ART


When other treatments for infertility have failed ART can be offered. Female infertility factors also influence the selection of ART. There are basicly 3 forms of ART and the choice depends on how many sperm cells are available. If there are more than 10 mil motile spermatozoa pr mL Intra uterine insemination (IUI) can be used.

Harvests under this should be treated with either In vitro fertilization (IVF) or Intracytoplasmic sperm injection (ICSI). In IUI, semen is simply injected into the uterus when ovulation occurs. This bypasses the cervix so that a larger number of motile sperm can progress to the fallopian tubes where fertilization normally occurs. In addition washing of semen and the selection of motile sperm might further increase the chances of fertilization.

IUI is used to circumvent low-quality sperm, immunologic infertility, and for men with problems in sperm delivery including ejaculatory dysfunction and malformations. IUI can be used with or without ovarian hyperstimulation (OH), which increases the number of available oocytes at the site of conception. OH is achieved by administering drugs which resemble the reproductive hormones to the woman. With OH there is however a risk of ovarian hyperstimulation syndrome (OHSS) and an increased rate of multiple pregnancies which raises the fetus/baby  mortality and the maternal morbidity.

As it has been shown that in male subfertility there is no change in overall pregnancy rates while the risk of multiple pregnancy multiple pregnancy rates increase ovarian stimulation should not be offered in the attempt to overcome male infertility. IVF consists of ultrasound-guided transvaginal egg retrieval (the same procedure is used for ICSI) and mixing of spermatozoa and eggs in Petri dishes which leads to fertilization. Embryos are then placed back in the uterus. IVF also entails ovarian hyperstimulation.

IVF bypasses the obstacles of the female reproductive tract and can bypass moderate to severe forms of male infertility but still relies on adequate number of functional spermatozoa. ICSI involves microinjection of a single sperm through the membrane and into the egg. ICSI is the artificial insemination treatment of choice if the number of spermatozoa is below 1 mil/mL and after repeated fertilization failure after conventional IVF. The procedure has a higher fertilization rate that and is feasible with few spermatozoa or even a single spermatozoon.

Ovarian stimulation and oocyte retrieval are similar as for conventional IVF. The clinical pregnancy rate from a 1998 database showed a live birth rate of 32. 2% compared with 33. 2% for IVF.

In two cohorts of 2889 ICSI and 2995 IVF pregnancies, similar rates of multiple pregnancies were observed and no difference in major malformations and neonatal complications were seen. ART is costly and invasive and include maternal risks from ovarian hyperstimulation as well as the potential complications of oocyte retrieval, multiple gestation pregnancy and increased pregnancy losses. Ovarian hyperstimulation occurs in approximately 5% of cycles. Also the fact that genetic abnormalities occur with greater frequency, in infertile men than in the general population and that a number of genetic causes normally causing infertility can potentially be transferred to the offspring raises some concerns, especially since the ART procedures bypasses at least part of the natural selection of sperm.

These problems underline the requirement for genetic counseling and ethical concerns involved in the use of artificial reproductive technologies and IVF/ICSI should be reserved only for severe male factor problems.

Fibroids