Subfertility in the era of assisted reproduction: changes and consequences.

OBJECTIVE

To review the major changes that have occurred during the last decade of assisted reproduction technology (ART) practice, looking at the various conditions that cause subfertility.

DESIGN

A short review describing the progress that has been made during the last decade of ART practice, analyzing the various conditions that cause subfertility, is presented. The efficacy of ART as a treatment of these conditions is discussed.

CONCLUSIONS

Assisted reproductive technology currently is used for a wide range of indications and has become an acceptable tool in the treatment of subfertile couples. Yet, there is an ongoing debate regarding the effectiveness of ART versus conventional treatment for the various conditions that cause subfertility. The effectiveness of IVF in terms of pregnancy rate (PR) was demonstrated only for patients with severe bilateral tubal disease and male subfertility. For couples with other causes of infertility the differences in PRs do not reach statistical significance, and the efficacy of IVF has not been demonstrated clearly to date. Moreover, much of the discussion about management of subfertility has centered on costs of ART and the cost-benefit of ART versus conventional therapy for subfertility. It has been shown that, in women with unexplained infertility, menotropin treatment is as successful, less expensive, and carries a smaller risk than the surgical approach used in ART. However, the exact role of ART in the management of polycystic ovarian syndrome, immunological infertility, and endometriosis still is to be determined. Yet, as embryo implantation after ART still is considerably lower than that of fertile couples who conceive naturally, we expect that the next major thrust improving the effectiveness of ART will occur after future elucidation of factors influencing embryonic implantation.