Infertility-epidemiology, aetiology and effective management.

Current epidemiological evidence suggests that 15% of couples will experience infertility and in half this number the problem will remain unresolved. Background prevalence rates now appear to be reasonably stable, but there is evidence of an increase in the rate of referrals for medical help. Rates of secondary infertility are higher in the population than represented by clinic referrals. The distribution of the main diagnostic groups is as follows: Male 25%; Ovulation 25%; Tubal 20%; Unexplained 25%; and Endometriosis 5%. Effective management in the male includes donor insemination and assisted reproduction (including intra-cytoplasmic sperm injection). Drugs are ineffective for idiopathic oligozoospermia, while the role of varicocele ligation is uncertain, but marginal at best. Ovulation problems can be treated with a high degree of success, except in cases of clomiphene resistant polycystic ovarian disease. However there are continuing concerns over multiple pregnancy rates and future research is needed to clarify the additional risks, if any, of ovarian carcinoma. Surgical correction of tubal abnormalities should be left to specialised units, where audit indicates that the results can match those achieved by assisted reproduction. There is no evidence that the medical (drug) management of endometriosis improves fertility, although surgery for moderate and severe disease can still be considered. However the results should be compared with those achieved by assisted reproduction. Superovulation and intra-uterine insemination appears to be an effective treatment for certain cases of mild male factor infertility, mild endometriosis and unexplained infertility and can be considered, where the duration of infertility is more than four years. A pregnancy rate of around 10% per cycle can be anticipated, but there is a significant risk of multiple pregnancy. The evidence is that IVF (and GIFT) has achieved significantly improved results in recent years, with fecundity rates of 20% per cycle being a reasonable target in women under 40 years.