Assisted reproductive techniques

Abstract

There is good evidence in the literature in favour of intrauterine insemination (IUI) as the best first-line treatment and most cost-effective procedure in cases of mild and moderate male factor subfertility before starting more invasive and expensive techniques such as in vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI). On the other hand, it seems very difficult to isolate individual semen parameters predicting the likelihood of pregnancy after IUI. A review of the literature confirmed that spermmorphology using strict criteria and the inseminating motile sperm count (IMC) are the most important sperm parameters for assessing the real impact of semen quality on IUI outcome. A universal threshold level above which IUI can be performedwith acceptable pregnancy rates has not been determined yet, although IUI success seems to be impaired with fewer than 5% normal spermatozoa using strict criteria and with an IMC of less than one million. In cases of severemale subfertility, it is not only the number of motile spermatozoa recovered after washing but also the number of oocytes retrieved that will guide the laboratory as to which procedure (IVF or ICSI) will be chosen. Only absolute immotility of spermatozoa seems to reduce the fertilization rate after ICSI. Epididymal aspiration of sperm and/or testicular sperm extraction can successfully be applied in most cases of azoospermia. These techniques revolutionized the treatment of azoospermic patients. For obstructive azoospermia, fertilization and pregnancy rates are comparable with those achieved with ejaculated sperm. The results with frozen testicular sperm are comparable to those obtained with fresh testicular sperm. In men with non-obstructive azoospermia, ICSI seems to be less successful. Approximately 10-15% of women will receive infertility treatment during their lifetime and in more than one-third of cases male infertility is involved. Of all subfertile couples, only 1-2% will undergo treatment with assisted reproductive technologies (ART). The increasing availability of ART during the past 20 years has received a lot of public attention, not least because of the ethical implications, the high costs associated with these treatments, the impact of age and multiple births on costs, the inequities in access to infertility services in many countries and the issue of safety. On the other hand, the true value of treatmentmodalities of infertility is poorly understood because there are many different measures of quality and effectiveness. Success of infertility treatment is generally described as cumulative pregnancy rate (andrological surgery, varicocele treatment, etc.) or pregnancy rate per treatment cycle (IVF, ICSI, IUI). For ART it is important to be aware of the complexweave of secondary issues to consider such as neonatal outcome, short- and long-term infant morbidity and maternal complications, all of which are closely linked to the higher incidence of multiple pregnancies. Consequently, ART (especially IVF and ICSI) account for 0.4-0.8% of the total health care costs in the USA. © 2006 Springer-Verlag Berlin Heidelberg.