Traditional management of infertility in the era of in vitro fertilization

Abstract

Purpose: The efficacy of assisted reproductive technology has improved significantly over the past decade. Due to lifestyle changes and sociological factors couples are delaying childbirth and resorting to the treatment of assisted reproductive technology. In spite of the success of IVF, traditional management of infertility has still a role to play. Recent findings: Expectant management and treatment with clomiphene should be the first line of management in couples with unexplained infertility where the cause for infertility cannot be detected. IUI with superovulation has been successful in some couples, but the risk of multiple pregnancies should be kept in mind. WHO guidance for semen analysis is still the method of choice to investigate male infertility. Hysterosalpingographyor sonohysterography can replace diagnostic hysteroscopy and diagnostic laparoscopy as a diagnostic tool in majority of patients with infertility. Operative hysteroroscopic procedures like myomectomy, polypectomy, metroplasty, and dissection of intrauterine adhesions can be performed when intrauterine pathology is detected. Tubal surgeries like tubal anastomosis, salpigostomy, and fimbrioplasty have a definite role to play in addition to other surgeries done to enhance the in vitro fertilization outcome. Endometriomas >4 cm need to be operated and a higher pregnancy rate has been found with laparoscopic excision rather than the popular methods of laparoscopic stripping, ablation or fenestration. The surgical mode of treatment for endometriosis has a limited place, like in conditions of chronic pelvic pain and whenever there is difficulty in follicular aspiration due to dense adhesions in IVF treatment. Inadvertent excision of healthy ovarian tissue is the most common complication of surgeries for ovarian endometriomas. Conclusion: In the present era of IVF there is still place for expectant management, ovulation inducing drugs, and limited place for laparoscopy and hysteroscopy surgeries before subjecting the infertile patients for IVF treatment.