Infertility is the failure to become pregnant
within one year of regular, unprotected intercourse.
Being labelled infertile is devastating
to the couple. In the words of one couple, "it
feels like being sentenced for a crime you have not
committed". For the vast majority of patients infertility
is totally unexpected. They look, feel and act normally
and everything appears to be functioning well. Suddenly,
a young and healthy couple has a medical label, a stigma
thrust upon them.
- 80 85 % of couple
achieve pregnancy if they so desire, within one year
of having regular, unprotected intercourse with adequate
frequency (4- 5 times a week).
- Another 10% will achieve
the objective by the end of the second year.
- As such, 5 10%
remain without a child by the end of second year.
responsible for fertility
Female reproductive systems in Sexual Activity
- Formation of healthy
spermatozoa and healthy ovum.
- Fertilisation of the
mature ovum by a healthy sperm.
- Transition of the healthy
zygote through the fallopian tube into the uterine
cavity and its implantation.
- Adequate hormonal internal
environment for the growth of pregnancy.
There may be
a problem in the male 30% cases. It may be a female
related factor 30%, or there may be factors in both
partners upto 30% cases.
The most common
causes of female infertility are:
Failure to release mature egg (ovum) which, may be
due to following reasons:
- Hormonal imbalance (FSH
- Obesity and weight gain.
- Prolonged excessive
- High levels of serum
- Cyst in the ovary.
- Various medications.
- Weight loss due to various
reasons, including eating disorders such as anorexia,
- Corpus luteum insufficiency:
In this, there is inadequate growth and function of
the corpus luteum.
- Lutenised unruptured
follicular syndrome (trapped ovum): In this condition,
the ovum is not released and is trapped inside the
follicle, which gets luteinsed.
to Fallopian tubes:
- Defective ovum picks
- Impaired tubal motility.
- Partial or complete
obstruction of tubal lumen.The impaired function of
any one above is related to tubal infection or adhesions
around the tube following pelvic surgery, infection
Which are soft tissue tumors. When they are located
close to tubal opening (ostia) or in the cervical
region can cause infertility.
Large fibroids particularly located under the
lining of the uterine cavity (submucus fibroid) can
be responsible for frequent pregnancy loss.
A tough band of healing cells (fibrous tissue) causing obliteration
of the cavity of uterus in varied severity can lead
Infection of uterine
cavity, vigorous curettage of the endormetrum during
incomplete abortion, dilatation and curettage (D and
C) or retained products of pregnancy can lead to adhesions.It
is advisable to avoid frequent medical termination
of pregnancy, D and C, which could lead to formation
Presence of wall in the uterine cavity can
cause recurrent pregnancy loss and infertility.
maldevelopment of uterus: unicornuate uterus,
and bicornuate uterus.
- Anatomic defects preventing
the sperm to ascend into the uterine cavity and thus
- Cervical mucus
faulty composition or amount of cervical mucus.
- Presence of anti-sperm
or sperm immobilizing antibodies in the mucus may
be implicated as immunological factors of infertility.
- Congenital narrowing
/ stenosis of the vagina.
- Presence of partial
or complete wall in the vagina.
- Infections of the vagina .
age: There is natural decline in fertility as
the age advances, more so after the age of 35 years.11%
by the age of 34 years.33% by the age of 40 years.
87% by the age of 45 years.
Fear, tension, nervousness, anxiety adds
to the problems of infertility.
However it is often a vicious cycle: Psychological
factors alone are responsible only for a small number
of fertility cases.
Undescended testes, while the hormone
secretion remains unaffected, the formation
of the sperm is depressed.
Factors: Few diseases like varicoceole
or big hydroceole or wearing tight undergarments
or working in hot atmosphere can depress the
formation of sperms.
Like mumps (local name), tuberculosis, etc.
in the passage of sperms to outside : This
may be due to male sterilization operation/vasectomy,
infections like tuberculosis, gonorrhoea,
which leads to clumping of sperms after
Problems: Certain diseases like diabetes,
/ Anatomic problems: failure to deposit
sperms high in the vagina, premature ejaculation,
of Infertile Couple
a baby is a joint effort by a couple. Hence if it doesnt
seem to be happening, as you want it to, it is better
for both of you to go together for evaluation.The doctor
will give you and your partner a thorough physical examination
to help investigate and find a treatment for your problem,
if any.It is important for you and your partner to have
full faith in your doctor. You must hand over complete
information regarding your health, physical and sexual
habits, so as to come to a conclusion of why pregnancy
doesnt seem to be happening and will ask both,
you and your partner questions during joint and separate
interviews.One must note this point the corrective therapy
administered which has to extend over a certain period
of time. It is well established that pregnancy rates
in normal non-pregnant women is 50% in 5 months, 85%
in about 10 12 months and 100% in about 15
18 months, the variation depending on the age of the
woman and the fertility of her partner. Hence it is
obvious that it would be a serious error to abandon
therapy or change the doctor as a failure after few
months. One must discuss the expected time period of
the treatment with the infertility specialist before
the start of treatment.
to a complete physical and gynecological examination,
the doctor may want to do the following tests. The idea
is to look for a cause. If it is present, you can be
given specific treatment to improve your chance of getting
Evaluation and treatment
When you visit
a doctor, there are few basic investigations, which
are undertaken. The idea is to look for a cause, if
it is present, you can be given specific treatment to
improve your chances of getting pregnant. The infertility
treatment advances in stepwise manner.
urine test of both partners:
To look for
anaemia and infection. It gives idea about general health
status and for anaesthesia fitness purpose.
group and Rh factor:
It rules out
the possibility of disease called Rh isoimmunization,
which uncommonly is a cause of infertility.
the possibility of syphilis (a sexually transmitted
disease) as a cause of infertility.
HIV test and Hepatitis test:
To rule out
the risk of AIDS and hepatitis infection.
To rule out
Blood sugar levels:
post meal levels are done routinely for women having
previous delivery of dead baby or neonatal (death of
baby in less than 1 month) death.
Semen analysis for male partners:
It is done
to rule out whether there is absence of sperms, less
number of sperms or there is problem in their motility
or large number of abnormal sperms. As these may become
the cause of infertility.The semen is to be collected
by manual expression. (Masturbation). The sample of
semen should be given in a clean wide mouth container
after 3 4 days of absence of sex. It is submitted
to laboratory within 1 hour.
tests are normal, usually the woman is prescribed to
take ovulation-inducing drugs known as clomiphine citrate
(brand name Clomid, Fertyl) to enhance the production
and maturation of the egg.Simultaneously, the ultrasonography
is advised to study the relation of uterus, ovary, and
fallopian tubes to each growing follicle called follicular
study.In this, the ultrasonography is done usually on
(day 10, 12, 13, 14, and 16) alternate days during
midcycle period to record the size of the maturing egg.Meanwhile,
the couple is advised to keep relations usually on alternate
days during mid cycle period. It is very vital to keep
relations during this period of maturation. Rupture
of the follicle releases the qualified egg for fertilisation.
Timing of relation is vital in this context also called
as planned relation.
of treatment is usually undertaken for a period of 6
months. The cumulative pregnancy rate approaches to
60 75% at the end of 6 months.
If no success
is obtained by the end of 6 months, usually a decision
is taken for Laproscopy and Hysteroscopy. Seeing
is believing, it is believed that these tests
should be done to actually look at the internal genital
organs to assess them. These are surgical procedures
and are done under anaesthesia. Some specialist may
opt to do these tests at the beginning of the treatment.
The decision is individual depending on the case
record, age of the couple and facilities available.
In this, a thin 1.8mm telescope,
called hysteroscope is installed through the mouth of
the uterus (cervix) to look into the cavity of the uterus.
This helps to diagnose conditions like fibroids lying
below the lining of the uterine cavity, polyps, and
uterine septum (wall in the uterine cavity), fibrous
bands (adhesions), blocked tubal openings which
can be treated simultaneously.
is a special telescope available in different sizes
is installed through the umbilicus and the reproductive
organs are visualised. Conditions like fibroids, cysts
of the ovary, fibrous bands (adhesions), blocked fallopian
tubes and endometriosis can be diagnosed and treated
simultaneously.By pushing a coloured solution into the
fallopian tubes during the procedure, your doctor can
document whether your fallopian tubes are open or blocked.
It is complimentary to the hysterosalphingography (HSG)
procedure and can be avoided if HSG is normal.
If you are
found to have a disease of the uterus like fibroids,
septum, polyps, adhesions or congenital abnormality
of the uterus, surgery can be done to correct this.
Remember however that certin antomical or structural
changes may not really interfere with your getting pregnant.
Only if no other correctable factors are present, your
doctor may suggest surgery such as myomectomy (removal
of a fibroid) or removal of a septum or adhesion. These
can be done by various techniques, details of which
are outside the scope of this discussion.
It is a procedure
in which a special dye is pushed through the mouth of
the uterine cavity and an X-ray is taken of lower abdomen.
The dye outlines the uterine cavity, tubes and gives
idea regarding the patency of the fallopian tubes. This
procedure doesnt require any anaesthesia and is
usually done after menstruation and before ovulation.
is done on day 1 or day 2 of menstrual bleeding. It
is a simple procedure and doesnt require any anaesthesia.
A small fragment of uterine lining is removed and studied
under microscope, to know how it responds to the hormones.
This is done
usually in mid cycle period. A sample of mucus from
cervix (mouth of uterus) is studied under the microscope.
This test gives information regarding sperm and mucus
interaction and the mucus characteristics can hint towards
test for sperms:
This is a
highly specialized test, which is aimed at determining
special cells called antibodies, which appears
in womans blood, cervical mucus or seminal vesicles
antibodies may react with the sperm and destroy or immobilize
them causing infertility. Another fairly common cause
of infertility is endometriosis a disease in
which the internal lining of the uterus (endometrium)
grows in or on other parts of the reproductive system.This
causes slowly progressive changes in and around the
genital organs reducing the fertility. Upto 1/3 of women
with this problem dont get pregnant without medical
surgery, hormonal drug therapy in the form of danazol,
medroxy progestrone acetate or both may be used to treat
If the fallopian
tubes are severely damaged, or the eggs is not produced
optimally or if there is a problem with the sperm count,
such patients need specialised infertility treatment
called assisted reproductive techniques
combinations of above tests are undertaken as per the
couple's progress, to determine the cause of infertility
and towards achieving a successful pregnancy.
techniques have varying success rates and carry the
risk of multiple pregnancy, but have allowed many couples
to become parents. All of these techniques involve stimulating
the ovary to produce an excess number of eggs and removing
(harvesting) the eggs from the woman.
vitro fertilisation (IVF):
In vitro fertilisation bypasses
most of the things that can go wrong in the process
of getting a healthy egg out of the ovary, into and
through the fallopian tube, and fertilised by accomplishing
those things outside the body. After the ovaries are
stimulate with hormonal drugs, your doctor will collect
the cultivated eggs from your ovaries with a laparoscope
or a needle directed by ultrasound. Eggs and sperm (either
from your partner or a donor) are then combined in a
lab dish. Between two and five days later, your doctor
will transplant one or more of the fertilised egg, or
embryos, into your uterus, with the hope that it will
implant itself in the uterine lining, thus establishing
intrafallopian transfer (GIFT):
as in vivo fertilisation, GIFT generally follows the
same procedure as IVF. A woman must have at least one
healthy fallopian tube to use this technology. Rather
than combining the egg and sperm in a lab dish as is
done with IVF, during GIFT the egg and sperm are placed
in the fallopian tube so fertilisation can take place
intrafallopian transfer (ZIFT):
is another variation of IVF and GIFT. ZIFT involves
transplanting an already fertilised egg (zygote) from
outside in to a fallopian tube.
may work if the females cervical musus seems to
reject or immobilize her partners sperm from a
male partner is implanted in the womans uterine
cavity as close as possible to the time of ovulation.
This is most commonly used in
cases on infertility where the male partner produces
no sperm and when he is unresponsive to medical or surgical
remedies. Even if the male partner has low sperm count
unhealthy sperm or sperm with poor swimming ability
(motility) artificial insemination using sperm from
a selected donor may be a good choice. When the woman
has no fertility problems, success rates from artificial
insemination, which simply means insemination by means
other than sexual intercourse, are quite high.
or embryo donation:
This is a
choice for the woman whose ovaries dont work properly
or whose eggs arent healthy or are absent but
whose uterus is able to sustain a pregnancy. Donor eggs
can be fertilised with the infertile womans partners
sperms or that of a sperm donor. Your doctor will then
transplant a couple of the fertilised eggs, or blastocysts
(mature embryos) into your uterus, with the hope that
one or at the most two will implant themselves in the
uterine lining, establishing pregnancy.
In patient care
may be necessary for surgery and some of the diagnostic
tests, but the vast majority of infertility treatments
can be performed on an outpatient basis.
who may be involved in treatment:
The following healthcare professionals may be involved
in your fertility treatment.
Obstetrician / gynecologists
& Diet Recommendations :
Both men and
women should avoid alcohol, tobacco, and other drug
use when theyre trying to get pregnant since these
substances hinder estrogen and sperm production. Of
course, women should also avoid these substances once
they conceive.While no specific diet can increase fertility,
your good health depends on good nutrition. You may
also want to ask your doctor about taking specially
formulated prenatal vitamins including folic acid, while
you are trying to conceive.
Men with a
low sperm count should avoid activities and clothing
that will raise scrotal temperature (which reduces sperm
production). Some culprits are tight-fitting underwear
and clothing (particularly those made of synthetic fabrics)
hot baths, hot tubs and saunas. Long distance cycling
may also cause pressure on the scrotum and testes and
should be avoided while youre trying to conceive.
fertility difficulties should avoid strenuous dieting
and extreme exercise (such as marathon or endurance-race
training) which may lead to excessive loss of body fat,
menstrual irregularity and cessation of ovulation.
and assisted reproductive technologies used to treat
infertility may result in multiple births (twins, triplets,
etc) while this aspect of fertility treatment is very
controversial, some couples view it as a blessing, not
a complication. This risk has recently been greatly
reduced by allowing the fertilised eggs to develop into
blastocysts before selection for transfer into the uterus.
For many men
and women, learning that they have fertility problems
is shattering. An infertility diagnosis can distort
our basic definitions of womanhood and manhood, however
temporarily. Shame anger, guilt, denial, and blame are
just some of the emotions you and your partner may be
dealing with.However thrilling the eventual outcome
may be fertility is a rough and rocky road for many
couples, one they may travel on for years. Fertility
treatment involves emotional, ethical, moral even religious
And only two
of you know how much medical assistance you want, can
tolerate, or afford in your goal to achieve pregnancy.
An open and ongoing discussion among you, your partner
and your doctors can help you at each juncture of your
treatment. Your family may also benefit from counseling
to understand your experience and reactions.
decide against aggressive fertility treatments, or should
your efforts prove unsuccessful, talk to your doctor
about bringing a child into your family through surrogacy