Infertility Issues
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.

Incidence:

• 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.

Factors responsible for fertility are:

Male and 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.

Causes of infertility:
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.

Female infertility

The most common causes of female infertility are:

Related to Ovary:

• Anovulation – Failure to release mature egg (ovum) which, may be due to following reasons:
• Hormonal imbalance (FSH and LH).  
• Obesity and weight gain.
• Prolonged excessive stress.
• High levels of serum Prolactin.
• Cyst in the ovary.
• Various medications.
• Weight loss due to various reasons, including eating disorders such as anorexia, etc.
• 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.

Related to Fallopian tubes:

1. Defective ovum picks up.
2. Impaired tubal motility.
3. 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 or endometriosis.

Related to Uterus:

• Fibroids : 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.
• Adhesions: A tough band of healing cells (fibrous tissue) causing obliteration of the cavity of uterus in varied severity can lead to infertility.

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 of adhesions.

• Septum: Presence of wall in the uterine cavity can cause recurrent pregnancy loss and infertility.
• Congenital malformations: maldevelopment of uterus: unicornuate uterus, and bicornuate uterus.

Related to cervix:

• Anatomic defects preventing the sperm to ascend into the uterine cavity and thus preventing fertilisation.
• Cervical mucus – faulty composition or amount of cervical mucus.
• Infection.
• Presence of anti-sperm or sperm immobilizing antibodies in the mucus may be implicated as immunological factors of infertility.

Related to vagina:

• Congenital narrowing / stenosis of the vagina.
• Presence of partial or complete wall in the vagina.
• Infections of the vagina .

Others:

• Advancing 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.

• Psychological: 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.

Evaluation of Infertile Couple

Having a baby is a joint effort by a couple. Hence if it doesn’t 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 doesn’t 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.

In addition 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 pregnant.

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.

Step I

Routine Tests:

Blood and urine test of both partners:

(i) Complete blood count:

To look for anaemia and infection. It gives idea about general health status and for anaesthesia fitness purpose.

(ii) Blood group and Rh factor:

It rules out the possibility of disease called Rh isoimmunization, which uncommonly is a cause of infertility.

(iii) Serum VDRL test:

To eliminate the possibility of syphilis (a sexually transmitted disease) as a cause of infertility.

(iv) Blood HIV test and Hepatitis test:

To rule out the risk of AIDS and hepatitis infection.

(v) Urine test:

To rule out urinary infection.

Specific tests:

(i) Blood sugar levels:

Premeal and 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.   

(ii) 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.

Treatment options:

• Medications

Once these 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.

• Fertility Injections :
  If this doesn’t correct the ovulation problem or you still do not become pregnant, fertility injections may be recommended. These are much more expensive and require closer supervision and monitoring. Hence they are usually not started as a first option.

• Human menopausal Gonadotrophin (HMG) – Provides extra supply of hormone (FSH and LH) helping to stimulate development of eggs.

• Follicle stimulating hormone (FSH) – Provides extra supply of FSH (hormone needed for the development of eggs)

• Human chorionic Gonadotrophin (HCG) – Triggers release of eggs (ovulation)

• Gonadotrophin releasing hormone analogue (GnRH analogues – Goserelin) – Used as an adjunctive therapy for controlled ovarian stimulation, which leads to production of few mature eggs for assisted reproductive technique.

This course 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.

• Surgery :

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.

• Hysteroscopy:

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.

• Laproscopy:

A laproscope 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.

• Hysterosalphingography (HSG):

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 doesn’t require any anaesthesia and is usually done after menstruation and before ovulation.

• Endometrial biopsy

This test is done on day 1 or day 2 of menstrual bleeding. It is a simple procedure and doesn’t require any anaesthesia. A small fragment of uterine lining is removed and studied under microscope, to know how it responds to the hormones.

• Post coital test:

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 ovulation.

• Antibody test for sperms:

This is a highly specialized test, which is aimed at determining special cells called ‘antibodies’, which appears in woman’s blood, cervical mucus or seminal vesicles .      These 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 don’t get pregnant without medical help.

Laproscopic surgery, hormonal drug therapy in the form of danazol, medroxy progestrone acetate or both may be used to treat this condition.

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’ (ART)

The permutation, combinations of above tests are undertaken as per the couple's progress, to determine the cause of infertility and towards achieving a successful pregnancy.

• Assisted reproductive technology (ART)

These expensive 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.

In 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 pregnancy.

Gamete intrafallopian transfer (GIFT):

Also known 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 there.

Zygote intrafallopian transfer (ZIFT):

This procedure is another variation of IVF and GIFT. ZIFT involves transplanting an already fertilised egg (zygote) from outside in to a fallopian tube.

• Other treatment

Intra-uterine insemination:

This technique may work if the female’s cervical musus seems to reject or immobilize her partner’s sperm from a male partner is implanted in the woman’s uterine cavity as close as possible to the time of ovulation.

Artificial insemination:

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.

Egg or embryo donation:

This is a choice for the woman whose ovaries don’t work properly or whose eggs aren’t healthy or are absent but whose uterus is able to sustain a pregnancy. Donor eggs can be fertilised with the infertile woman’s partner’s 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.

Appropriate Healthcare Setting:
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.

Professionals who may be involved in treatment:
The following healthcare professionals may be involved in your fertility treatment.

Obstetrician / gynecologists

Urologists.

Reproductive endocrinologists.

Activity & Diet Recommendations :

Both men and women should avoid alcohol, tobacco, and other drug use when they’re 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 you’re trying to conceive.

Women experiencing 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.

Some drugs 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 dilemmas.

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.

Should you decide against aggressive fertility treatments, or should your efforts prove unsuccessful, talk to your doctor about bringing a child into your family through surrogacy or adoption.