INFERTILITY

What is infertility?

In general, infertility is defined as not being able to get pregnant (conceive) after one year of unprotected sex. Women who do not have regular menstrual cycles, or are older than 35 years and have not conceived during a 6-month period of trying, should consider making an appointment with a – an infertility specialist. These doctors may also be able to help women with recurrent pregnancy loss – 2 or more spontaneous miscarriages

Pregnancy is the result of a process that has many steps.

To get pregnant –

• A woman’s body must release an egg from one of her ovaries (ovulation).
• A man’s sperm must join with the egg along the way (fertilize).
• The fertilized egg must go through a fallopian tube toward the uterus (womb).
• The fertilized egg must attach to the inside of the uterus (implantation).

Infertility may result from a problem with any or several of these steps.

Impaired fecundity is a condition related to infertility and refers to women who have difficulty getting pregnant or carrying a pregnancy to term.

Is infertility a common problem?

Yes. About 6% of married women 15-44 years of age are unable to get pregnant after one year of unprotected sex (infertility).

Is infertility just a woman’s problem?

No, infertility is not always a woman’s problem. Both men and women contribute to infertility.

Many couples struggle with infertility and seek help to become pregnant; however, it is often thought of as only a women’s condition.

What causes infertility in men?

Infertility in men can be caused by different factors and is typically evaluated by a semen analysis. A specialist will evaluate the number of sperm (concentration), motility (movement), and morphology (shape). A slightly abnormal semen analysis does not mean that a man is necessarily infertile. Instead, a semen analysis helps determine if and how male factors are contributing to infertility.

Conditions that can contribute to abnormal semen analyses include –

• Varicoceles, a condition in which the veins on a man’s testicles are large and cause them to overheat. The heat may affect the number or shape of the sperm.
• Medical conditions or exposures such as diabetes, cystic fibrosis, trauma, infection, testicular failure, or treatment with chemotherapy or radiation.
• Unhealthy habits such as heavy alcohol use, testosterone supplementation, smoking, anabolic steroid use, and illicit drug use.
• Environmental toxins including exposure to pesticides and lead.

What causes infertility in women?

Women need functioning ovaries, fallopian tubes, and a uterus to get pregnant. Conditions affecting any one of these organs can contribute to female infertility. Some of these conditions are listed below and can be evaluated using a number of different tests.

Ovarian function (presence or absence of ovulation and effects of ovarian “age”)

• Ovulation. Regular predictable periods that occur every 24–32 days likely reflect ovulation.
• A woman with irregular periods is likely not ovulating. This may be because of several conditions and warrants an evaluation by a doctor. Potential causes of anovulation include the following:
  • Polycystic ovary syndrome (PCOS). PCOS is a hormone imbalance problem that can interfere with normal ovulation. PCOS is the most common cause of female infertility.
  • Functional hypothalamic amenorrhea (FHA). FHA relates to excessive physical or emotional stress that results in amenorrhea (absent periods).
  • Diminished ovarian reserve (DOR). This occurs when the ability of the ovary to produce eggs is reduced because of congenital, medical, surgical, or unexplained causes. Ovarian reserves naturally decline with age.
  • Premature ovarian insufficiency (POI). POI occurs when a woman’s ovaries fail before she is 40 years of age. It is similar to premature (early) menopause.
  • Menopause is an age-appropriate decline in ovarian function that usually occurs around age 50. It is often associated with hot-flashes and irregular periods.
• Ovarian function. Several tests exist to evaluate a woman’s ovarian function.
• No single test is a perfect predictor of fertility.
• The most commonly used markers of ovarian function include follicle stimulating hormone (FSH) value on day 3–5 of the menstrual cycle, anti-mullerian hormone value (AMH), and antral follicle count (AFC) using a transvaginal ultrasound.

Tubal Patency (whether fallopian tubes are open, blocked, or swollen).

• Risk factors for blocked fallopian tubes (tubal occlusion) can include a history of pelvic infection, history of ruptured appendicitis, history of gonorrhoea or chlamydia, known endometriosis , or a history of abdominal surgery.
• Tubal evaluation may be performed using an X-ray which is called a hysterosalpingogram (HSG), or by chromopertubation (CP) in the operating room at time of laparoscopy, a surgical procedure in which a small incision is made and a viewing tube called a laparoscope is inserted.
  • Hysterosalpingogram (HSG) is an X-ray of the uterus and fallopian tubes. A radiologist injects dye into the uterus through the cervix and simultaneously takes X-ray pictures to see if the dye moves freely through fallopian tubes. This helps evaluate tubal calibre (diameter) and patency.
  • Chromopertubation is similar to an HSG but is done in the operating room at the time of a laparoscopy. Blue-coloured dye is passed through the cervix into the uterus and spillage and tubal calibre (shape) is evaluated.

Uterine contour (physical characteristics of the uterus)Depending on a woman’s symptoms, the uterus may be evaluated by transvaginal ultrasound to look for fibroids or other anatomic abnormalities. If suspicion exists that the fibroids may be entering the endometrial cavity, a sonohystogram (SHG) or hysteroscopy (HSC) may be performed to further evaluate the uterine environment.

How long should women try to get pregnant before calling their doctors?

Most experts suggest at least one year for women younger than age 35. However, women aged 35 years or older should see a health care provider after 6 months of trying unsuccessfully. A woman’s chances of having a baby decrease rapidly every year after the age of 30.

Some health problems also increase the risk of infertility. So, women should talk to a health care provider if they have-

• Irregular periods or no menstrual periods.
• Very painful periods.
• Endometriosis.
• Pelvic inflammatory disease.
• More than one miscarriage.

It is a good idea for any woman and her partner to talk to a health care provider before trying to get pregnant. They can help you get your body ready for a healthy baby, and can also answer questions on fertility and give tips on conceiving.

How will doctors find out if a woman and her partner have fertility problems?

Doctors will begin by collecting a medical and sexual history from both partners. The initial evaluation usually includes a semen analysis, a tubal evaluation, and ovarian reserve testing.

How do doctors treat infertility?

Infertility can be treated with medicine, surgery, intra-uterine insemination, or assisted reproductive technology. Many times these treatments are combined. Doctors recommend specific treatments for infertility based on –

• The factors contributing to the infertility.
• The duration of the infertility.
• The age of the female.
• The couple’s treatment preference after counselling about success rates, risks, and benefits of each treatment option.

What are some of the specific treatments for male infertility?

Male infertility may be treated with medical, surgical, or assisted reproductive therapies depending on the underlying cause. Medical and surgical therapies are usually managed by an urologist who specializes in infertility. A reproductive endocrinologist may offer intrauterine inseminations (IUIs) or in vitro fertilization (IVF) to help overcome male factor infertility.

What medicines are used to treat infertility in women?

Some common medicines used to treat infertility in women include –

• Clomiphene citrate is a medicine that causes ovulation.It is often used in women who have polycystic ovarian syndrome (PCOS) or other problems with ovulation.
• Human menopausal gonadotropin or hMG are medicines often used for women who don’t ovulate because of problems with their pituitary gland-hMG acts directly on the ovaries to stimulate ovulation. It is an injected medicine.
• Follicle-stimulating hormone or FSH are medicines that work much like hMG. It causes the ovaries to begin the process of ovulation. These medicines are usually injected.
• Gonadotropin-releasing hormone (Gn-RH) analog are medicines often used for women who don’t ovulate regularly each month. Women who ovulate before the egg is ready can also use these medicines. Gn-RH analogs act on the pituitary gland to change when the body ovulates. These medicines are usually injected or given with a nasal spray.
• Metformin  is a medicine doctors use for women who have insulin resistance and/or PCOS. This drug helps lower the high levels of male hormones in women with these conditions. This helps the body to ovulate. Sometimes clomiphene citrate or FSH is combined with metformin. This medicine is usually taken by mouth.

 

Many fertility drugs increase a woman’s chance of having twins, triplets, or other multiples. Women who are pregnant with multiple fetuses have more problems during pregnancy. Multiple fetuses have a high risk of being born prematurely (too early). Premature babies are at a higher risk of health and developmental problems.

What is intrauterine insemination (IUI)?

Intrauterine insemination (IUI) is an infertility treatment that is often called artificial insemination. In this procedure, specially prepared sperm are inserted into the woman’s uterus. Sometimes the woman is also treated with medicines that stimulate ovulation before IUI.

IUI is often used to treat-

• Mild male factor infertility.
• Couples with unexplained infertility.

What is assisted reproductive technology (ART)?

Assisted Reproductive Technology (ART) includes all fertility treatments in which both eggs and sperm are handled outside of the body. In general, ART procedures involve surgically removing eggs from a woman’s ovaries, combining them with sperm in the laboratory, and returning them to the woman’s body or donating them to another woman. The main type of ART is in vitro fertilization (IVF).

How often is assisted reproductive technology (ART) successful?

Success rates vary and depend on many factors, including the clinic performing the procedure, the infertility diagnosis, and the age of the woman undergoing the procedure. This last factor – the woman’s age – is especially important.

CDC collects success rates on ART for some fertility clinics. According to the CDC’s 2013 ART Success Rates, the average percentage of fresh, nondonor ART cycles that led to a live birth were –

40% in women younger than 35 years of age.

• 32% in women aged 35–37 years.
• 21% in women aged 38–40 years.
• 11% in women aged 41–42 years.
• 5% in women aged 43–44 years.
• 2% in women aged 44 years and older.

Success rates also vary from clinic to clinic and with different infertility diagnoses.

ART can be expensive and time-consuming, but it has allowed many couples to have children that otherwise would not have been conceived. The most common complication of ART is a multiple foetus pregnancy. This is a problem that can be prevented or minimized by limiting the number of embryos that are transferred back to the uterus. For example, transfer of a single embryo, rather than multiple embryos, greatly reduces the chances of a multiple foetus pregnancy and its risks such as preterm birth.

What are the different types of assisted reproductive technology (ART)?

Common methods of ART include:

• In vitro fertilization (IVF), meaning fertilization outside of the body. IVF is the most effective and the most common form of ART.
• Zygote intrafallopian transfer (ZIFT) or tubal embryo transfer. This is similar to IVF. Fertilization occurs in the laboratory. Then the very young embryo is transferred to the fallopian tube instead of the uterus.
• Gamete intrafallopian transfer (GIFT), involves transferring eggs and sperm into the woman’s fallopian tube. Fertilization occurs in the woman’s body. Few practices offer GIFT as an option.
• Intracytoplasmic sperm injection (ICSI) is often used for couples with male factor infertility. Sometimes it is also used for older couples or for those with failed IVF attempts. In ICSI, a single sperm is injected into a mature egg as opposed to “conventional” fertilization where the egg and sperm are placed in a petri dish together and the sperm fertilizes an egg on its own.

ART procedures sometimes involve the use of donor eggs (eggs from another woman), donor sperm, or previously frozen embryos. Donor eggs are sometimes used for women who cannot produce eggs. Also, donor eggs or donor sperm is sometimes used when the woman or man has a genetic disease that can be passed on to the baby. An infertile woman or couple may also use donor embryos. These are embryos that were either created by couples in infertility treatment or were created from donor sperm and donor eggs. The donated embryo is transferred to the uterus. The child will not be genetically related to either parent.