sperm injection, and she conceived after embryo transfer. Her pregnancy follow-up was unremarkable until she delivered a healthy boy pretermly at 31 and half weeks.     

Medical treatment to improve sperm quality

Approximately 30% of cases of couple infertility are due to a male factor. Several conditions can interfere with spermatogenesis and reduce sperm quality and production. Treatable conditions, such as hypogonadism, varicocele, infections and obstructions, should be diagnosed and corrected, but many aspects of male factor infertility remain unclear. Various agents have been used in the attempt to increase the fertility potential of subjects with idiopathic oligoteratoasthenozoospermia. The rationale of medical treatment to improve sperm quality in these subjects has been questioned by the introduction of assisted reproductive technologies. However, there is now growing awareness of the importance of good quality spermatozoa for embryonic development and higher birth rates. Confounding factors in assessing the efficacy of male infertility treatments have erroneously inflated the superiority of assisted reproductive technologies over conventional approaches. A systematic review is given of relevant randomized controlled trials and effects on semen parameters. The analysis reveals that although results are heterogeneous, gonadotrophins, anti-oestrogens, carnitine and trace elements may be beneficial in improving sperm quality, although their effect on pregnancy rate remains controversial. The most common drug regimens are compared and an estimate of the results expected from these treatments provided.     

The subfertile couple

Subfertile couples are those who require medical help to achieve pregnancy after trying unsuccessfully for a variable period of time. Although the term ‘subfertility’ is also occasionally used in the context of women who can conceive but suffer recurrent miscarriages, this aspect is outside the scope of this review. Subfertility can seriously affect mental and social well-being. It is not generally viewed as a disease that significantly causes physical ill health, though it may be an early manifestation of serious coexisting disease. Advances in assisted reproductive technology in the last 22 years have simplified and diversified treatment options, rendering the terms ‘infertility’ and ‘sterility’ unfashionable. As a result, there is now an unfortunate trend towards only a superficial medical history and perfunctory physical examination. There are many guidelines on the initial investigation and subsequent management of subfertile couples, and it is now relatively easy to help them to achieve pregnancy. However, dealing with the devastating news of causative factors such as azoospermia, genetic disease, congenital anomaly and premature ovarian failure can be difficult. To discuss these sympathetically, professionals require interpersonal skills in breaking bad news. A multidisciplinary team approach should be adopted to cater for the long-term health consequences when co-morbidities are detected.     

The occurrence of ectopic pregnancy with and without clomiphene citrate use in assisted and nonassisted reproductive technology

An eleven-year review of treatment records of patients who became pregnant as a result of infertility treatment (n=3692) was conducted. All records were examined to determine whether clomiphene citrate (CC) was used in the cycle of conception and whether or not an ectopic pregnancy occurred. Data were additionally analyzed for the incidence of ectopic pregnancy with and without assisted reproductive technology (ART). The incidence of ectopic pregnancy was similar between CC (3.4%) and non-CC (3.4%) treatment groups receiving non-ART treatment. For non-ART treatments, tubal disease and severe endometriosis resulted in an increase in ectopic pregnancies independent of CC use. The incidence of ectopic pregnancy in patients receiving CC + human menopausal gonadotropin (hMG) for in vitro fertillization (5.4%) and gamete intrafallopian transfer (3.1%) was similar compared to ART treatments with hMG alone. The incidence of ectopic pregnancy was more closely associated with infertility diagnosis rather than CC use.Presented in part at the Annual Meeting of the Pacific Coast Fertility Society in Palm Springs, California, April 12, 1989.     

Fertility following radical, conservative-surgical or medical treatment for tubal pregnancy: a population-based study

Objective To investigate the factors influencing the choice of treatment for ectopic pregnancy and to compare the subsequent fertility rates of radical, conservative-surgical or medical treatments.
Design Population-based study of 835 ectopic pregnancies registered between 1992 and 1996.
Setting Auvergne Ectopic Pregnancy Register (France).
Sample Four hundred and seventy-six women with tubal ectopic pregnancy who were not using contraception at the time of conception. Subsequent fertility was studied for the 291 women who attempted to conceive again.
Methods Comparison of reproductive outcomes according to ectopic pregnancy treatment. Cumulative fertility curves were calculated by the Kaplan-Meier estimator and compared by log rank test for univariate analysis and by Cox regression to take into account confounding variables.
Main outcome measure Recurrence and fertility rates after ectopic pregnancy.
Results The first treatment given was 'radical' for 178 women (37%), 'conservative-surgical' for 262 (55%), and 'medical' for 35 (8%). The treatment failed in 1% for radical treatment, 5% for conservative-surgical treatment, and 36% for medical treatment. The two-year cumulative rate of recurrence was 27% with no significant difference between treatments. For women with previous infertility factors (in particular diseased contralateral tube), the treatments differed significantly, with the rate of intrauterine pregnancy lower for radical treatment and higher for medical treatment than for conservative-surgical treatment. For women with no infertility factor, there was no significant difference between treatments.
Conclusions These results should be confirmed in a controlled trial. The results of this study provide the elements necessary to plan such a trial.     

子宫腺肌病合并不孕患者的生殖预后及助孕策略

在子宫结构异常疾病中，子宫腺肌病在育龄妇女中有较高的发病率。随着影像技术和治疗水平的提高，越来越多的研究表明子宫腺肌病可能影响育龄妇女的生育能力。子宫腺肌病合并不孕的机制尚不明确，子宫内膜容受性异常、子宫结合带的结构异常、免疫功能异常等可能是子宫腺肌病患者生育能力低下的原因。希望保留生育能力的主要治疗方案有药物治疗、辅助生殖技术（ART）和手术切除子宫腺肌病灶。目前，ART可以改善子宫腺肌病合并不孕症患者的妊娠结局，促性腺激素释放激素类似物对生殖有积极的影响，在子宫腺肌病合并不孕症应用中有很重要的价值。综述子宫腺肌病合并不孕症影响生育的可能机制、生殖结局及治疗策略以探讨子宫腺肌病与不孕的关系。     

性腺发育异常患者的生育问题

性腺发育异常是指患者性腺性别异常的一类先天性疾病。现代诊疗多采用激素补充和手术治疗,可有效促进性腺发育异常患者内外生殖器的发育,维持激素平衡,并预防肿瘤发生。在对性腺发育异常患者进行管理的过程中,需对患者的生殖潜力予以考虑。尽管大部分性腺发育异常患者合并不孕,但辅助生殖技术为性腺发育异常患者提供了供卵、体外受精-胚胎移植等多种治疗选择。性腺发育异常患者可通过个体化的治疗成功妊娠并分娩正常胎儿,获得良好的母婴结局,实现生育愿望。文章着重就性腺发育异常患者的生殖潜力及生育问题的治疗进行阐述。     

Endocrine disorders and medically assisted procreation

A normal endocrine environment is imperative to maintain normal reproduction in women. The major endocrine organs that play a part in the reproductive system include hypothalamic pituitary axis, adrenal gland, thyroid gland, and the ovary. Each endocrine organ is in close communication and relationship with one another. Any endocrine disorders that significantly affect any of these organs would disrupt reproduction resulting in infertility. In this review, we will provide an overview of the common endocrine disorders and the available medical management including assisted reproductive technology (ART) and hormonal supplementation to overcome the endocrine disorders in order to achieve fertility for the female patients.     

子宫内膜异位症和子宫腺肌病与妊娠结局

子宫内膜异位症（内异症）和子宫腺肌病是生育年龄女性的常见病,也是引起女性不孕的常见原因。由于内异症病灶的侵袭性,妊娠期可引发一系列妊娠并发症。内异症相关不孕患者是接受辅助生育技术的一个群体,对于如何改善内异症和子宫腺肌病患者的妊娠结局,在近十余年来的研究中取得了不少令人瞩目的结果。