Various infertility treatment options such as intrauterine insemination (IUI) and in vitro fertilization (IVF) can be offered to patients. However, before giving recommendations, doctors need to know which is the most suitable treatment type for each patient's condition. Infertility caused by different conditions can require different treatment types.

Infertility Treatment Options for Men and Women
image source: https://www.austinfertility.com



According to the WHO definition, infertility is a reproductive system disease characterized by failure to achieve pregnancy after a partner has had regular (unprotected) coitus for 12 months or more.


Causes of Infertility

The most common causes of infertility in women are:
  1. ovarian dysfunction with anovulation (25–35%), 
  2. fallopian tube abnormalities (20–25%), 
  3. endometriosis (10–20%), 
  4. uterine pathologies such as uterine myoma (5–10%) and unexplained infertility. (20–30%). 

In men, more than 90% of infertility cases are caused by low sperm count, poor sperm quality, or a combination of both.


Infertility Treatments

Preparation Before Infertility Treatment

Before doing infertility treatment, it is necessary to make an informed shared-decision making. Doctors need to inform the patient about infertility-related matters completely and inform the available treatment options to get the most suitable treatment. Doctors need to recommend specific infertility treatments based on:

Factors that contribute to infertility:

  • The duration of infertility
  • Age
  • The couple chooses the treatment method after getting information about the success rate, benefits, and risks.

Infertility treatment includes managing any conditions that may interfere with fertility, conception, and pregnancy resistance. For example, if a patient has HIV infection, Chlamydia trachomatis, rubella, or toxoplasmosis, these infections must be treated first before undergoing further treatment.


A. Non-invasive Treatment Methods for Infertility

Non-invasive treatment Methods for Infertility are:
  1. healthy lifestyle counseling,
  2. tracking the ovulation cycle,
  3. ovulation induction,
  4. and intrauterine insemination (IUI).

A sperm donor program can also be considered if needed and agreed upon by the patient.

1. Healthy Lifestyle Counseling
Instruct the patient not to smoke and consume no more than 1-2 units of alcohol per week. Patients should maintain a healthy diet and exercise for cardiovascular health for about 20-30 minutes per day.

Advise obese patients to undergo a weight loss program. Instruct female patients to take 0.4 mg of folic acid as a daily supplement and increase the dose to 5 mg if they have a history of giving birth to a baby with spina bifida or taking epilepsy drugs.

2. Tracking the Ovulation Cycle
Teach patients how to recognize their fertile period by tracking luteinizing hormone (LH) levels to predict when ovulation will occur. LH levels in the urine will usually increase 24-48 hours before ovulation.

Provide patients with a detector for increased LH levels in urine so they can do this at home themselves. This tracking will provide the best opportunity for the couple to have coitus and experience fertilization naturally.

3. Ovulation Induction
Do ovulation induction if the patient has ovulatory dysfunction. Give her ovulation stimulation drugs such as:
  • clomiphene citrate,
  • letrozole, 
  • human menopausal gonadotropin (hMG), 
  • follicle-stimulating hormone (FSH), 
  • gonadotropin-releasing hormone (GnRH), 
  • metformin, 
  • bromocriptine.

4. Intrauterine Insemination
Intrauterine insemination and IVF methods are preferred for:
  • patients with unexplained infertility, 
  • for women with minimal endometriosis, 
  • and for men with Oligoasthenozoospermia.
Although further investigation is needed, a Cochrane meta-analysis suggested that IUI may increase the cumulative live birth rate compared to timed intercourse with ovarian hyperstimulation.

5. Sperm Donors
Advise the patients to undergo insemination using donor sperm if:
  • the patient (male) has azoospermia, 
  • HIV infection, 
  • or has severe infertility problems but refuses to undergo in vitro fertilization (IVF) with intracytoplasmic sperm injection (ICSI).


B. Invasive Treatment Methods for Female Infertility

For infertility cases in women, invasive treatment methods are:
  1. tubal surgery,
  2. uterine surgery,
  3. IVF, 
  4. Assisted Hatching,
  5. Gamete intrafallopian transfer (GIFT) and Zygote intrafallopian transfer (ZIFT),
  6. and oocyte donors.

1. Tubal Surgery
Recommend selective salpingography with catheterization or hysteroscopic tube cannulation to women with proximal tubal obstruction. Because it is thought to increase the chances of getting pregnant. Advice the Women with hydrosalpinges to undergo laparoscopic salpingectomy before undergoing IVF.

2. Uterine Surgery
Women who develop amenorrhoea with intrauterine adhesions may be advised to undergo hysteroscopic adhesiolysis. It can increase their chances of becoming pregnant. Uterine surgery can also be performed in cases of endometriosis and fibroids. However, the effect of fibroid surgery on fertility needs further study. 

3. IVF
Perform the IVF (in vitro fertilization) method if the patient has fallopian tube problems or has unexplained infertility.

IVF can be done using the regular embryo transfer (ET) method or the frozen embryo transfer (FET) method. At the FET, some embryos obtained from the IVF cycle are frozen and stored for future use. If necessary, these frozen embryos will be removed from the storage area, warmed, and transferred into the recipient's uterus.

The effectiveness of the FET is controversial. Studies report that babies born using this method are significantly premature or have low birth weight. However, in general, IVF is the most rational method for unexplained infertility for women with minimal endometriosis and for men with oligoasthenozoosperm (if the wife is young). IVF is especially recommended for patients who have attempted to experience natural conception for two years but have failed.

4. Assisted Hatching
This method involves using a laser beam, mechanical means, or chemicals to attenuate the zona pellucida. This zone thinning is carried out mainly in older women, thinking that the zone's thickness may hinder implantation. Patients who can undergo this method are patients over 38 years of age who have undergone IVF and FET but failed. 

5. Gamete Intrafallopian Transfer and Zygote Intrafallopian Transfer
This procedure can be an option other than IVF, but its effectiveness in unexplained infertility and male infertility cases still does not have a strong evidence base.

6. Oocyte Donor
Indications of Oocyte Donor are a premature ovarian failure, gonadal dysgenesis, ovarian failure after chemotherapy or radiotherapy, or if the case is judged to fail by IVF. An oocyte donor may also be recommended for patients who have undergone bilateral oophorectomy.


C. Invasive Treatment Methods for Male Infertility

Invasive treatment methods for men include:
  1. microsurgery or restoration surgery for ductal patency, 
  2. Sperm Retrieval
  3. intracytoplasmic sperm injection (ICSI), 
  4. and the high digital manifestation of sperm methods.

1. Microsurgery or Restoration Surgery for Ductal Patency
This method is for patients with:
a history of vasectomy,
patients who need to bypass epididymal blockade, such as patients with obstructive azoospermia,
and patients with ejaculatory duct obstruction. 

Surgery for varicocele cases does not always result in improved semen quality, but it can be given as an option to patients because it can be useful in some patients. This micro and reconstructive surgery will largely depend on the cause and location of the obstruction. If surgery is not possible, sperm retrieval may be an option.

2. Sperm Retrieval
There are various methods of sperm retrieval MESA, TESE, and TESA. 
a. Microsurgical epididymal sperm aspiration (MESA) involves open surgery under a microscope to search the epididymal tubules and collect large sperm amounts. 
b. Perform Testicular sperm extraction (TESE) in obstructive azoospermia and nonobstructive azoospermia. The sperm is taken directly from the testes. 
c. Testicular sperm aspiration (TESA) is another option for taking sperm directly from the testicles with fine-needle aspiration.

3. Intracytoplasmic Sperm Injection (ICSI)
ICSI is part of the IVF procedure. The doctor injects a single sperm into an egg to aid in fertilization using a tiny micromanipulation device. Performing this method can with or without a preimplantation genetic diagnosis (PGD). ICSI is the most common method for male severe infertility problems and repeated IVF cycle failures.

4. Digital High Magnification of Sperm
This method involves the IVF procedure as well as the ICSI. This method is performed on male patients who experience severe infertility due to abnormal sperm count or morphology. This method involves selecting the best sperm for injection into the egg using a sophisticated digital magnifying device to visualize a sperm image up to 7300 times its magnification.

The advantages of Digital High Magnification of Sperm are:
  • Increase the chance of fertilization
  • Increase the pregnancy rate
  • Reducing the rate of miscarriage in cases of severe male infertility

However, this method also has the disadvantage that sperm are selected in plain view (taken because of their physical appearance that looks good from the outside) and cannot detect sperm chromosomes. If there is a chromosomal disorder, the baby born will also be affected by the abnormal chromosome.



Conclusion
Various types of infertility treatment can be given to patients, ranging from non-invasive to invasive treatment methods. After the patient and partner have undergone the examination, the doctor needs to formulate a treatment plan that suits each individual's condition. Each cause of infertility will require a different type of treatment. Doctors need to inform patients of each treatment option's benefits and risks so that the patient and their partner can make an informed decision.