RHPRC-REPRODUCTIVE HEALTH PROGRAME for RURAL COMMUNITIES

TREATMENT OF INFERTILITY.

The treatment of infertility should be tailored to the problems unique to each couple. Even so, a woman above 30 years is treated hastily because the biological clock is closer to menopause and also because epidemiological studies have proven the increasing health risks associated with increased age of  mother at birth of the baby.

Ovulatory Dysfunction

Treatment of ovulatory dysfunction should first be directed at identification of the etiology of the disorder to allow specific management when possible. Dopamine agonists, for example, may be indicated in patients with hyperprolactinemia while life-style modification may be successful in women with low body weight or a history of intensive exercise.

Medications used for ovulation induction include clomiphene citrate, gonadotropins, and pulsatile GnRH.

1.       Clomiphene citrate is a nonsteroidal estrogen antagonist that increases FSH and LH levels by blocking estrogen negative feedback at the hypothalamus. The efficacy of clomiphene for ovulation induction is highly dependent on patient selection. It induces ovulation in 70 to 80% of women with PCOS and is the initial treatment of choice in these patients.

2.       Gonadotropins are highly effective for ovulation induction in women with hypogonadotropic hypogonadism and PCOS and are used to induce multiple follicular recruitment in unexplained infertility and in older reproductive-aged women. Disadvantages include a significant risk of multiple gestation and the risk of ovarian hyperstimulation, but careful monitoring and a conservative approach to ovarian stimulation reduce these risks.

3.       Pulsatile GnRH is highly effective for restoring ovulation in patients with hypothalamic amenorrhea .Pregnancy rates are similar to those following the use of gonadotropins, but rates of multiple gestation are lower and there is virtually no risk of ovarian hyperstimulation.

None of these methods are effective in women with premature ovarian failure in whom donor oocyte or adoption are the methods of choice.

Tubal Disease

If hysterosalpingography suggests a tubal or uterine cavity abnormality, or if a patient is ≥35 at the time of initial evaluation, laparoscopy with tubal lavage is recommended, often with a hysteroscopy. Although tubal reconstruction may be attempted if tubal disease is identified, IVF is often used instead, as these patients are at increased risk of developing an ectopic pregnancy.

Endometriosis

laparoscopic resection or ablation appears to improve conception rates even though most women with mild cases of endometriosis are capable of giving birth to babies within a year.

 Medical management of advanced stages of endometriosis is widely used for symptom control but has not been shown to enhance fertility.

In moderate to severe endometriosis, conservative surgery is associated with pregnancy although some patients prefer IVF as the treatment of choice.

 Though often effective, IVF is expensive and requires careful monitoring of ovulation induction and invasive techniques, including the aspiration of multiple follicles. IVF is associated with a significant risk of multiple gestation (31% twins, 6% triplets, and 0.2% higher order multiples).

Assisted Reproductive Technologies

The development of assisted reproductive technologies (ART) has dramatically altered the treatment of male and female infertility. IVF is indicated for patients with many causes of infertility that have not been successfully managed with more conservative approaches. IVF or ICSI is often the treatment of choice in couples with a significant male factor or tubal disease, whereas IVF using donor oocytes is used in patients with premature ovarian failure and in women of advanced reproductive age. Success rates depend on the age of the woman and the cause of the infertility.