Assisted Reproductive Techniques (ART)

By Fady I. Sharara, MD, FACOG

Virginia Center for Reproductive Medicine

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Assisted Reproductive Techniques (ART)

Part 1

The traditional definition of infertility is the failure to conceive after 12 months of trying. Roughly 10-15% of couples of reproductive age suffer from infertility. The causes of infertility include a female factor in 40% of couples, a male cause in 40%, and a combination of both in 20%. This however depends on age, and the incidence of infertility increases with increasing age. For instance, the incidence of infertility is 10% in women less than 30 but increases to at least 25% by age 40, and therefore a 40-year-old woman does not have the luxury of time to attempt to conceive for a year before asking for help. A three months wait is more reasonable in this instance.

The most common mistake that couples suffering from infertility (and some of their physicians) make is to procrastinate the treatment of the underlying cause, or to perform futile ineffective treatments that will only waste time, energy and money. It is therefore crucial that infertile couples are aware of the precise diagnosis behind their infertility and understand the approach taken by her/his physician to treat the condition. Quick referral to a fertility specialist ensures an expedited course of action.

In part I of this series, I will review the male factor; one of the most common causes of infertility where the most appropriate treatment is the use of assisted reproductive technologies (ART). ART involves advanced treatment involving in-vitro fertilization and intracytoplasmic sperm injection (ICSI).

The Sperm Factor

The male is responsible for about 40% of cases of infertility. The initial screening evaluation of the male should be performed early in the infertility work-up. A semen analysis is the most important test to start the investigation of the infertile couple. There are three important variables that one looks at when evaluating the sperm

1) Count the number of sperm present in the ejaculate.

2) Motility the ability and percentage of the sperm moving forward.

3) Morphology the shape of the sperm head and tail.

Any major abnormalities involving any of these variables could result in lowering the chances of conception. Unfortunately, the cause of most sperm abnormalities cannot be determined or treated successfully with simple therapy. On the other hand, advances in reproductive treatments, such as in vitro fertilization (IVF) and specifically intracytoplasmic sperm injection (ICSI), have revolutionized the treatment of male factor infertility. Today, the prospect of a successful outcome in couples suffering from this type of infertility is excellent.

The traditional treatment of intrauterine insemination (IUI) is not the best way to treat moderate or severe male factor infertility. There is a false impression that “washing sperm” for IUI improves the quality of the sperm. All it does is separate the portion of the sperm that is of “better quality” but actually the absolute number of “good sperm” not only does not increase but it might even decrease during the actual washing process.

There is however a place for IUI treatments. Some of these indications include abnormal cervical mucus, problems with erection or intercourse, mild male factor, problems with timing of intercourse, or when used in combination with fertility hormones treatment for better timing. Men with moderate or severe male factor should move directly towards IVF with ICSI. Another group that requires ART includes men who had a prior vasectomy or failed a vasectomy reversal.