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A perspective view of the treatment of infertility
Modern
medical treatment of infertility commenced with the development of In
Vitro Fertilisation (IVF), and is still largely based on it. The
treatment comprises five main components: - stimulation of ovulation with hormones
- removal of eggs from the stimulated ovary
- preparation of a sample of viable sperm
- fertilisation and incubation of the eggs with the sperm
- replacement of (a number of) fertilised eggs in the womb
At
its best, this can achieve a 30% success rate at the first attempt,
rising to a cumulative total of around 50% over three cycles, after
which the success rate falls away rapidly. The procedure can prove
traumatic for the woman, due to psychological effects of the hormones,
and the fact that egg removal is a significant surgical procedure
requiring general anaesthesia and an overnight hospital stay. Moreover,
IVF is costly, typically around £4,000 per cycle in the UK, and
$10,000 in the USA. For these multiple reasons, both patients and
doctors are reluctant to use it as soon as a couple seeks help.
Up
till now few suitable methods of establishing the cause of infertility
have been widely adopted. Often, a couple will progress from natural
attempts at conception, to ovarian stimulation, firstly using
Clomiphene and normal intercourse. If this fails then it is followed by
more vigorous stimulation with gonadotropins, usually with
Intra-uterine Insemination (IUI), in which a semen sample is processed
to sort viable from non-viable sperm and then inserted directly into
the uterus at the time of ovulation. Commonly between 3 and 5,
sometimes up to 10 cycles of IUI are tried, with the cumulative success
rate around 30% (except where donor sperm are used).
It should
be pointed out that stimulated IUI, while it may work for women whose
main problem is failure to ovulate, will not work for women who have
abnormalities of the reproductive organs (see below). These account for
25-30% of all female infertility. Generally, only when IUI has failed
is IVF attempted, and this is also without a detailed process of
diagnosis. Up to a point, this works, because IVF is able to overcome a
number of possible problems.
However, in fact many of the
problems that IVF is able to overcome are capable of being diagnosed
and treated much more simply, cheaply, and without distress to the
woman. The main problem is to identify them early on, and treat them
appropriately. The reason this does not happen is that the diagnostic
procedures normally used are very limited in their utility. In fact,
they are limited to an assessment of ovarian function. There is
generally no routine assessment of abnormality or disease of the upper
reproductive tract, even though this is a frequent cause of infertility.
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