Editing Infertility: Management (section)

===Assisted Reproductive Technology===
====Indications====
#'''Surgically unreconstructable obstruction such as congenital absence of the vas deferens'''
#'''Few viable sperm in the ejaculate'''
#'''Azoospermia with varicoceles (half of these men will respond to varicocelectomy with return of enough sperm to ejaculate to achieve pregnancy using In-vitro Fertilization (IVF) with/out Intracytoplasmic Sperm Injection (ICSI)'''
#'''Non-obstructive azoospermia'''
#'''Idiopathic infertility'''
====Options====
*'''<span style="color:#ff0000">Intrauterine insemination (IUI)'''
*'''<span style="color:#ff0000">In-vitro Fertilization (IVF) with/out Intracytoplasmic Sperm Injection (ICSI)'''
====Intrauterine insemination (IUI)====
*'''Technique'''
**'''<span style="color:#ff0000">Involves processing a semen specimen and placing the low volume washed semen into the uterine cavity at the time of ovulation'''
**May be done with or without ovarian stimulation of the female partner to enhance oocyte production
***Pregnancy rates with IUI are increased in couples with abnormal semen parameters if the woman undergoes ovulation induction.
****In men with male factor infertility due to abnormal semen parameters, natural cycle intracervical or intrauterine insemination (IUI) is no better than timed vaginal intercourse.
*****Natural cycle refers to allowing the woman to ovulate on her own without pharmaceutical induced stimulation of the development of multiple follicles through ovulation induction.
*****Natural cycle IUI is useful in infertility caused by mechanical problems such as hypospadias, retrograde ejaculation, impotence, or pure cervical factor infertility.
*'''Males with low total motile sperm count (<5 million motile sperm after processing) are expected to have lower pregnancy rates after IUI than using sperm from men with normal total motile sperm counts.[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**Since approximately 50% of sperm do not survive semen processing, a total motile count of at least 5 to 10 million sperm is usually required to allow for an adequate number of motile sperm for insemination.[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]
====In-vitro Fertilization (IVF) with/out ICSI====
*'''<span style="color:#ff0000">In IVF, the egg and sperm (of which there are multiple) are left in a petri dish to fertilize on their own. In ICSI, one sperm is directly injected into the egg.'''
*'''ICSI minimizes any adverse effects of sperm “quality” as measured by sperm concentration, motility, and morphology as long as viable sperm are present to inject into all oocytes'''
**With IVF, abnormal sperm motility and morphology adversely affect fertilization rates. The application of ICSI during IVF treatment provided fertilization rates comparable to that observed with otherwise normal sperm
*Requires only a small number of motile sperm, compared to IUI[https://pubmed.ncbi.nlm.nih.gov/33295257/ §]
*Involves limited medical risk to the female partner
*IVF treatment requires more than a week of ovarian stimulation, procedures for oocyte retrieval and intrauterine embryo transfer
*Couple may need to undergo several cycles of IVF treatment in order to achieve a pregnancy
**Each attempt typically allows for a 33% live delivery rate per initiated IVF cycle
***Pregnancy and live birth results are closely related to female age, with progressively lower success with increased female age (>35 years)
***≈19% of all deliveries involve twins
*'''In men undergoing surgical sperm retrieval, either fresh or cryopreserved sperm may be used for ICSI[https://pubmed.ncbi.nlm.nih.gov/33295257/ ★]'''
**A meta-analysis evaluating the use of sperm from men with NOA found no significant differences in fertilization, pregnancy, or live birth rates from ICSI in men for whom sperm was extracted and used with or without cryopreservation, as long as there were sperm of adequate number and survived cryopreservation and thawing.[https://pubmed.ncbi.nlm.nih.gov/29785532/]