BASICS OF INFERTILITY

Infertility refers to an inability to conceive after having regular unprotected sex. Infertility can also refer to the biological inability of an individual to contribute to conception, or to a female who cannot carry a pregnancy to full term. In many countries infertility refers to a couple that has failed to conceive after 12 months of regular sexual intercourse without the use of contraception.

Studies indicate that slightly over half of all cases of infertility are a result of female conditions, while the rest are caused by either sperm disorders or unidentified factors.

Chances of conceiving within one year

In Europe, North America and much of the world approximately 85% of couples will conceive within one year if they have regular unprotected sex. Research has shown that;

  • 20% will conceive within one month
  • 70% will conceive within six months
  • 85% will conceive within 12 months
  • 90% will conceive within 18 months
  • 95% will conceive within 24 months.

Therefore, doctors will not usually diagnose a couple as infertile until 24 months have passed without conception and regular unprotected sex.

Infertility tests for women

·         General physical exam: the doctor will ask the woman about her medical history, medications, menstruation cycle, and sexual habits. She will also undergo a gynecological examination.
·         Blood test: several things will be checked, for example, whether hormone levels are correct and whether the woman is ovulating (progesterone test).
·         Hysterosalpingography: 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. If the doctor identifies any problems, such as a blockage, surgery may need to be performed.
·         Laparoscopy: a thin, flexible tube with a camera at the end (laparoscope) is inserted into the abdomen and pelvis to look at the fallopian tubes, uterus and ovaries.
A small incision is made below the belly button and a needle is inserted into the abdominal cavity; carbon dioxide is injected to create a space for the laparoscope. The doctor will be able to detect endometriosis, scarring, blockages, and some irregularities of the uterus and fallopian tubes.

  • Ovarian reserve testing: this is done to find out how effective the eggs are after ovulation.
  • Genetic testing: this is to find out whether a genetic abnormality is interfering with the woman’s fertility.
  • Pelvic ultrasound: high frequency sound waves create an image of an organ in the body, which in this case is the woman’s uterus, fallopian tubes, and ovaries.
  • Chlamydia test: if the woman is found to have Chlamydia, which can affect fertility, she will be prescribed antibiotics to treat it.
  • Thyroid function test: According to the National Health Service (UK) between 1.3% and 5.1% of infertile women have an abnormal thyroid.

 

Courses of Female Infertility

Age

Unfortunately for many women age plays a big role in their infertility. As a woman ages just like with all the other organ system of the body, her reproductive organs do not function as well as they did when she was younger. Women have the most follicles of their lifetime in-utero. So therefore, as a woman ages her ovarian follicular pool decreases. The American Society for Reproductive Medicine says that, Fecundity declines gradually but significantly beginning approximately at age 35 years, and decreases more rapidly after age 37 years, reflecting primarily a decrease in egg quality in association with a gradual increase in the circulating level of FSH.

Ovulation disorders

Problems with ovulation are the most common cause of infertility in women, experts say. Ovulation is the monthly release of an egg. In some cases the woman never releases eggs, while in others the woman does not release eggs during come cycles.

Ovulation disorders can be due to:

  • Premature ovarian failure- the woman’s ovaries stop working before she is 40.
  • PCOS(Polycystic ovary syndrome) is a serious condition resulting in ovaries which cannot ovulate an oocyte. Polycystic ovaries are the main cause of infertility in women. According to The Federal Government Source for Women’s Health Information, ―In women with PCOS, the ovary doesn’t make all of the hormones it needs for an egg to fully mature. The follicles may start to grow and build up fluid but ovulation does not occur. Instead, some follicles may remain as cysts. For these reasons, ovulation does not occur. Women with PCOS produce an excess amount of androgens. When too much is produced, it can prevent ovulation as well. .
  • Hyperprolactinemia: if prolactin levels are high and the woman is not pregnant or breastfeeding, it may affect ovulation and fertility.
  • Poor egg quality: eggs that are damaged or develop genetic abnormalities cannot sustain a pregnancy. The older a woman is the higher the risk.
  • Overactive thyroid gland
  • Underactive thyroid gland
  • Some chronic conditions, such asAIDS or cancer.

Problems in the uterus or fallopian tubes

The egg travels from the ovary to the uterus (womb) where the fertilized egg grows. If there is something wrong in the uterus or the fallopian tubes the woman may not be able to conceive naturally. This may be due to:

  • Surgery: pelvic surgery can sometimes cause scarring or damage to the fallopian tubes. Cervical surgery can sometimes cause scarring or shortening of the cervix. The cervix is the neck of the uterus.
  • Submucosal fibroids: benign or non-cancerous tumors found in the muscular wall of the uterus, occurring in 30% to 40% of women of childbearing age. They may interfere with implantation. They can also block the fallopian tube, preventing sperm from fertilizing the egg. Large submucosal uterine fibroids may make the uterus’ cavity bigger, increasing the distance the sperm has to travel.
  • Endometriosis: cells that are normally found within the lining of the uterus start growing elsewhere in the body.
  • Infertility often results from complications from having a sexually transmitted infection. According to research The top four STD’s that affect fertility are Chlamydia, Gonorrhea, Syphilis, and HPV. PID (pelvic inflammatory disease) is often 2 associated with these four STD’s. Sadly, women can have an STI and not even know it because many times a person will not present symptoms. And even without symptoms these infections in the upper genital tract may cause permanent damage to the fallopian tubes, uterus, and surrounding tissues, which can lead to infertility.

Mental stress – studies indicate that female ovulation and sperm production may be affected by mental stress. If at least one partner is stressed it is possible that the frequency of sexual intercourse is less, resulting in a lower chance of conception.

Fertility treatments for women

Ovulation disorders – if the woman has an ovulation disorder she will probably be prescribed fertility drugs which regulate or induce ovulation. These include:

  • Clomifene(Clomid, Serophene): this medication helps encourage ovulation in females who do not ovulate regularly, or who do not ovulate at all, because of polycystic ovary syndrome (PCOS) or some other disorder. It makes the pituitary gland release more FSH (follicle-stimulating hormone) and LH (luteinizing hormone).
  • Metformin(Glucophage): women who have not responded to Clomifene may have to take this medication. It is especially effective for women with PCOS, especially when linked to insulin resistance.
  • Human menopausal gonadotropin, or hMG, (Repronex): this medication contains both FSH and LH. It is an injection and is used for patients who don’t ovulate on their own because of a fault in their pituitary gland.
  • Follicle-stimulating hormone(Gonal-F, Bravelle): this is a hormone produced by the pituitary gland that controls estrogen production by the ovaries. It stimulates the ovaries to mature egg follicles.
  • Human chorionic gonadotropin(Ovidrel, Pregnyl): this medication is used together with clomiphene, hMG and FSH. It stimulates the follicle to ovulate.
  • Gn-RH (gonadotropin-releasing hormone) analogs: for women who ovulate prematurely, before the lead follicle is mature enough during hmG treatment. This medication delivers a constant supply of Gn-RH to the pituitary gland, which alters the production of hormone, allowing the doctor to induce follicle growth with FSH.
  • Bromocriptine(Parlodel): this drug inhibits prolactin production. Prolactin stimulates milk production in breast feeding mothers. If non-pregnant, non-breast feeding women have high levels of prolactin they may have irregular ovulation cycles and have fertility problems.

Risk of multiple pregnancies

Injectable fertility drugs can sometimes be the victims of their own success and cause multiple births – when the woman gets pregnant she has twins, triplets, or perhaps more babies in one go. Oral fertility drugs also raise the risk of multiple pregnancies, but much less so than injectable ones. It is important to monitor the patient carefully during treatment and pregnancy. The more babies the mother carries inside her the higher is her risk of premature labor.

If a woman needs an HCG injection to activate ovulation and ultrasound scans show that too many follicles have developed, it is possible to withhold the HCG injection. Couples may decide to go ahead regardless if the desire to become pregnant is very strong.

Multifetal pregnancy reduction is possible if too many babies are conceived – one or more of the fetuses is removed. Couples will have to consider the ethical and emotional aspects of this procedure.

Surgical procedures for women

·         Fallopian tube surgery: if the fallopian tubes are blocked or scarred surgery may repair them, making it easier for eggs to pass through them.

  • Laparoscopic surgery: a small incision is made in the woman’s abdomen. A thin, flexible microscope with a light at the end (laparoscope) is inserted through the incision. The doctor can then look at internal organs, take samples and perform small operations. For women with endometriosis, laparoscopy removes implants and scar tissue, reducing pain and often aiding fertility.

IUI (intrauterine insemination)

A fine catheter is inserted through the cervix into the uterus to place a sperm sample directly into the uterus. The sperm is washed in a fluid and the best specimens are selected. This procedure must be done when ovulation occurs. The woman may be given a low dose of ovary stimulating hormones.

IUI is more commonly done when the man has a low sperm count, decreased sperm motility, or when infertility does not have an identifiable cause. The procedure is also helpful for males suffering from severe erectile dysfunction.

IVF (in vitro fertilization)

Sperm are placed with unfertilized eggs in a Petri dish; the aim is fertilization of the eggs. The embryo is then placed in the uterus to begin a pregnancy. Sometimes the embryo is frozen for future use (cryopreserved).

Infertility tests for men

·      General physical exam: the doctor will ask the man about his medical history, medications, and sexual habits. The physician will also carry out an examination of his genitals. The testicles will be checked for lumps or deformities, while the shape and structure of the penis will be examined for any abnormalities.
·      Semen analysis: the doctor may ask for some specimens of semen. They will be analyzed in a laboratory for sperm concentration, motility, color, quality, infections and whether
any blood is present. As sperm counts can fluctuate, the man may have to produce more samples.
·      Blood test: the lab will test for several things, including the man’s level of testosterone and other male hormones.
·      Ultrasound test: the doctor will determine whether there is any ejaculatory duct obstruction, retrograde ejaculation, or other abnormality.
·      Chlamydia test: if the man is found to have Chlamydia, which can affect fertility, he will be prescribed antibiotics to treat it.
In the male, the most important part of fertility is the functionality of his sperm. In order for fertilization to occur his sperm count, morphology, and motility all have to be sufficient. In the male, infertility occurs when there are abnormalities with his sperm or abnormalities with his reproductive organs.

  • Varicoceles: The most common causes of infertility are varicoceles, complications from diseases and infections, retrograde ejaculation, obstruction, environmental hazards, and genetics. Varicoceles have a high correlation with male infertility. Varicoceles are abnormal enlargements (dilations) of the pampiniform plexus of veins within the scrotum. The pampiniform plexus is believed to have an important functional role in maintaining testicular temperature in the appropriate range for sperm production. The pampiniform plexus cools blood in the testicular artery before it enters the testicles, helping to maintain an ideal testicular temperature, essential for optimal sperm production. According research, Varicoceles are present in an estimated 15 percent of all men. It is not known how many lead to infertility but approximately 40 percent of men undergoing evaluation for infertility are found to have a varicocoele and decreased sperm motility.‖ Therefore, varicocoeles can affect a man’s fertility by changing the optimal temperature for sperm production and thus not producing sperm cells properly.
  • Retrograde ejaculation can affect male fertility. Retrograde ejaculation occurs when semen pushes backwards into the bladder instead of out the penis. This is caused by the failure of nerves and muscles in the bladder neck to close during orgasm. It is one of several difficulties couples may have delivering sperm to the vagina during intercourse. Research has shown that, Retrograde ejaculation can be caused by previous surgery, medications or diseases affecting the nervous system.‖
  • Obstruction of any portion of the male reproductive tract can lead to infertility. Obstruction can be defined as, blocking sperm from its normal passage. Obstructions can be caused by a number of factors, such as repeated infections—possibly from an STI—, prior surgery—including vasectomy—, inflammation, or development problems. Any portion of the male reproductive tract, such as the vas deferens or epididymis, can be obstructed, preventing normal transport of sperm from the testicles to the urethra, where it leaves the body during ejaculation. ―A history of undescended testes as a child and/or sport and back injuries may result in problems with sperm production and transport.‖
  • Research has shown that regular smoking impacts the sperm in a variety of ways. It decreases the size and movement of these cells and damages their DNA content. Smoking also can impact the seminal fluid, ejaculated with the sperm.‖ Another interesting player in male infertility is the free radical. According to research, a relatively new interest area in male infertility, Reactive Oxygen Species (ROS) refers to small molecules present in many bodily fluids, such as seminal white blood and sperm cells. When in appropriate concentrations, ROS can help prepare the sperm for fertilization. However, if in excess, ROS can be harmful to other cells….Recent studies have demonstrated an increase in presence of these molecules in the semen of infertile men.‖
  • Low sperm count(low concentration): the man ejaculates a lower number of sperm, compared to other men. Sperm concentration should be 20 million sperm per milliliter of semen. If the count is under 10 million there is a low sperm concentration (subfertility).
  • No sperm: when the man ejaculates there is no sperm in the semen.
  • Low sperm mobility(motility): the sperm cannot “swim” as well as it should.
  • Abnormal sperm: perhaps the sperm has an unusual shape, making it more 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 (structure) and motility (movement) are wrong it is less likely to be able to reach the egg and fertilize it.

It is important to understand that fertility and infertility is a very complicated matter. There are no clear-cut determinations for when men and women will or won’t be fertile. Luckily, the majority of couples are able to become pregnant with no trouble. Yet, there will always be those who try every resource available to them and never conceive. In today’s world we have countless professionals who are working to make infertility less common and easier to overcome.

Fertility treatments for men

·         Erectile dysfunction or premature ejaculation – medication and/or behavioral approaches can help men with general sexual problems, resulting in possibly improved fertility.
·         Varicocele – if there is a varicose vein in the scrotum, it can be surgically removed.Blockage of the ejaculatory duct – sperm can be extracted directly from the testicles and injected into an egg in the laboratory.
·         Retrograde ejaculation – sperm can be taken directly from the bladder and injected into an egg in the laboratory.
·         Surgery for epididymal blockage – if the epididymis is blocked it can be surgically repaired. The epididymis is a coil-like structure in the testicles which helps store and transport sperm. If the epididymis is blocked sperm may not be ejaculated properly.
REFERENCES

http://www.medicalnewstoday.com/articles/165748.php

http://obgyn.ucla.edu/infertility

http://www.webmd.com/infertility-and-reproduction/guide/female-infertility#

http://natural-fertility-info.com/top-10-causes-of-infertility.html

http://americanpregnancy.org/infertility/female-infertility/

http://www.mayoclinic.org/diseases-conditions/infertility/symptoms-causes/dxc-20228738