General Infertility: Infertility Causes, Testing and Treatment
Infertility is a disease of the reproductive system that impairs one of the body’s most basic functions: the conception of children. Conception is a complicated process that depends upon many factors: on the production of healthy sperm by the man and healthy eggs by the woman; unblocked fallopian tubes that allow the sperm to reach the egg; the sperm’s ability to fertilize the egg when they meet; the ability of the fertilized egg (embryo) to become implanted in the woman’s uterus; and sufficient embryo quality. Infertile couple are the ones who have failed to conceive after 12 months of regular sexual intercourse without the use of contraception.
( A ) Common Causes of Infertility in Female :
- Advancing maternal age: Delaying child birth until thirties and forties has unmasked the adverse effect of ageing on egg number and quality or the likelihood of an egg being genetically normal, decreases as well. This decline in fertility starts in late twenties and is rapid after age of 36 years. A woman is rarely fertile beyond the age of 45.
- Ovulation disorders: Ovulation is the monthly release of a mature egg. Ovulation disorders can be due to:
- PCOS (polycystic ovary syndrome) – the woman’s ovaries function abnormally, ovulates infrequently
- Hypogonadotropic hypogonadism (from signaling problems in the brain)
- Hyperprolactinemia – high prolactin hormone levels affects ovulation and fertility.
- Premature ovarian failure – the woman’s ovaries stop working before she is 35
- Poor egg quality – older women or women with poor reserves have eggs that are damaged or develop genetic abnormalities and hence cannot sustain a pregnancy.
- Thyroid gland malfunction
- Some chronic medical conditions,
- Tubal occlusion (blockage): History of sexually transmitted infections including chlamydia, gonorrhea, or pelvic inflammatory disease or surgery can predispose a woman to having blocked fallopian tubes. If a tube is blocked and filled with fluid (called a hydrosalpinx), then minimally invasive surgery (laparoscopy or hysteroscopy) to either remove the tube or block/separate it from the uterus prior to any fertility treatments is recommended.
- Endometriosis: Endometriosis is a condition whereby cells very similar to the ones lining the uterine cavity, or endometrium, are found outside the uterine cavity. It is found in approximately 10-50% of reproductive-aged women causes pain and infertility by distorting the pelvic anatomy by inflammation and scarring, decreasing ovarian reserve, having detrimental effect on egg and embryo quality.
- Uterine Fibroids: approximately 40% of women may have them but they need not necessarily cause infertility. Only the ones lying majorly in the uterine cavity or large one occupying the wall elongating or distorting the cavity contribute significantly to infertility and warrant removal.
( B ) Common Causes of Infertility in Male :
Sole cause of infertility in one third and contributory in another one third with female factor. Abnormal semen is responsible for about 75% of all cases of male infertility. The following semen problems are possible:
- Low sperm count (low concentration) – Sperm concentration should be 15 million sperm per milliliter of semen.
- No sperm – Azoospermia – absent sperms in the ejaculate
- Low sperm mobility (motility > 40%) – the sperm cannot “swim” as well as it should.
- Abnormal sperm – If sperm has an unusual shape, making it difficult to move and fertilize an egg. Sperm must be the right shape and able to travel rapidly and accurately towards the egg. If the sperm’s morphology (> 4 % by Strict Kruger’s Criteria) and motility (movement) are poor it is less likely to be able to reach the egg and fertilize it.
Causes of abnormal semen
- Overheating the testicles – frequent saunas, hot tubs, very hot baths, or working in extremely hot environments can raise the temperature of the testicles. Tight clothing may have the same effect on some people
- Ejaculation disorders , Hypospadias ,Undescended testicle
- Hypogonadism – testosterone deficiency can result in a disorder of the testicles.
- Mumps – this viral infection usually affects young children. However, if it occurs after puberty inflammation of the testicles may affect sperm production.
- Testicular cancer and Testicular surgery ,Radiotherapy
- Some diseases Cushing’s syndrome, Diabetes, Thyroid disease.
Sulfasalazine – this anti-inflammatory drug can significantly lower a man’s sperm count. The drug is often prescribed for patients with Crohn’s disease or rheumatoid arthritis. Usually this side effect goes away after the patient stops taking the medication.
Anabolic steroids – often taken by bodybuilders and athletes; anabolic steroids, especially after long term use can seriously reduce sperm count and mobility.
Chemotherapy – some medicines may significantly reduce sperm count.
- Illegal drugs – consumption of marijuana and cocaine can lower a man’s sperm count.
( C ). Unexplained: Sometimes a full evaluation does not reveal the cause of infertility. This occurs approximately 15% of the time. Thankfully, even when the cause of infertility is not known, various fertility treatments options are available.
Evaluation Of Infertile Couple
History and physical examination if history is indicative.
Semen analysis : Semen sample is analysed for volume, sperm count, percentage motility and morphological appearance and other physical & biochemical parameters. An abnormal semen analysis warrants further investigation -hormonal profile, Ultrasound scrotum, genetic testing as the case may be.
Relevant history about menstruation, pregnancy, sexual history, and physical examination with baseline investigations required before being able to carry pregnancy.
Hormonal evaluation: As history would indicate, to confirm ovulation, test for ovarian reserve
Hysterosalpingography – for tubal evaluation wherein fluid is injected into the woman’s uterus which shows up in X-ray pictures. X-rays are taken to determine whether the fluid travels properly out of the uterus and into the fallopian tubes and established its patency
Pelvic ultrasound – To evaluate uterus, endometrial lining, ovaries and its reserve and other pelvic abnormality if any.
Laparoscopy & Hysteroscopy – a thin, flexible tube with a camera at the end is inserted into the abdomen and pelvis to diagnose and correctabnormalities relating to the fallopian tubes, uterus and ovaries. It is done if indicated by pelvic ultrasound, Hysterosalpingography or in some cases of unexplained infertility
- Counselling about treatment options and its realistic chances of success in the incipient couple depending upon the investigation forms an important part of management.
- Surgery – After a thorough history, physical examination, and ultrasound are performed, your doctor may recommend surgery to correct and abnormality. In reproductive medicine, the most common surgical procedures are laparoscopy, hysteroscopy, and myomectomy (removal of uterine fibroids )
- Ovulatory Factors: The medications that help stimulate the ovary to develop mature eggs for ovulation come in two forms: pills taken by mouth and injections. The most commonly prescribed pill to stimulate ovulation (generally of one mature egg) is clomiphene citrate. This pill generally is taken from menstrual cycle days 2 – 7. The most commonly prescribed injections that stimulate the ovary are called Gonadotropins. The gonadotropins in these formulations are either FSH or HMG ( a combination of FSH and LH )They act directly on the cells of the ovary to stimulate egg development. Once a follicle containing an egg reaches a mature size, another hormone injection called HCG is often given to mimic the natural LH surge that occurs at the time of ovulation. This leads to the final maturation and release of the egg
- Intrauterine insemination, also known as IUI, is a process by which sperm is washed and prepared for placement into the uterine cavity, therefore bypassing the cervix and bringing a higher concentration of motile sperm closer to the tubes and ovulated egg. These washed motile and viable sperm are then placed in a very small amount of media, and then very gently and painlessly injected into the uterine cavity using a very thin, soft, and flexible catheter..
- In Vitro Fertilization (IVF): In vitro means “outside the body.” IVF is a process whereby eggs are collected and then fertilized by sperm outside the body, in an embryology laboratory. The first IVF baby was born in 1978 in England. IVF involves removal of eggs directly from the ovary, fertilization with sperm in the laboratory, followed by transfer of the embryos directly into the uterus, thereby bypassing the tubes. Although tubal disease was the original indication for IVF, many more indications have developed over the years.
- Intracytoplasmic sperm injection , ICSI is a process by which semen is washed and prepared for direct injection of one sperm into each egg collected during the IVF process.This process bypasses the normal fertilization process, which may be compromised due to poor sperm function.
- Third party reproduction: This is a general reference to a process where another person provides sperm or eggs, or where another woman acts as a gestational surrogate, with the purpose of helping another couple have a child. The four types of third party reproduction are 1) sperm donation; 2) egg or ovum donation; 3) embryo donation 4) gestational surrogacy – a process where another woman will undergo an embryo transfer and carry the pregnancy for the couple who have provided Eggs and Sperms.
Dr K D Nayar
MD, DGO, Dip Obst ( Ireland)
Director & Chief Consultant Akanksha IVF Centre
Mata Chanan Devi Hospital
C-1 Janakpuri Delhi.