Infertility

 

Fertility Treatment

There are two types of treatment available to treat male infertility i.e. Medical and Surgical Treatment. Persistance with therapy is required to produce results in treating male infertility.

Medical Treatment

In some cases where medical treatment is not beneficial, person can choose the option of ICSI. This technique is indicated for severe oligospermic male, unknown infertility, previously failed IVF cycles and obstructive azoospermia. Sperms are recovered from epididymis or testis through aspiration or biopsy.

Treatment of Male

Surgical Treatment :

1. Varicocelectomy :
Group II and III varicocele cases respond well. If it is Grade I, surgery is contraindicated as count may further reduce. Varicoselectamy not only number but quality of sperm also improves.

2. Herneoraphy or hydrocelectoy : while doing this surgery one must be careful about VAS

3. Transurethral or rectal surgery on seminal vesicle duct and prostate.

4. Vasoepidydimo – Anastamosis –Blocks in the epidydimus can be repaired with this procedure. But success rate is very very low.

5. Vasovasostomy : Vas can be recanalised with this procedure after vasectomy.

a. Vasovasostomy :- [reconnection of the two severed ends of the vas deferens]

This procedure performed through small [½-1”] scrotal incisions, usually under a general anesthetic condition, the ends of the vas are identified and scar tissue is removed.


6. Sperm Extraction in cases of Azoospermia to proceed with ICSI.

Percutaneous edpidymal sperm Aspiration [PESA]

Testicular sperm Extraction [TESA]

Non – Surgical Treatment

1. Specific Treatment

a. Hypogonadotropic Hypogonadism :

Causes
  • Pituitary tumor
  • Isolated gonadotropin deficiency
  • Panhypo pituitarism
  • Pituitary trauma
  • Anbolic steroid use

Congenital Hypogonadotropic Hypogonadism

Cause
  • Abnormal production or secretion of GnRH by the hypothalamus

Initial Evaluation

  • Head CT or MRI [ to rule out possibility of a pituitary tumor
  • Prolactin level
Treatment :

Patients with gonadotropin deficiency – normal spermatogenesis can be restored by

  • Exogenous gonadotropin or GnRH
  • hCG [1,500 – 3,000 IU /sc thrice / week] 8-12 weeks after hCG therapy
  • hMG [37.5-150 IU/ sc /2-4 times / week]

Hyperprolactinemia :

Prolactine has a negative influence on the hypothalamic secretion of gonadtotropin releasing hormone and have an inhibitory effect on LH binding to leyding cells in the testis. This hyperprolactinemia patient may have decreased serum gonadotropin and decreased testosterone level.

Causes
  • Pituitary tumor
  • Hypothyropidism
  • Liver disease
  • Drugs [like phenothiazine and some antidepressants]
Treatment
  • For Hypothyroidism Patient – Thyroid replacement therapy itself will bring prolactin in normal range.
  • For idiopathic hyper prolactinemia patients – bromocriptine [2.5 – 7.5 mg/2-4 times /day]

c. Congenital Adrenal hyperplasia[CAH] :

CAH patient has

  • Decreased cortisol secretion due to deficiency in adrenal hydorxylase.
  • Increased adrenal androgen production
  • Suppression of spermatogeneis
  • Diagnostic test

    Urine 17 – Ketosteroids or dehydroepiandrosterone [DHEA] glucocorticoid replacement

    d. Immunologic infertility

    Treatment – oral prednisone will decrease significant Antisperm Antibody titre or Assisted Reproductive technigues [ART]

    e. Genital Tract Infection :

    Infection

    Enterobacteriaceae
    Chlymydia trachomatis Neisseria Gonorrhoeae
    Pyospermia (> 1million WBC/ml of semen)
    Testicular atrophy
    inflammation
    generate ROS
    Testicular atrophy
    Treatment
    • Culture proven antibiotic
    • Non steroidal anti-inflammatory drugs.

    f. Ejaculation disorders

    The ejaculatory event is comprised of seminal emission and ejaculation. Seminal emission refers to the deposition of semen into the posterior urethra by contraction of the vas deferentia and seminal vesicles. These events are mediated by the sympathetic nervous system. Ejaculation is the forceful expulsion of semen from the posterior urethra out of the urethral meatus in an antegrade fashion.

    Disorder of ejaculation include

    • Retrograde ejaculation
    • Anejaculation
    • Retarded ejaculation
    • Premature ejaculation

    Retrograde Ejaculation

    abnormal backward flow of semen into the bladder with ejaculation

    Etiology

    • Anatomic [prostatectomy, bladder neck surgery
    • Neurogenic [spinal cord injury, retroperitoneal surgery
    • Pharmacologic [use of certain drugs
    • Idiopathic
    Treatment
    • Phenyl propanolamine – 75 mg bid-10 days
    • Pseudoephednine hydrochloride – 60mg qid/10days
    • Ephedinine sulfate – 50 mg quid/10 days
    • Imipramine hydrochloride – 25 mg bid /10 days
    • Recovery of sperm from urine and use for either IUI or IVF/ICSI procedure

    An ejaculation

    Etiology

    • Spinal cord injury
    • Retroperitoneal lymph node dissection
    • Retroperitoneal surgery
    • Diabetes
    • Multiple sclerosis
    • Psychogenic or idiopathic
    Treatment :

    Rectal probe electro ejaculation [RPE]

    • Penile vibratory stimulation
    • ICSI

    2. Clomiphene Citrate treatment

    Clomiphene citrate is a synthetic, nonsteroidal anti-estrogen that is structurally related to diethylstilbestrol (DES). It competitively binds to the estrogen receptors in the hypothalamus and pituitary, thereby blocking feedback inhibition on these organs and effectively increasing the secretion of GnRH, FSH, and LH.
    Clomiphene citrate is prescribed in doses of 12.5-50 mg per day and may be given continuously or on a 25-day cycle with a 5-day “rest period” each month. Monitoring of serum gonadotropins and testosterone is essential to make certain that the testosterone level remains within the normal limits, since higher levels may have a negative influence on spermatogenesis. In addition, because a small percentage of patients experience a decline in sperm density and motility while taking this medication, frequent semen analyses are mandatory.
    Controversy still exists with regard to the efficacy of clomiphene citrate for the treatment of male factor infertility. It is possible that a select group of patients responds to clomiphene therapy. It is also conceivable that by some as yet undetermined mechanism clomiphene improves pregnancy rates without improving bulk seminal parameters or sperm fertilizing capacity. Although it is difficult to predict which patients will respond to clomiphene, patients not likely to benefit from this therapy include those with elevated baseline serum FSH levels, severe oligospermia, asthenospermia, teratozoospermia or azoospermia, and those with extremely abnormal testis – biopsy is needed.

    3. Specific therapy

    a. Antioxidant Treatment : either invivo or invitro in sperm preparation technique.
    Antioxidants useful to reduce oxidative stress are
    • Carnitine
    • Arginine
    • Zinc
    • Selenium
    • Vit B12
    • Vit C & E
    • Glutathione
    • CoEn.Q.10
    b. Platelet –Activating Factor [PAF]

    No.of endogenous biochemical factors attributed to fertility potential of spermatozoa.
    One such factor is PAF. PAF treated sperm has a increased motility and better fertilization rate
    PAF is unique and novel signaling phospholipid with pleiotropic biological properties like

    • Involved in ovulation
    • Increases the sperm motility
    • Sperm capacitation [acrosome reaction]
    • Fertilization potential
    • Preimplantation embryo development
    • Implantation
    • Parturition

    Use of exogenous PAF in sperm preparation technique will improve motility, fertilization rate, implantation rate and pregnancy rate.

    Treatment of Female

    Treatment for Female Infertility

    Chart below outlines the condition and treatment for that condition.

    S.No>ConditionDefinitionTreatment
    1VaginitisInfection in VaginaTreatment of respective infections For eg.Candida, yeast, bacteria etc.
    2Ovulation Problems

    1. Anovulation or irregular period
    2. Absent ovary
    Menstrual cycle irregularity

    No ovary either by birth , surgical removal, premature ovarian failure or menopause

    Ovulation stimulating drugs like clomiphene citrate, tomoxfen, gonadotropin, injections, hCG, etc connecting prolactin or thyroxin level
    Oocyte donation & IVF
    3Uterine problems

    1. Anatomically abnormal
    2. Fibroids
    3. Polyps
    Different size & shape of uterus by birth eg. Septate or bicornuate uterus Growth of tissueSurgical treatment
    Surgical removal
    Surgical removal
    4Tubal ProblemsBlocked or damaged tube prevent path for egg release from ovary to uterusLaparoscopic surgery Or IVF
    5Poor egg qualityEggs that become damaged or developed chromosomal abnormalitiesEgg donation
    6Poly cystic ovarian syndrome
    • Ovaries contain many small cysts
    • Hormone imbalance
    • Ovulation irregularity
    • ovulation stimulating drugs
    • Laparoscopic micro cauterization of ovarian capsule
    • IVF-ET
    7EndometriosisPresence of uterine lining
    [endometrium] other than natural place
    1. Drugs
    2. Hormonal therapy
    3. Surgery
    4. IVF-ET
    8Immunological InfertilityAffects entry of sperm in the genital tract or into egg
    1. Immuno suppression
    2. IUI
    3. IVF
    9Coital failureNo coitus
    1. Psychological counseling
    2. Surgical correction
    3. Use of lubricants
    4. Treatment for any infection