Abstract and Introduction
Abstract
The concept of unilateral care of the female partner has gained momentum in the reproductive health community, especially with the advent of in vitro fertilization and intracytoplasmic sperm injection. Herein, the authors examine the existing evidence in support of evaluating and treating the male patient as part of the routine evaluation of the infertile couple. This evidence includes assessments of efficacy, cost-effectiveness, and safety, and--when considered broadly--argues strongly against unilateral care.
Introduction
Infertility is a common problem. Current data predict that 15% of couples will have difficulty initiating their first pregnancy. Infertile couples face uniquely difficult decisions with regard to reproductive choices, as the emotional toll of treating infertility can be immense. At the same time, recent advances in the field of reproductive biology have afforded new hope to couples that were previously unable to have children. The most important of these advances is the addition of intracytoplasmic sperm injection (IVF/ICSI) to the already effective procedure of in vitro fertilization (IVF).
IVF and IVF/ICSI allow couples with either male or female factor infertility to have children regardless of many of the known underlying causes. IVF/ICSI in particular allows for pregnancy even in those couples where a severe male factor exists. As a result of this fact, and as a by-product of the fact that fertility visits are often initiated by the female partner, the practice of modern assisted reproductive technology (ART) can oftentimes proceed without a complete evaluation of the male partner. Instead, almost any couple, after being evaluated by only a reproductive endocrinologist, can theoretically become pregnant using IVF/ICSI.
Recent reports have expanded upon this concept of unilateral reproductive care; both studies advocate limited evaluation of the male partner in infertile couples and increased use of assisted reproductive techniques. Importantly, although this argument rests upon several debatable hypotheses, including the absence of evidence-based literature in the field of male infertility and the "safety" of sperm extraction procedures performed by gynecologists or their staffs, it is important to keep in mind that these reports operate on the premise of trying to efficiently and safely help infertile couples achieve a greatly desired and important outcome: pregnancy. At first glance, this does not seem a problematic notion at all. If infertile couples can be afforded the opportunity to have a child in a time-efficient, cost-efficient, and safe manner, one might conclude that this event represents an ideal outcome. However, when one asks the question of whether the male patient even needs to be evaluated given the availability of IVF/ICSI, several simple, conceptual problems do present themselves. Indeed, a large volume of data exists that argues that failure to evaluate the male is (a) less safe for male patients, their partners, and their offspring and (b) less cost-efficient. Even the reality of time-efficiency in the immediate performance of IVF/ICSI for infertile couples can be argued against; for those couples who are able to conceive naturally and desire more children beyond their first pregnancy, the opportunity to avoid future need for ART of any sort will most certainly ultimately save patients time.
This article answers the question, "Why evaluate the male partner in the era of ART?" The text outlines the existing evidence in support of the idea that an evaluation of the male partner is mandated by both patient safety and cost-effectiveness. This data are summarized both with regard to IVF and IVF/ICSI; importantly, the World Health Organization International Committee for Monitoring ART (ICMART) does not include intrauterine insemination (IUI) in the category of ART. Despite this definition, some analysis of the cost-efficiency data regarding IUI is included in this report for the purposes of assessing the cost-efficiency of treating reversible causes of male infertility.