Human Reproduction vol.7 suppl.l pp.115-121, 1992
Indications for in-vitro fertilization and results
K. Diedricb, S. Al-Hasani, H. van der Ven, O. Bauer, A. Werner, D. Krebs Universitfits-Frauenklinik, Sigmund-Freud StraBe 25, 5300 BonnVenusberg, Germany
During the last few years, many healthy children have been born after in vitro fertilization and embryo transfer, fulfilling the wish for a child for many couples who had often nearly given up hope. Because of in vitro fertilization and other related methods developed subsequently (gamete intra-Fallopian transfer, intratubal embryo transfer), progress in the diagnosis and treatment of involuntary childlessness took place and has helped many patients. Furthermore, by dealing with these methods, new knowledge about ovarian function, fertilization and early embryonic development could be gained. This has also led to better treatment of childless couples. Despite the broad diagnostic and therapeutic possibilities of reproductive medicine, its limits must also be taken into account These limitations have been recognized early by physicians and scientists dealing with this subject and also by society. Guidelines and laws have been drawn up which now give a clear framework.
Introduction
The developments of the last 15 years in the field of reproductive medicine offer the possibility of treating patients for whom there has previously been no chance of adequate therapy to fulfil their wish for a child. In addition to the hope arising from in vitro fertilization (IVF) and embryo transfer, and the other treatment regimes - gamete intra-Fallopian transfer (GIFT) and embryo intra-Fallopian transfer (EIFT) - these methods have significantly broadened our knowledge of reproductive events and have decisively influenced the modern treatment of patients wishing for a child. We will outline these methods of treatment in reproductive medicine. The indications for treatment will be presented and the results listed and discussed. In Vitro Fertilization and Embryo Transfer
In 1978, the first child was born after in vitro fertilization and embryo transfer (Steptoe and Edwards, 1978). In this way a new method of treatment was presented for infertility which had so far been untreatable. Since then, in vitro fertilization has become an effective and widely used therapy for infertile couples. Indications
The decision to use IVF to treat an infertile couple is made only © Oxford University Press
in the absence of a better and more promising possibility. Even nowadays, the low chance of success has to be taken into account. There is a definite indication for IVF for those couples where the natural place of fertilization, the Fallopian tube, is not functioning or has been removed. Disturbance of tubal function is one of the most common causes of involuntary childlessness, the literature gives a frequency of 20% to 40% (Doring et al., 1970; Dor et al., 1977; Schirren et al., 1989; Schlosser et al., 1986). The main reason for tubal infertility is inflammation of the pelvis by ascending bacteria, endometriosis and peritubal adhesions caused by operations, intrauterine contraceptive devices or ectopic pregnancies. Tubal infertility is treated either by microsurgical reconstruction (Decleer et al., 1990) or by in vitro fertilization and embryo transfer. Different criteria have to be taken into account and the therapy should be chosen which leads prospectively and quickly to pregnancy and birth. It is possible to state the success rate per treatment cycle when using IVF in spite of the heterogeneity of patients and indications, whereas this is almost impossible for microsurgical operations. For a successful operation, the size and type of the tubal defect, the experience of the surgeon and the technique used are very important. Therefore, it is almost impossible to state a success rate for all indications. Additional factors influencing the decision are the age of the patient, the duration of infertility, the possible danger of tubal pregnancy and the attitude of the patient towards the new treatments. While counselling and selecting patients for the different treatment regimes, prognostic criteria from the literature based on the success rate after IVF and microsurgery should not be used, but the possibilities in the individual hospital should be taken into account. Therefore, an accepted standard for the success rates of both treatment methods in one hospital should be reached for use in counselling patients. If microsurgury is considered to two to three cycles of IVF for the patient (Decleer et al, 1990), microsurgery is recommended for reversal of sterilization, thin walled hydrosalpinx, fimbrioplasty, and minimal to mild adhesions; IVF is recommended for salpingectomy on both sides, many pelvic adhesions (frozen pelvis), combined tubal block with fibrosis of the wall and tubal infertility after microsurgical operation. Table 1 shows the pregnancy rates after microsurgery versus IVF in patients with tubal infertility. The results of the different tubal operations are taken from the literature. The pregnancy rate of 42% per patient after in vitro fertilization and embryo transfer with a mean of 2.4 follicular puncture procedures comes from the University of Bonn. This comparison is a good basis for decision-making when counselling couples with tubal infertility. When dealing with an andrological disturbance, the gynaecol115
K-Diedrich at at
MALE INFERTILITY
Table 1. Microsurgery versus in vitro fertilization: pregnancy rates per patient. Results from the University of Bonn (Decleer, 1987)
3 - 6 treatment cycles ovarian stimulation/ftyperstlmulation
Pregnancy rate I. Microsurgery: Salpingostomy, Adhesiolysis Reanastomosis Fimbriectomy+tubes
Indications for in-vitro fertilization and results
K. Diedricb, S. Al-Hasani, H. van der Ven, O. Bauer, A. Werner, D. Krebs Universitfits-Frauenklinik, Sigmund-Freud StraBe 25, 5300 BonnVenusberg, Germany
During the last few years, many healthy children have been born after in vitro fertilization and embryo transfer, fulfilling the wish for a child for many couples who had often nearly given up hope. Because of in vitro fertilization and other related methods developed subsequently (gamete intra-Fallopian transfer, intratubal embryo transfer), progress in the diagnosis and treatment of involuntary childlessness took place and has helped many patients. Furthermore, by dealing with these methods, new knowledge about ovarian function, fertilization and early embryonic development could be gained. This has also led to better treatment of childless couples. Despite the broad diagnostic and therapeutic possibilities of reproductive medicine, its limits must also be taken into account These limitations have been recognized early by physicians and scientists dealing with this subject and also by society. Guidelines and laws have been drawn up which now give a clear framework.
Introduction
The developments of the last 15 years in the field of reproductive medicine offer the possibility of treating patients for whom there has previously been no chance of adequate therapy to fulfil their wish for a child. In addition to the hope arising from in vitro fertilization (IVF) and embryo transfer, and the other treatment regimes - gamete intra-Fallopian transfer (GIFT) and embryo intra-Fallopian transfer (EIFT) - these methods have significantly broadened our knowledge of reproductive events and have decisively influenced the modern treatment of patients wishing for a child. We will outline these methods of treatment in reproductive medicine. The indications for treatment will be presented and the results listed and discussed. In Vitro Fertilization and Embryo Transfer
In 1978, the first child was born after in vitro fertilization and embryo transfer (Steptoe and Edwards, 1978). In this way a new method of treatment was presented for infertility which had so far been untreatable. Since then, in vitro fertilization has become an effective and widely used therapy for infertile couples. Indications
The decision to use IVF to treat an infertile couple is made only © Oxford University Press
in the absence of a better and more promising possibility. Even nowadays, the low chance of success has to be taken into account. There is a definite indication for IVF for those couples where the natural place of fertilization, the Fallopian tube, is not functioning or has been removed. Disturbance of tubal function is one of the most common causes of involuntary childlessness, the literature gives a frequency of 20% to 40% (Doring et al., 1970; Dor et al., 1977; Schirren et al., 1989; Schlosser et al., 1986). The main reason for tubal infertility is inflammation of the pelvis by ascending bacteria, endometriosis and peritubal adhesions caused by operations, intrauterine contraceptive devices or ectopic pregnancies. Tubal infertility is treated either by microsurgical reconstruction (Decleer et al., 1990) or by in vitro fertilization and embryo transfer. Different criteria have to be taken into account and the therapy should be chosen which leads prospectively and quickly to pregnancy and birth. It is possible to state the success rate per treatment cycle when using IVF in spite of the heterogeneity of patients and indications, whereas this is almost impossible for microsurgical operations. For a successful operation, the size and type of the tubal defect, the experience of the surgeon and the technique used are very important. Therefore, it is almost impossible to state a success rate for all indications. Additional factors influencing the decision are the age of the patient, the duration of infertility, the possible danger of tubal pregnancy and the attitude of the patient towards the new treatments. While counselling and selecting patients for the different treatment regimes, prognostic criteria from the literature based on the success rate after IVF and microsurgery should not be used, but the possibilities in the individual hospital should be taken into account. Therefore, an accepted standard for the success rates of both treatment methods in one hospital should be reached for use in counselling patients. If microsurgury is considered to two to three cycles of IVF for the patient (Decleer et al, 1990), microsurgery is recommended for reversal of sterilization, thin walled hydrosalpinx, fimbrioplasty, and minimal to mild adhesions; IVF is recommended for salpingectomy on both sides, many pelvic adhesions (frozen pelvis), combined tubal block with fibrosis of the wall and tubal infertility after microsurgical operation. Table 1 shows the pregnancy rates after microsurgery versus IVF in patients with tubal infertility. The results of the different tubal operations are taken from the literature. The pregnancy rate of 42% per patient after in vitro fertilization and embryo transfer with a mean of 2.4 follicular puncture procedures comes from the University of Bonn. This comparison is a good basis for decision-making when counselling couples with tubal infertility. When dealing with an andrological disturbance, the gynaecol115
K-Diedrich at at
MALE INFERTILITY
Table 1. Microsurgery versus in vitro fertilization: pregnancy rates per patient. Results from the University of Bonn (Decleer, 1987)
3 - 6 treatment cycles ovarian stimulation/ftyperstlmulation
Pregnancy rate I. Microsurgery: Salpingostomy, Adhesiolysis Reanastomosis Fimbriectomy+tubes
